So your development in India, your business? No, I have companies that are in different places. Yeah, in the U.S., in the U.S. And I work a lot in development. You should be here. You should be here. Healthcare program, China, India, Africa, Latin America. Everything is about making things affordable and accessible by being in control. Great. I'm at the end of all aspects. Maybe you can say your more information about your product. I think the China is... I did the same kind of thing in China. We produce all the medical equipment, CDMR, ultrasound, X-ray. And this moment... Welcome. Thanks for joining in this early afternoon. This session part of the public program on the health advantage. In a minute, our moderator, Lee Yat-sen, will present our guest. So I won't go there. And I would like to discuss the term advantage. Advantage. We know those numbers very well. USA, $8,000 in terms of annual cost per individual. 79-year-old life expectancy, 18% of GDP. China, 75-year-old. $275 per individual. Well, actually, in actual dollars because they were as in 1990 dollars, it's closer to 400. Still less than 500. 5% of GDP. Singapore, 4% of GDP, 83-year-old life expectancy. Does it matter? Does it matter? Well, from an employer standpoint, if you can't recruit the best talent, because you can't afford to offer the best insurance program, it matters. For a city, if you rank very low in the ranking of the best livable city of the world because your healthcare system is not the one people would expect when they migrate, it matters. For states, when your healthcare system is going to result in high level of absenteeism, disability, reduced output, productivity loss, it matters. We estimate the direct cost of healthcare expenses worldwide to be $7 trillion. And Norbert, we've worked on that before. We think the true cost of healthcare is $47 trillion. When you take into consideration the indirect costs of not providing healthcare at the right level and the elements I just mentioned, we estimate that in the US alone, the productivity loss due to the absenteeism is $250 billion. For a company of 1,000 employees in the US, the cost of obesity is $280,000 annually. Now, it is time to rethink the healthcare systems. It is time to find new ways of building them or rebuilding them. And my expectation from the session is that our panelists should cover, and I think they will, how can we integrate innovation seamlessly into existing healthcare systems? How can we work in multi-stakeholder ecosystems along the continuum of care? What about business model innovation? Innovative financing. And let's not forget regulatory systems that have to promote innovation as well as safety. We have no further due. I pass on to you. Thank you very much, Anna. And let you introduce our guest. Do I need the microphone? Not sure. Thank you very much, Anna. And welcome, ladies and gentlemen. Anna did a terrific job of introducing the topic. I think he's done the first part of my job for me. But let me start then by introducing the panel. We have a terrific panel here today. We're very fortunate to have with us the Health Minister of Malaysia, Dr. Subra with us. Welcome, Dr. Subra. We have David Green, who's the founder of Auralab Indra and the Swab Foundation fellow at David. We have Andrew Lee, who's the Vice President Northeast Region Aitner from the United States. We have Gordon Liu, who's the Director of the China Center for Health Economics Research at the National School of Development from Peking University. And welcome. And last but not least, we have Mr. Liu Tiren, who's the Chairman and Chief Executive Officer of New Soft Corporation from China. Welcome to you all. Just in terms of housekeeping, we're going to have a conversation here for about half an hour. And then we're going to throw it open to you guys to ask whatever questions of any one of the panelists or to all of us that you want as well so we can make this as interactive as possible. But let me kick off and ask you, Dr. Subra, the situation in Malaysia. What is the Malaysian government doing? What is your ministry doing in terms of implementing universal health care in Malaysia? What are some of the challenges that you are facing? Okay. Thank you, Jason. As you know, there's a third session on health and speaking in this forum. Each with different titles to it. The first one was entitled, Economy and Health. The second one was leapfrogging over health. And now we are meeting advantage in health. So essentially it's all the same. And the material is going to be the same. To start off with, Malaysia has sort of assured universal health coverage through the public health system. This has been done since independence. So we have in terms of principle, all Malaysians are entitled to free health care through the public service system. So when you look at that, then the three areas in which we're probably to look at it. One is, of course, access. Second is affordability and third is quality. If you talk about access, I think we are fortunate through a very extensive network of both the public health service and also an equally widespread availability of private health services. There is good access to health care for all Malaysians. We have got a primary health clinic for every 50,000 population with five feeder clinics which feed to these main clinics. So we have met access. We have met affordability because public health is 98% subsidized by the government. So anybody who has got no money has got access to public health service. But how affordable is it for the government? That's the other issue. That's what I'm coming to the third issue. The third part is the quality. So that is where, of course, when you provide a service which is so extensive, so widespread, then you have to meet qualities in expectation of the people, not as defined by the government. So when that comes, of course, that is, I think, it's our biggest challenge in terms of whether we can meet up to the expectations of the people in terms of waiting time, in terms of giving them the correct kind of technology. And, of course, making sure that all forms of ailments which they have can be treated according to the current knowledge of medicine and science. I think that probably is our biggest challenge and that's the challenge we are trying to meet with and that probably will answer your question. And I won't give you the answer now because we're in the process of transforming and finding an answer to that question. Okay. Very good. Thank you. China and Malaysia. You come from a university perspective. When I look at the Chinese health system now and my staff, for instance, will start queuing in the morning at five o'clock in the morning to attend a hospital because they have a cold. So there's emphasis on hospitals and tertiary care. That strikes me tremendously inefficient. From your perspective, what's happening in China and how can China sort of break through some of these challenges and some of these barriers? Well, the health care system in China has been long concentrated at the hospital at the center of the service system. In other words, in China, there is no gatekeeper for people to obtain the health care for their common conditions like cold conditions in the community settings. Instead, most people, if possible, would all go to tertiary hospitals for all conditions. That is because the way we allocate resources which are highly concentrated at tertiary hospitals, that's our problem. That's our challenge. That's why you would see the long queue in almost all hospitals for any conditions. So I think our goal is to change the way the services are delivered from the hospital-centered system to primary care-centered in community settings and only have the patients who need the inpatient care going to the hospitals. That's our challenge. That's our job. I want to come back to that a bit later and the challenges around that. But obviously, some of the things that enable what you're talking about, the community delivery of health care is obviously technology. I want to refer to Mr. Liu here now in terms of what your company is doing, your technology company, the software company, and you're very involved in health care technology. Is there a linkage here in terms of the technology solutions that you're putting into the market? I think that is the linkage between the hospital with the community or the health care services in the community. The reason is that most of why the people come to a big hospital is because all the best doctors are very much centralized. It's not only in big hospitals, but also in the best cities. The best doctors in China are living in Beijing, Shanghai, Guangzhou. The second tier, that means our quality of health care is at the second level. And the rural areas, we have a barefoot doctor. So many of the doctors are not very much educated. Like myself? So that means in China, you can say every people is a doctor. If they are very hard to access public health or hospital, they can buy the drugs. They can handle some kind of trouble by himself. So now as a technology company, our mission is we try to use digital technology to connect big hospitals with small community hospitals. We want to convert those kind of knowledge or very, very limited resources to be shared by everybody. So we use the Internet. We share all big data. We use cloud as a platform to connect each individual, each small hospital. We build a group. I gave a name called Coordinate Medicine. So that means not just one single hospital to face-to-face provide a kind of services. It can build a kind of community like a more doctor working together. And for that kind of purpose, just like Dr. Liu mentioned about that, we can like a different kind of condition. It comes to the right place. So right place means right cost. So that is technology can drive those kind of transformation of healthcare system of China. But technology can't solve everything, right? I mean, I think some of the things you've talked about are going to trust. People just don't trust the barefoot doctors like Gordon here. Thirty years ago. So technology in itself doesn't solve trust. I wanted to throw to David here now and to us. So you're a social entrepreneur now in India. You were in the commercial sector before you developed products. I wanted to ask you about the role of the civil society, the role of social entrepreneurs in this space. But particularly, I wanted to ask you about trust. How do you build trust in at the grassroots level? If somebody thinks the only way I think I can be confident I get good quality healthcare is to go to this enormous big hospital that's had millions of dollars put into it. How does somebody trust a local primary care facility? Well, my background is mainly in eye care. And so by providing a good outcome to surgery, principally cataract surgery, and providing that service where free is the lowest price, that's what creates the buzz in the marketplace. So if the farm are working on my land, if his mother gets a good result from cataract surgery, then yes, of course, I'm going to go to Aravind Eye Hospital also. But it has to do with quality, pricing, and access. So I've been working for many years developing both hospitals, primarily eye hospitals, but also technology companies and financing. And so I've helped develop maybe over 300 eye hospitals that have become self-financing and do over a million surgeries per year. By contrast, China only does about a million cataract surgeries a year. At Aravind Eye Hospital in South India, they do about 400,000 surgeries a year through their network in Tamil Nadu, South India, and they have a system where free is the lowest price. 50% pay well above cost, 25% are free, 25% pay two-thirds cost, and yet they're able to have a profit margin of 38%. So we've spread this model to different mentoring, training institutions. They have become living laboratories, which then help other eye care programs develop similarly. One of them is here in China, which I helped develop, the HER Eye system in Liaoning Province, which does between 40,000 and 50,000 cataract surgeries a year. So coupled with that service delivery model, we've focused on bringing down the cost of the products used in eye care. So in 1992, we set up AuraLab to make intraocular lenses and then suture, pharmaceuticals, surgical blades, other ophthalmic equipment. And so we dramatically lowered the cost of the consumables, and at the same time, we started creating training programs in the better surgical technique, going from cataract surgery without intraocular lens where the patient would be given thick cataract glasses, which 50% would lose or break within a year, to the surgically implanted lens restoring good vision. And what happened was that this combination of affordable products, creating training programs, not just surgical but clinical, managerial, outreach, business planning, pricing, we were able to bring about a revolution in India. So AuraLab, when it started in 1992, India was doing something like 800,000 cataract surgeries a year. A lot of other companies came in and started competing with AuraLab, and they actually drove AuraLab's price down from $10 a lens at a time when we started, it was $300 a lens. They drove our price down today to what it is, $2 a lens for the lowest price lens. But in the meantime, India's surgical volume went from 800,092 to over 5 million by the new century, and now it's leveled off at 6 million, very much due to this price competitive market. China, again, by contrast, only does a million surgeries. So when I think about what's to be exported to other countries, especially the United States, it's this idea of price competition. In the United States, there is no price competition, there's no price transparency, and that's why the health system costs so much. Okay, but is that going to work? So you've just talked about business model here, and it's a business model that seems to work for that type of company in an emerging market. I mean, I'm interested in the big company sort of view here. Can you guys do something like that? And how would you feel if these highly entrepreneurial companies from emerging markets came into developed markets with extremely price competitive technologies and product offerings? What's that going to do to the status quo? Well, in the United States, we're in a system that's in the midst of transformation right now. And frankly, I think that kind of innovation is exactly the prescription that the United States needs. One of the lessons I would say that emerging markets really ought to take from the United States experience is that don't replicate it. There's so many flaws in the United U.S. health care system that for emerging markets to look at the developed health care systems is probably a mistake. And so there are probably many more lessons to avoid than there are things to embrace. Now, I would say that because the U.S. health care system is in this period of transformation, we're actually starting to see the kind of innovation that you're talking about. And that's actually very exciting. And when I think about a high performance health care system, I really think about a couple of things. Number one is this sort of shift toward population health management. So instead of just managing the individual patient, you think about how to manage outcomes for an entire population. So that's, I think, a wonderful concept that emerging markets ought to be looking at. The second thing is really around health information technology. The United States, we have $800 billion of waste. I mean, it's an incredible amount. And I think some of the emerging economies, they have an opportunity to eliminate some of that waste. And a big role, a big driver of that is going to be through health information technology that essentially turns data, big data, into knowledge that can be used to drive out excess and inefficiency in the marketplace. And then the third thing I would touch on in terms of thinking about a high performance system is something that we haven't touched on, but I think weighs on all of our countries enormously, which is the rise of chronic disease. You know, 63% of all deaths around the world are due to chronic disease. And we need to open our eyes and think creatively about how does it design systems that address the problem of chronic disease. Because unless we tackle that and we continue to sort of treat patients in an acute setting, we're not treating chronic disease, we're all in for a big surprise. And I think very much that we need to think about how to design systems that are going to work for the people in the future. And it's things like transparency. It's things like having competitiveness at the right levels rather than at the wrong levels. It's about changing incentive systems. It's about dealing with medical professional shortages, which China and many other countries around the world are really grappling with. That's great. Let's see where this goes. Take it where you want to go. I want to comment on your first point. I can't agree more on a transition from what we call disease-based medical care system to a health management system. Because this is a really important key to solve many kinds of problems that healthcare system faces. For example, in China in October 2013, the State Council issued a very important policy call for such a transition from disease-based medical care system to health management system, which would expand the medical care services to two sites. On the one hand, to extend the services to serve not only the patients, but also people who are not sick yet. But we have a lot of things to do to maintain their health status. Also, we can extend the services to the right-hand side to provide services for those people who just finished their surgical treatment. But they don't have to stay in hospital for post-treatment services. But China does not have formal sectors to take over these people. So if we can make this transition from disease-based medical care system to health management system, I think that's going to be a very, very powerful policy transition for both healthcare system and for economic transition. Now, I just want to make one more point to our dollars leader. He mentioned that the worldwide spend too much money out of GDP on healthcare. For example, in the U.S., we spend about 18% of GDP on healthcare. To me, I would not worry too much about how much we spend in total out of GDP on healthcare. What I would worry is what we would spend these money for. So services are different. We really have to prioritize what kind of technology, what kind of services should be included with the first priority. So we would encourage people to use those services that are more cost-effective than others. As long as we hold the cost-effectiveness basis to prioritize medical services including technology drugs, I think I would not worry how much we spend. Even if we spend 30% of GDP on health, that's fine with me. But if we waste a lot of money on those unnecessary technologies, even if we spend less than 10%, I would worry much about it. Just to take up on this point, what you said, I think this is an issue I think we have repeatedly re-emphasized in this forum over the last two days, is I think health cannot be seen as an entity that just belongs to the confines of the Ministry of Health itself, but to be looked at as a broader perspective of the entire government to ensure the ecosystem of health. I mean, you talk about the ecosystem of health. It involves, of course, anything from environment to sanitation, to city planning, to laws and legislations on nutrition and food down to the provision of facilities. So I think that will take us to what you said just now, to prevent. And I think to prevent diseases, that's where our investment is to come, is to ensure that the proper ecosystem is provided so that it actually generates community based on principles of health in which disease is actually put far away. Certainly in the context of chronic disease, you need an ecosystem approach, because it's not just killing a bug, but it's a much more complex issue. Any other contributions on this line of thought? I just want to pick up on what Dr. Lucid. You know, we think about the continuum of care. And today we have a really fragmented system. I think that's more the rule than the exception around the globe. We tend to think of health care in very particular silos, right? So we think of physical health, mental health, behavioral health, emotional. You know, we think of things in silos. And I think, you know, as we look to the future, we need to very aggressively just destroy those silos and think about the continuum of care, everything from staying healthy and preventing disease to dealing with acute care when you do get sick, all the way to sort of end-of-life care. We need to think of it very holistically. Okay, so who's we, right? So everybody with self-interested actors, different people with different incentives, we talked about prevention. So if we have a preventative system, big-drunk companies are going to go out of business. So who drives this agenda? Well, one stakeholder that we haven't mentioned yet but I think plays an absolutely vital role in the high-performance health system is the consumer himself or herself. And that's where sort of technology can really take hold. You know, if you think about the rise of technology, more people have access to mobile phones than they have access to toilets today. And that's just a, you know, that's a shocking example, but it tells you that the future may lie in sort of personalized technology in making it easy for patients and consumers to get price information, to get quality information about either facilities or their doctors and make it very easy for them to keep themselves healthy so they can avoid going into the hospital for the acute care. So I think the consumer or the patient, the end-user plays an absolutely vital role in this. We really have to understand the statistical distribution of patient population and healthy population are not independent. They are correlated highly. In other words, if we can treat the patients through medical care system, in the meantime, we can also serve healthy population with health services so our customers are not only patients, but the entire population. We can keep the patient population as small as possible, as delayed as possible. Otherwise, you know, your patient population may become larger and larger, sooner and sooner. These two populations are not independent distributed. Most governments or insurance schemes don't pay for prevention. I mean, it's a really hard thing to get covered. My sense is, you know, if you look at a country's disease profile, it's the 80-20 rule. You know, where's 20% of the disease concentration? What 20% of diseases affect 80% of the population? A lot of it's cardiovascular, or like in my case, you know, in eye care, it's cataract and now increasingly becoming diabetic retinopathy or macular degeneration. And I think that the approach that I take, and I work in many different countries, including the United States, is to look at vertical integration. Like, if you take a procedure like a pacemaker for arrhythmias, I worked with Medtronic and India to look at how you broaden the reach to lower-income Indians that have arrhythmias in need of pacemakers. You have to create a whole community surveillance system to pick up the arrhythmias before they show up half-dead at the hospital. You have to figure out how you bring down the price of the pacemaker, the price of the procedure. We looked at how we do retail financing to make it affordable. And what I got out of that whole experience working with... It's possible to lower the cost. The real value of competition is creating players that force the industry to lower their price points. Medical device companies, pharmaceutical companies, doctors will not lower their price point unless you're competing with them. I have an example. Oralab beat out a major company, I won't mention its name, on a suture contract. It's a company that makes 90% of the world's suture. They sued us, they lost, they appealed, they won. And then we took it to the Indian Supreme Court and ultimately won that case. But in the meantime, they lowered their price point from $240 for a box of suture to $23 in order to beat us out on the next bid. So that's the power of competition. When I look at just about any medical device, when you demystify cost and then deconstruct supply chains and take out all the non-value-added margin and add it up, it's better than cocaine, it's better than heroin margins, it's better than marijuana margins. So this is a sort of demystification that somebody has to do and it's very difficult to get governments to get into it. I tried to get U.S. state governments looking at Medicaid paying out for durable medical equipment and supplies. I had their data, I analyzed it and I said, you're paying 10 times what it would cost in a competitive market. But they didn't want to upset the apple cart of special interest. We're talking about the cost, maybe the cost from very expensive check and medical treatment. But I think the people from a customer point, they don't care about payment, they care about our car, the quality of services. Now if we look at what is the reason people waste the money, the first point is the doctor like an artist, each of them is individual. So hospital to hospital, doctor to doctor, everything is isolate. They don't share in our knowledge, they don't share in our data. So many of our waste is because people recheck and they come to one hospital to another hospital. The people have just like you mentioned about this, not continual data to like doctor have a clear picture to say what is their condition from first day to today. They come to different hospital, the doctor ask the same kind of questions in China, take a very long line, given 40 minutes ask 20 minutes questions. And then second day you're coming repeat again. So because not any data can recording the, you know, that the conditions, the situation and changing everything. So I think that based on that point, we solve that problem, the firstly we must be sharing that data. That is a big challenge. Secondly, we must build for every people, everybody have their personal health care record. That should be integrated with a hospital. It's like a doctor can use daily data or lifestyle data or a lot of questions from their home, not just in the moment come to a hospital.  But today we can say it's a big challenge, it's driven by technology. The firstly we really, really can go out more and more personal health care information. Yesterday you say that Apple announced new technology about phone, they embedded a lot of lifestyle apps to the phone.  The secondly, Internet gives more and more opportunity like we call, coordinate the medicine. So that means diagnostic is not from an individual doctor. So if you really have problem, you can like many hundred doctor, you can, you can give those kind of data to the doctor in Beijing, maybe US. So maybe, you know, we call integrated medicine. Before you have a one-med problem, you'll find some doctors very much focus on each of the areas. But when you solve that problem, you got another problem. But now Internet make that possible. Let's go to that area if there's no other interventions. Just responding to what Liu said, I think it is true that we are transiting from a period in which medical data was considered a very private document where the medical doctor was held ownership to it to a situation where technology will probably dictate that it becomes the ownership of the individual. Because previously we never had the technology. And it's very interesting yesterday in the ideas lab under which you're sponsored by the National University of Singapore where we actually discussed a concept called individual patient's health concierge. And every individual patient will have his own data record of health including the risk factors, concomitant of the genetic makeup and the behavioral element of the individual from birth to death. And how at any point you actually can intervene and actually suggest what are the risk factors which are going to have a different stage and how to modify it. So I think it is not an impossibility as what we discussed yesterday. It was not an impossibility. Even we discussed the modalities which are to be put to cause the behavioral changes which reduce the risk factor. I think these are things which will come by virtue of technology. I think I foresee a day where medical profession as such has to recognize that records are no more sacred to them but it's something which will own to the patient. And the patient will have a right to contain it and that will probably dictate the changes which is required upon them to make the changes. Very good. Let's some. I propose we open it up a little bit now if people are happy. So we're taking questions from the floor. If you have a question please raise your hand and I think the helpers will put a mic in your hand over here and then here. Let's start with those two. Okay. Norbert Hildenschmidt. Yeah, we're off. Let's work. Norbert Hildenschmidt from Bain. I have a little bit of a provocative question actually because you haven't touched on it. And the key question would be if I'm a consumer and again I'm not a patient, would I trust the doctor that the doctor really has a good understanding of what health means to me? Would I really believe, you know, that the medical profession doesn't need to change as well and would I actually go to a hospital which still has a little bit of a stigma of disease? So I think this is one of the key barriers that I would at least see in terms of transitioning from paradigm shift from disease to health. What is your view on this? Why don't I start and ask others to join in. So I think quality has, at least in the context of the United States, quality has been largely shielded from the consumer. So it's very difficult to know hospital outcomes, doctor quality, you know, and at the same time what you see happening is variation from clinical guidelines. And I think big data can play a key role in starting to eliminate that because as you have these terabytes of data about clinical pathways, you can start to create best practices and I think consumers ought to be holding their providers or their healthcare professionals accountable to maintaining and adhering to those clinical best practices or guidelines. But I think it really begins with this question of transparency where if you can introduce transparency into the system, suddenly people start paying attention because today in the United States it's very difficult to have any idea about the quality of the institution or the individual practitioner. I think the trust between doctors and a general population, not necessarily a patient, must be based on mutual understanding of modern medicine. See what is the role of modern medicine, how much medicine can really do for the health, how much medicine cannot do for our health. In a medical literature it is very well known that medical technology, medical intervention itself can only contribute at most somewhere 10 to 15 percent of health determination. Individual behavior contributes at least 50 or 60 percent. So as long as we both understand that knowledge, then the trust can be built. As long as we the healthcare sector, the government sector can transform, promote that information to a general population, I think trust has a basis to be developed. Any other tight groups? There was a question back here. My question is for David Green, but I appreciate the inputs from the others. I'm overwhelmed by the successes of Oralab and the Aravind model and the deconstruction of the pricing chain. I'm wondering if you could speculate on almost your wildest imagination. What would be other targets of the top two or three enormously inefficient but very important devices or practices where that kind of treatment could be impactful? Pacemakers, stents, and knees and hips, hip joints. If you look at any medical device realm, there's anywhere from two to five players they have bought up other companies and there's unspoken price fixing and that's how they maintain very high pricing. That's where competition is needed. I would say those are the main ones. I have another company that's making an affordable hearing aid. We figured out how to demedicalize the fitting of hearing aids. We have an app on a smartphone or a computer that you can download and wirelessly test your hearing in just a few minutes and then it automatically programs the device and we're selling this and I'm actually wearing them for like $80 and the technology is on par with hearing aids that cost between $2,000 and $3,000 a piece. Again, it's because of unspoken price fixing there's only five players serving the 95% of the market and they keep prices high artificially. Hearing is a really important arena to address from a public health point of view. Frank Lynn at Hopkins shows that hearing loss is directly related to cognitive decline. As your decibels go down so does your cognition and so this is a major public health problem. There's only 7 million hearing aids sold each year and yet 600 million people could benefit from a hearing aid that's 1.2 billion years since most people have bilateral hearing loss. So these are just... If you look at any medical device and I think it's probably the same with pharmaceuticals and you see that it really doesn't cost that much to make then you can make it affordably. Yeah, I would have a question David. I would like to play a David's Attocate on this one for a little while because you know what the argument is, you can do so at your own risk. And we'll continue the dialogue afterwards. Now it's just to take also the perspective of some of the medical players that are going to tell you well the reason why the cost of healthcare system in the US is 18% is because the healthcare system in the US has been funding innovation and where Indian players can develop a stand for less than 50 bucks today it's because for many years they've invested in R&D and they made those losses in the innovation and the cost of bringing a new drug to market is well in excess of 50 billion. If you look at Medtronic pacemakers it's 20 year old technology. I know, the IP has gone. There's only three players and by my estimation as your forensic cost accountant here it doesn't cost them more than $80 to make a pacemaker but yet I think the lowest price is $2,000. I agree. My point is because you were mentioning 38% gross margin I think with 38% gross margin you are not going to fund innovation in the long run. I've developed many products on a very low budget that have novel IP and that don't have the same R&D cost that the industry claims is derigor so I think a lot of it is hyper inflated and hyped. I think that there was some major review done on how much does it cost to really develop a pharmaceutical the industry says it's a billion dollars when in fact it's really about 250 million and most of those drugs are gleaned from NIH supported research where industry buys it for very little and then so the US taxpayer gets to pay twice both to develop the drug and then to purchase it. There's probably a whole lot of low cost innovation that can happen along the drug discovery like clinical trials for instance and using mobile technology to lower the cost of clinical trials there's probably a whole lot of innovation that can lower the cost of development as well. So there's a question here and then here and then here. Okay. Pay Amazon from Sweden a country well known for its welfare system I think we spent about 10% of GDP on healthcare. We've gone through a very dramatic change during the last 30 years in moving from a system where a new one had the right to choose a doctor or hospital to a system where you have personal choice within the framework of a system which is paid for by taxes probably 95% is taxes. Now there is an interesting debate what happens when people like to spend more on healthcare do something extra that is not allowed in Sweden basically. So my question to you is what trends do you see long term in the development in various parts of the world are we moving to a system where more private money will go into healthcare or are we preserving universal healthcare system where it's being paid for by taxpayers. What trends do you see? Well I can share one research evidence with you and two economists in the United States conducted very solid research for the prediction of healthcare in the United States as a percentage of GDP by 2050. Now guess what? You think 18% of GDP on healthcare is too much today and these two economists named Robert Hall and Charles Jones both at Stanford showed that by 2050 at least 30% of GDP will be spent optimally on population health.  So the diminishing return to the use of almost everything except health was our age, our life expectancy reached 90. Do we reduce our effort to make things possible to survive for one more year? We may not reduce our efforts. As a result the whole world will spend more and more on health. Now I think to ask you a question then who should pay private sector individuals or government according to our research, the research we conducted we find if government spent public finance for health care that would create more job positions create more higher employment in the macroeconomy so if that's something we care about so we may want to promote more public finance but I want to just make one last point since we're talking about the course of care everybody saying well we spend too much I think we have to think about the value of investment in health first of all health care is part of the economy it's a zero sum game, it's an economy let's put that aside but in addition we find that if we spend every 10% in health care market in the long run based on 21 APEC country data for the past 40 years we find for every 10% increase in health care per capita that would lead to about 5% in GDP per capita that means as long as health care does not account for more than 50% of GDP we gain in economic performance so if we really want to know the relationship between health and economy and you said you participated in that session earlier I wish I was in that session I can share that data with them I just report that data to the APEC meeting two weeks ago in other words for every 10% increase in health care spending per capita that would lead to about 5% in GDP per capita so as long as health care does not account for more than 50% of GDP we gain economically that's a pretty amazing algorithm you can create an app around that one any other comments to that question? one quick comment on this in both the United States and in China the consumer pays quite a bit of the health care cost and one of the interesting things we're seeing a trend that we're seeing in the United States where the employer also pays a substantial portion of health care costs is the employers are thinking about sort of defined contributions so let's take colonoscopies for example in New York City where the price variation is unbelievable it is lowest $740 at the low end for a colonoscopy all the way up to $8,500 for a routine and arguably commoditized service where there is no real variation in quality so what explains that difference? and so a growing number of employers are saying well let's look at the market and figure out an average and hand those dollars over to their employee and say if you want to have a colonoscopy that costs over $8,000 we'll only reimburse you at this level and you eat the rest and if you want to do it for less than the average then you get to keep some of the savings and so we're seeing some interesting things around defined contributions I think for most of the emerging country you ask the question who pays but like a country like China we ask pay to who so the reason is there's very limited kind of services for healthcare of course we know the government pays something like a hospital but you really want to use your personal money to buy it's very hard to buy so I think that's another kind of the thing I fully agree with Dr. Liu's comments is we must be leveraging the government funding and private funding to work together to solve healthcare problems it's coming from the government I think the government has got multiple responsibilities and health is not the only area in which the government funding has to be given too so I think it's a difficult issue I mean how high, like the Swedish example the Malaysian example is also the public service is paid through general taxation how high are we going to increase general taxes to meet up to the increasing needs and what is that, the impact of that is going to be the consumption ability of the population at large so these are balances which we have to make I think eventually what governments have probably to decide is what are the essential components of the healthcare which should be provided by the state and which are the components which probably has to be met by the individual and drawing this line will be an inevitable line by virtue of the economics of that time and what is public and what is private what are public goods and what are private goods in that equation I think we had a comment here a question here following on the comment that we have to take care of the patients but also of the non-patients the population that doesn't use healthcare what should you take on the role of insurance or particularly private insurance or fund pooling in controlling healthcare costs around the world I can only speak for the Chinese situation according to the official documentation issued by Chinese state council when we start offering health services including medical care but also other non-medical care services like for health maintenance, health management the state council documentation says we should encourage or promote the role of commercial insurance programs first for some years and then perhaps the state-led insurance programs will kick in to pay more and more later so the current policy design is to have private insurance to play a greater role in the beginning that's the situation in China based on the official documentation to just look at another perspective whether private insurance in itself can assist in the element of prevention as it does for the management of disease I think there are very few insurance companies which actually fund preventive programs as part of the insurance mechanism a lot of them don't even put screening normal screening into the scheme but I think one which has been coming off is dis-incentives given to high-risk behavior in terms of premium that might be one component which might actually promote we are trying to trigger the behavioral change towards health whether that can be one component which can be contributory as an insurance representative I can assure you that we think long and hard about the role of prevention our own employees we take metabolic syndrome tests and get refunds on our premiums if we pass the metabolic syndrome test and we roll out disease management programs across the country and increasingly across the world and also investing heavily in health information technology because we see the promise both in eliminating waste and encouraging this transformation from a system that's primarily based on treatment of disease to one that can facilitate and promote wellness and so we very much as we think about our future role around the world and certainly in the United States we're transforming ourselves to have that very orientation around wellness very good I think we have time for one more question before we wrap up Hi, my name is Kumar we just heard about the conversation on continuum of health and breaking silos talked about the monopolies and how people are charging what they want and of course the investments being made behind those research and that's the reason why it's so expensive and we also heard about the fact that the consumer at the end of the day can make choices about what they have to do but the information is not always available to consumers what choices they can make what is generic what is and of course providers and of course hospitals and doctors always want to make sure patients come to hospital otherwise how will they make money but the role of government the question therefore is probably to and I don't know how what is a policy or what is this thinking of governments today to give more information out there all the information is already there also may be not available to a patient or a customer when they want it to know specifically something about health how to prevent something from happening so what is the role that governments and agencies who support you know not for profit others coming together to do something really to prevent and manage wellness instead of going to hospitals and also informing people about where you can and they're paying more money for colonoscopy as opposed to you can pay less why don't we put all the information out there for people to make choices and become aware of what is be done today care of themselves much more than what's being done today and what's the governments doing about it I think in a situation where there is reimbursement to such payment from the state there are systems in which this information is available because at the end of the day the state reimburses the cost of going to whichever doctor which is there but unfortunately in our system we don't have these reimbursement so those who come into the public service are taken completely care by the public service and the private sector is a market driven entity where the individuals make the choice like in Malaysia I have started a triggering of the creation of very strong consumer health groups while you have consumer groups which take care of products for example or food prices or other things there are very few active consumer health groups which actually fight for optimal market of health care like what we are saying so as a result of which the health market has been completely unregulated both by the policy makers and also by the consumers themselves by virtue of pressure so I think there is a need for consumers to organize themselves into pressure groups which will actually cause this change and they can create this empowerment within society to make sure people can make the right choices so the government could be the trigger force to create such a fire and that will be the strongest entity I think the government can really make a first call to create the environment conditions government can make a first call to issue policies to encourage market to respond but I think the central driving force for such a healthy product for the health population have to come from market forces so everyone over here if you are interested in health product market now you are most welcome to China to do the business so don't just focus on medical care but health products that's what most needed in China which has a huge business very good other than it was a terrific place to finish the government, the market thank you all very very much for your contributions great panel, I've certainly learnt a lot and thank you to the audience as well for all of your contributions thank you


Can I remind members of the Covid-related measures that are in place and that face covering should be worn when moving around the chamber and across the Holyrood campus? The final item of business is a member's business debate on motion 2784 in the name of Evelyn Tweed on response to Storm Arwyn in Stirling and future resilience planning. This debate will be concluded without any questions being put and I would ask those members who wish to speak in the debate to please press the request to speak buttons now and I call on Evelyn Tweed to open the debate up to 7 minutes please on this Tweed. Thank you, Deputy Presiding Officer. I would firstly like to declare my interest as an elected member of Stirling Council. Storm Arwyn was one of the worst recent storms in this country. Winds in parts of my constituency reached 96 miles per hour and it was much more damaging than the beasts from the east. My office and I were inundated with requests for help and assistance, ranging from those with critical medical needs to others concerned about loved ones who were unreachable. Scottish and Southern electricity networks, SSEN, estimate that 135,000 homes lost power, a quarter waiting 48 hours or more before being reconnected. Some homes in rural Stirling were only reconnected after seven days while others across Scotland waited longer. This length of time of off supply is unacceptable and I thank everyone who is here today to try and improve this response to such incidents. SSEN is part of Scottish and Southern energy SSE, a multinational energy company and member of the FTSE 100. We should remember that SSE is the product of a merger of two formerly publicly-owned energy companies, both privatised in the 90s by the ideologically driven deregulation of the energy market. The north of Scotland hydroelectric board was formed in 1943 to provide electricity to the Highlands. Scores of hydro dams and power stations were built across beautiful but incredibly challenging terrain to dramatically improve lives in Scotland. In southern England, the southern electricity board had been created in 1948. The investment was made by the public sector because no private business could see profit in providing power to those areas. Profits of the privatised utility companies that should have gone in to improving services have since been diverted into generating dividends for shareholders and eye-watering director salaries. SSE operating profits were up 7 per cent last year to wait for it £1.5 billion. The chief executive of SSE earns a basic salary, excuse me, approaching £1 million. With bonuses and other payments, his total remuneration package was over £3 million. Other directors earned well over £1.5 million each. Perhaps if more of the annual £1.5 billion profits were diverted into creating better infrastructure, employing more local staff and having better resourced and tested resilience plans, that debate would not be required tonight. I carried out a survey of residents affected by the storm in my area. The top issues raised with SSEN were that people could not get through to the SSEN hotline and, when they did, the information that they were given was incorrect. SSEN did not publicise quickly enough how claims could be made for compensation for the cost of food and alternative accommodation when consumers were cut off for days on end. SSEN's vulnerable person list relied on phone connections, which were knocked out by the storm and a lack of power. Other information was given via social media and text message, which was again useless when people had no internet or mobile signal. One constituent wrote that communication from SSEN was at best misleading and inaccurate and at worst non-existent. My 97-year-old neighbour was totally and utterly forgotten about. We looked after her the best way we could, but if we hadn't, she would have left in the cold alone without food and I doubt would have survived. My survey found a lack of confidence in the resilience planning of both SSEN and the local authority. For example, a manager of a care home with 18 vulnerable adults wrote to say that they had zero contact from any local authorities or the energy company. We had to move them all to a hotel that was extremely difficult. Thankfully, our staff worked around the clock, but they were very disappointed that no-one even contacted us to see if we were okay. However, I must be very clear here that there was very positive feedback for the staff of SSEN and the council who worked hard in very difficult circumstances. I congratulate Evelyn Tweed on the debate. Can we pay tribute to the front-line workers of Stirling council? I am a resident as she is of Stirling council. We should pay tribute to them, but at the same time, I highlight the fact that the energy companies were incredibly poor at helping to pinpoint households that had hired the power cuts. Therefore, the help that the local authority wanted to offer was not able to be delivered in an expeditious way. Mr Kerr, I had made that point and I am going to say that at the end, but thanks for your intervention. I welcomed the 15 recommendations of the Storm Arwen review that was published last week for the Scottish Government and its partners. It is great to see that the vital role of volunteers and community groups was highlighted and the intention to bring those groups into the heart of local resilience planning. I want to thank the countless volunteers across Stirling and Scotland for their dedication and selfless efforts to directly help others when they needed it most. I also want to thank the efforts of staff from Stirling council, the emergency services, Cullen mountain rescue team, Trossac cert and rescue, the international rescue core, the British Red Cross as well as local businesses across Stirling. I had actually said it before. Sorry that I did not do that through the chair. I also found the response of Scottish Water to be worthy of praise and perhaps a lesson for others. Peter Farer, its chief operating officer, said at the recent Westminster Scottish affairs committee session on Storm Arwen, power supplies were lost to Scottish Water assets that supplied about 1.5 million customers. Fortunately, we had proactively turned on our emergency generators prior to the event happening, which protected the majority of our customers. It is perhaps no coincidence here that Scottish Water remains in public ownership. Presiding Officer, I am concerned that it is expected that the main burden of responding to a failure of a privatised industry should fall on volunteers and cash-strapped local authorities. I will be asking the Scottish Government to contact the UK Government to ensure that Stirling Council and other local authorities across Scotland are directly financially compensated for SSEN for having to fill the gaps in its woeful response. Claire Baker, who is running remotely, has a prior engagement, but was very keen to participate in the debate, which I am quite happy with. I welcome the opportunity to contribute to the debate this afternoon on Storm Arwen and future resilience planning. I thank Evelyn Tweed for bringing the debate to the chamber. We cannot do so without mentioning the impacts of Storm Relic and Corry, which are still being felt in parts of the country. Thousands of homes are again left without power, some of whom are still to be reconnected, and schools remain closed and rural businesses are just emerging from the pandemic have already been hit again. There has also been a tragic loss of life in this weekend through the storms. My thoughts are with the families who have been affected. As in the response to storm arwen, the hard work and support provided by communities and organisations should be praised, and the efforts to reconnect homes and businesses as quickly as possible is welcomed. The weekend's events only underline the importance of resilience planning and make sure that our communities are prepared to deal with storms and other emergencies. The commitment from the Scottish Government to review the preparations for and respond to storm arwen was welcome. We know the disruption that caused to infrastructure, power supply, education, travel, care services and the environment, as well as sadly the loss of life of a driver in Aberdeenshire. Amid the talk of arwen being an exceptional storm, we need to recognise that wither events like this and like Storm Corry and Malik are part of our lives in the changing environment that we continue to inhabit and impact on. We must learn from exceptional storms as we do from the pandemic and make sure that we are prepared for the next time. We should also remember that it was not unforeseen. Storm arwen was forecast, but communities were not adequately equipped to respond. Part of our response has to be to address that and to improve on it. Resilience arrangements must always be evolving and improving, and communities must be kept up-to-date with them. However, extreme weather is forecast, we need to maximise the communication routes available before it hits. We need to make sure that people know where to go for help and who they can contact. When we talk about storms in a community, we know that that does not just mean power lines or roads but households, families and individuals. After the statement on storm arwen, I asked the cabinet secretary about the response in Starline. I had received reports of people being left in freezing temperatures with no rest centres being open or no access to generators. For some people, there was a swift local response with food and information and support available, but others said that the sport was inadequate and that they felt abandoned. The recommendation in the Government's review of storm arwen to prioritise assistance to the vulnerable is welcome, but we cannot always predict who will be in need. The review acknowledges the important point that storm damage can make anyone vulnerable. Being without power, heat or food, being cut off by geography or from communication, such circumstances would be difficult for most people to deal with, and we need to find ways to work to quickly assess who needs support and how to get it to them. Communication is a key aspect of any response, but without power, options are pretty quickly limited. The review recommends that subgroups of resilience partnerships would review and test plans and include more traditional means of communicating. We need to see clear information provided in advance when possible, and local networks can be part of that. We should look at how to utilise existing community groups as part of our response. Through the pandemic, we have seen a strong community response and support networks develop. Those are the kind of local networks that we should be able to activate in response to events such as storm arwen. I recognise the duty on statutory authorities in responding to emergencies, and I recognise the comments that Evelyn Tweet has made about the responsibility of the energy companies. However, a key recommendation in the review is to improve the integration of community and voluntary sectors into resilience planning. Local groups are often best placed to respond quickly, and they should be resourced and supported to do so as part of a co-ordinated process. It is crucial that the review is now put into action, and as we have seen this weekend, it is a matter that needs urgent attention. I now call Julie Martin to be followed by Dean Lockhart. Thank you to Evelyn Tweet for the debate of great importance to the people I represent in Aberdeenshire. Last week, the Scottish Government published a resilience review into House that the storm impacts managed between themselves, local authorities and energy providers. This is a welcome report. I was first to call for it in this chamber, probably straight after the storm arwen, which devastated my constituency to be told. The impact of the storm is still felt today. As I stand in the chamber, my constituency has been severely impacted by not one but two storms over the weekend. Some homes still remain without power. Over this week, families, businesses and communities have been left without power—thousands of them and phone signals—so they cannot even communicate. There has been still a bit confusing messaging about when they can expect their power to return from SSEN. It is going to be of the utmost importance that, when the future of the SSEN makes clear what the suitability of the current infrastructure is and how we can ensure better resilience next winter and beyond, not just of the communities in response, but we need the infrastructure to be much more robust to withstand the extreme weather that we get, particularly in my part of the country. I would like to associate myself with Evelyn Tweed's points about the SSEN's responsibility to invest in that infrastructure, and particularly the response to vulnerable customers. They have what is called a priority list, which seems to me, from the contacts that I have been getting from my constituents, to be a bit not much more than token, because some of my constituents—some of them are with family members on medical equipment that they need to keep going—were struggling to get that additional help. In the Storm Arwin resilience review, there were a few recommendations that stuck out for me. The first was on how information is relayed to the public. For so many of us in the digital age, we use our mobile phones to access basic information. Of course, there were so many mobile services down, and there was no way for people to access information. There was a resilience effort out there, and community groups and volunteers out there providing services and help for people, but people did not know about it. I was pleased that there was a recommendation about using local radio and local radio working more with the local authority to get that information out there. Most households still have battery-operated radio somewhere, and if they thought that was going to be the conduit for information in the future, then, if they did not have one already, they might go out and get one and have it there for emergencies. I want to talk about the contribution and response of the community during Storm Arwin and this weekend. I would like to highlight some of the community groups and organisations in Aberdeenshire East that went above and beyond when the storms impacted us. First, I would like to put on record my thanks to Rothi Norman Community Association, who provided refuge for residents. The community of Colliston, a windy place at the best of times, also came together to support their neighbours. Following the impact of Storm Arwin, the community is now looking to form its own resilience group, so that it can continue to help each other locally in their time of need. In Potterton, Jenny Nicol and Shona Jenkins took it upon themselves to set up a community hub, and they worked with the council and volunteers to serve hot soup and food, and both of them did not have power in their own homes. Many of the volunteers across Aberdeenshire East were without power, but still went out and knocked on doors for our most vulnerable people to see if they were okay. That is just a glimpse into my constituency. I want to thank every volunteer. I cannot name them all today, but the schools, the community centres, the councillors, the Red Cross and all the community groups that provide support. I am proud of them. I thank them for everything that they have done, but I will also finish by thanking my constituency team, some of them who did not have power, both last weekend and in Storm Arwin, who still managed to get help to my constituents. I also thank Evelyn Tweed for bringing this important debate to the chamber. The frosty and impact of Storm Arwin isolated many communities across the Stirling region and plunged many people into a prolonged period without power, water or any means of communication. Many rural communities across the northern and western areas of the Stirling council region, including Finchry, Doon and Killan, bore the full brunt of the storm. At times like these, the strength of our communities really shines through. There were countless individual selfless acts across communities to assist those who are most in need. Volunteer organisations such as Killan Mountain Rescue and Trossic Search and Rescue responded immediately, as did many local businesses. The staff of SSEN, Scottish Water, Scottish Fire and Rescue Service, Police Scotland all responded immediately to those in need, all backed up by assistance from Stirling council, international rescue corps and British Red Cross. There were many instances where, without this urgent assistance, consequences for many could have been incredibly serious. The experiences of these local communities during storm Arwin clearly demonstrate that the support that is offered by councils and by the Scottish Government can be improved. Therefore, I welcome the review carried out by the Scottish Government into the response to the response of Storm Arwin. While it contains some useful initial recommendations, I think that there is still a great deal more work that needs to be done. I have also supported calls for Stirling council to seek feedback from local communities and I am pleased that the survey and the feedback mechanism is now available. Because feedback and suggested improvements coming from those directly affected by the storm will be invaluable and should really be the basis for building on those initial recommendations. From the information that I have received from constituents, I would highlight the following key additional points that should be considered by local authorities and by the Scottish Government. First of all, when communications are down, the only way to assess a situation is immediate presence on the ground. Decision making must be streamlined and resources prioritised. For example, mobile generators are being made available and installed at the most critical facilities immediately. That was not always the case during storm Arwin. In many cases, the traditional landline remains the only working means of communication during a power cut, as Gillian Martin and others have highlighted. Many in rural locations keep an old-style telephone for that purpose. However, landlines are due to be moved to internet-based connections by 2025, so thought therefore needs to be given as to how we are going to retain fallback communication capacity that has proved so important on occasions and during storms like this, because the mobile networks were out for a significant amount of time during storm Arwin and other recent storms. As for the Government emergency response, there needs to be a change in how local and central Government use the capacity within our local communities. At present, the approach is too cautious. There were many people in communities across Stirling with the necessary equipment to help with the immediate response during storm Arwin. A number of local community members helped to clear hundreds of trees, and the efforts made a significant difference as to how quickly crucial roads could be used again. I agree with the member that the SSEN was at fault here. I think that there were a number of issues in response to SSEN's overall approach to the storm, and I agree with many of the issues that the member raised with regard to the response. I think that it was unhelpful that the SSEN gave unhelpfully short periods of time or forecast for when power was going to come back on that were not met. It generated expectations among the community that were unrealistic. That compounded the problems, so I think that more accurate forecasting, fully recognising the challenging circumstances, more accurate forecasting would be very helpful. I know that I am up against the clock. We need a more positive approach that recognises how local communities with the appropriate equipment and experience can bring a huge amount of capacity at a time when official services are unable to cope. The Scottish Government should consider that Forestry and Land Scotland should be included as an official responder organisation. Its extensive forest road network is a vital asset and could be used in supporting many communities that are cut off when their public road is blocked. I will wind up on the point that other members have made. Our climate is changing, there will be further challenges such as storm Arwyn. I think that the best thing that we can do is work together across the UK, Scottish and local government to ensure that the different areas of responsibility are considered together and the necessary changes are made. I thank Evelyn Tweed for securing this motion for debate. Storm Arwyn has been catastrophic for us in the north-east and has caused widespread extensive damage, so much so that we may never see the return of parts of landscape in my constituency in my lifetime and possibly that of my children's again. The Deputy First Minister stated on his welcome visit to the north-east in the wake of storm Arwyn that this was indeed an extraordinary scale of a storm. It had affected most of Scotland and, acutely, my constituency of Bampshire and Bucking Coast. The level of damage that was inflicted on the power network was colossal. Indeed, the level of casework and contact, much like my colleagues with my office throughout the crisis, illustrated that people had suffered enormous hardship, including one person from my constituency that cost their lives. For some, the level of suffering that they experienced was unique and devastating. We had to down-chol, so to speak, in the office on everything that we were working on and, straight away, went into crisis centre mode, acting as a conduit between Aberdeenshire and Murray Council. Resilience partnerships, third sector community groups, welfare groups and constituents arranging welfare checks, water drops and more to liaise and assist so much as possible. The good that can come from social media was evident for a change, but we also needed those boots on the ground to spread the word. Also, being in continuous online and telephone communication with the power company and Scottish Water. I have produced several motions in this Parliament recognising individual organisations and businesses for their response to help others in their community during and in the days following Storm Arwyn and Storm Barra. Those individuals, businesses and community organisations opened their doors to the public, provided hot food and water, charging points, places to wash clothes and, in some cases, even a place to sleep. The local humanitarian effort was awe-inspiring and reminiscent of those first days of the pandemic when the true meaning of neighbour was evident. It represents the very best of humanity at a time when it was needed and in the right places. Each and every one of them are heroes in my mind. From the military to the volunteers, as well as the brave engineers and staff of the utility companies, many of whom have placed their own lives in jeopardy. This is an experience that I shall never forget and I know that it applies to all of us while witnessing how so many went that extra mile. Each deserving a medal and praise for their unselfish hard work and bravery, it should give us all hope and desire to learn lessons and act upon them. On that point conversely, the anger and frustration of constituents, the seemingly underinvestment in our energy infrastructure in private hands, the drip-drip messages of delayed deadlines of reinstated power, creating hope and then dismay amongst many in the dark and cold, including the elderly and vulnerable, is a matter of on-going concern and is amongst a long list of issues that must be addressed. Whilst we can be eternally grateful for the effective local resilience support on the ground, we must take seriously our reflection on the issues that have become exposed to build all that into our planning for the future. We have got to make sure that the resilience arrangements that we put in place to support the people when they go off supply are effective and adequate. I have grave concerns that lessons have not been learned in some regards, not least when SSC changed their policy for support sometime between Storm Irwin at Barra and the latest storm to hit my constituency hard, Storm Malik and Corrie. They reduced available compensations. We must hold those with the responsibility to account, but I do hope that we can do that constructively. I do note that, following Storm Irwin, SSC has committed an additional £500,000 to the Resilient Communities Fund to help communities to become more resilient in the face of storms, severe weather and prolonged power interruptions. I look forward to having discussions on exactly how that will be implemented and when. I hope that this is just a start and the rest will be proportional to profit. We will face more extreme weather due to our climate emergency and what we do now will lay foundations for the future. We must ensure that we can indeed weather the storms together. Due to the number of members who wish to speak in this debate, I am minded to accept a motion without notice under rule 8.14.3 to extend the debate by up to 30 minutes. I now invite Evelyn Tweed to move a motion without notice. Could Ms Tweed move the motion, please? Thank you, Ms Tweed. The question is that the debate be extended by up to 30 minutes. Are we all agreed? That is agreed. I now call Mark Ruskell to be followed by Colin Smith up to four minutes, please, Mr Ruskell. I thank Evelyn Tweed for bringing forward this debate. I enjoyed her speech, I enjoyed her deconstruction of electricity market deregulation as well and what some of the impacts have been in terms of investment. I think that one of the most surprising aspects of Storm Irwin was the really arbitrary nature in the way that the storm hit Scotland. While there were parts of the sterling area that were less affected, we saw pockets of destruction, particularly the area between Dune and Calender, where there was a huge amount of devastation. I remember the morning after the storm going out, looking at the wood of Dune, and it did not look like a storm had hit it, it looked like a twister had hit it. It was just a small area, but absolutely devastated. Many communities living alongside the River Teeth were affected and had power outages for many days. I think that we saw that environmental destruction across Scotland. I learned recently that there are 800 seal pups that were killed in the storm at St Abbs in East Lothian. There was a forestry area, an area of forestry woodland size of Dundee that was flattened through Storm Irwin. It is welcome that the Scottish Government has conducted an early review into lessons learned. I look forward to progress being reported against the recommendations to this Parliament in June. I also welcome some of the initiatives to engage with the experiences of people who are affected by the storm, particularly Stirling Council's use of their Engage website. I was interested to hear of Evelyn Tweed's own work in her constituents. You are reaching out to constituents to understand how things could be done better. I would like to focus on a couple of the recommendations from the Scottish Government review. One that struck a chord with me and many of my constituents was the need for better assessment and communication of restoration timelines. Certainly, the power companies had a very challenging situation to deal with. They were dealing with faults that were in succession, so they fixed one fault and then put the power back on. It would trigger another fault down the line and they would be back to square one again. However, what they were not great at was creating an expectation among householders that the power lines would be fixed within a couple of hours. If you contacted the app, if you contacted the customer phone lines, you are often getting contradictory information that power lines and energy would be restored within a couple of hours. However, as the storm and the effects of the storm stretched from a couple of hours into days, it was quite clear that restoration deadlines were being missed and that, in fact, power was not going to be restored for some time. The power companies were particularly poor at communicating what compensation was available, which made it difficult for people to plan ahead. What householders really need in this situation is the information so that they can continue to hope for the best, but they can also plan for the worst. I know that that is hard for the companies to do that, but they need to balance that. They need to not create an expectation that this is all going to be sorted in a few hours when, clearly, there are more significant problems that people need to plan for. I think that some of the other recommendations from the review as well improve processes for identifying and assisting those who are most at risk. I do not think that it was clear in Stirling that there were any door-to-door checks taking place for the most vulnerable. I think that we really need to get a handle on that and ensure that there is consistency across Scotland. If I can get the time back up, I will definitely lessen. Just to make a point to the member, yes, there were certain checks that the council organised with some of the voluntary groups. Mark Ruskell? That is good to hear, but I think that what we need to do is to ensure that there is consistency within council areas and also across Scotland as well. I think that there is probably room for improvement there. I think that another recommendation was around the need for better voluntary sector partnerships as well, understanding what the capacity is in our community and building that into resilience plans. My own community of staying in Deanston at a time started to gather blankets and food and set up their own welfare facility, not actually aware that there was another facility being set up down the road in Dune, so better planning and training is needed. Presiding Officer, in closing, I would just like to thank all those who helped to restore power and support communities. I think that with climate change we are going to see far more events like this, but the only silver lining I think is that we will end up with stronger and more resilient communities as a result. Thank you, and I call Nic Collin-Smith to be followed by Mike O'Mara. Mike O'Mara will be the last speaker before I ask the Deputy First Minister to respond. Up to four minutes, Thank you, Deputy Presiding Officer, and thank you to Evelyn Tweed for the table in her motion. I do not represent the Stirling area, but I do very much recognise the issues in Evelyn Tweed's motion and in the speeches that we have heard when it comes to the impact of storm Arwin on my own south Scotland region. Like Stirling, the borders in Dumfries and Galloway were battered by 100 miles per hour winds. Tens of thousands of trees were uprooted, many homes were left with no water, and huge parts of the region lost power to 40,000 homes at one point. I want to echo others thanks to all those who assisted with the response to the devastation of the storm in such atrocious conditions, emergency services, community resilience groups, councils and front-line workers from energy firms working to reconnect communities. However, we know that there were significant failings in that response, in particular from energy firms such as Scottish Power in my own area when it came in particular to the information or rather I should say misinformation that was being given to those often vulnerable people wondering where their homes would have power again. There are also serious questions to answer when it comes to the robustness of the network in rural communities. That would not happen, Presiding Officer, in our cities because that network is underground. So I await the outcome of the review into the energy networks response being carried out by Ofgem and the UK Government. I also welcome the Scottish Government's review into their response to the emergency and I agree with many of the recommendations, but I do think that we need to go further and I want to briefly highlight just two areas where, as the Scottish Government review highlights, the statutory responsibilities to manage emergencies in Scotland are set out in the civil contingency act 2004 and the contingency plan in Scotland regulations 2005. They placed six duties on category 1 responders and an additional seventh on local authorities in respect of business continuity. However, over the last 17 years much has changed in the way we respond to emergencies with building resilience now key. I'm a home region of Dumfries and Galloway. I've seen the growing importance and impressive work from the council and promoting, supporting and harnessing the huge commitment of volunteers within community resilience groups. There's now over 80 such groups all with community resilience local plans in place and they really did step up to the mark during Storm Arwyn. However, given that the need for that front-line response will continue to grow as the frequency of such emergencies grows, I wonder now whether it's time for the Government in consultation with local authorities to consider an additional eighth duty for councils to promote community resilience in the same way that they are required to promote business continuity. Crucially, that needs to come with funding. One of my other concerns is the fact that current support to councils isn't adequate enough to deal with the emergencies that they face. When we do face events such as Storm Arwyn, the Government has asked what financial assistance that will provide councils, and ministers often announce that they've opened the bellwine scheme. It sounds impressive at the time, but look at the fine print of the scheme. Does the member agree that SSEN in this case should be asked for compensation, given that the issue was down to SSEN to help councils in that regard? Absolutely. SSEN was certainly responsible in the Stirling area. Scottish Power failed when it came to Dumfries-Garwin borders. The compensation from the power companies is absolutely crucial. The lack of confusion around what compensation is available to households is also an issue that needs to be tackled. I come back to the point about funding from the Scottish Government to local authorities when it comes to all the emergencies that they face. The problem with the current bellwine scheme is that it covers only what is classed as immediate actions to safeguard life and property, or to prevent suffering or severe inconvenience. That rules out much of what councils face when it comes to costs. It also covers costs over and above a substantial threshold. In the case of Dumfries-Garwin Council, that is nearly £700,000 in 2021-22, and in the borders it is over £500,000. I suspect that no council will have received support from the bellwine scheme as a result of Storm Arwin. It is often forced to look for other funding elsewhere that it could be from power companies. However, it is often a further ask of Government. Just weeks before Storm Arwin, my own region suffered devastating flooding. Towns such as Dumfries, the largest in Scotland, floods on a regular basis, but still has no flood protection scheme saw at the banks of the nith bust again. Government funding for flood protection schemes is oversubscribed for the next five years. On the River Arran, two historic foot bridges, the Cuthbertson bridge and Jubilee bridge, were washed away by the flooding. A week later in Dremor, in the west of the region, 40 feet of the harbour wall was destroyed by Storm Barra. I know that the Deputy First Minister knows those issues very well. He visited Arwin to see the damage for himself. He told Parliament that the Government was considering what support it could give to the reinstatement of the foot bridges in Arwin and the harbour wall in Dremor. I hope that the Deputy First Minister and the Government are true to their word, and we see funding allocated to those communities for the devastating impact of the storms. In the long term, I hope that we see additional support to councils and communities to build that community resilience and to continue to improve our response to emergencies. As others have mentioned, I want to add my own thanks to our first responders from a vast array of services that put themselves at risk to ensure the safety of others. The impact of the efforts from local authorities in all emergency services and volunteers cannot be understated. Both Karen Adam and Gillian Martin gave particularly warm tributes to the community spirit and their constituency, which I would echo. Storm Arwin brought with it a rare red weather warning, and the damage was extreme. Unusial wind patterns from the north made mitigations in our built environment less able to cope and, particularly, impacted on trees that do not usually have to sustain winds from that direction. That has resulted in levels of devastation, which I think continues, as many members have mentioned, to surprise and shock people across Scotland when they come into contact with it. However, our immediate thoughts on the aftermath of these storms, three souls, were lost during that storm, and our thoughts are with their loved ones. The broader impact in Scotland was that 80,000 homes were without power, and our energy infrastructure simply could not cope. Many of those people were within my region of the north-east and with Aberdeenshire bearing the brunt of the impact. For too many, the response was unacceptably slow, and I think that there is a broad agreement across the chamber on that fact. Miscommunication throughout the following days became deeply frustrating. Mark Ruskell echo his comments on the issue about expectation management from the power companies. One of the greatest frustrations when people were trying to cope with the situation and plan the days ahead to make sure that they had enough food and fuel to cope and that there were great mistakes made in that regard. On 8 December, almost two weeks after the storm Arwyn and following Storm Barra, which came just after it, I raised an urgent question in this chamber because 600 homes and businesses were still without power as winter approached. I think that that is a scale of the longevity of the problem, which I hope that the current reviews will continue to deal with. The Parliament was rightly told by the Government that the response would be reviewed, and the lessons would be learned to improve how those events are reacted to in the future. We have heard some about those that were reviewed tonight. Unfortunately, we did not have to wait long for resilience teams to be needed again. As Storm Scorry and Malik hit last weekend, we can leave 118,000 homes without power in Scotland and claiming two lives across the UK. I just want to focus on the realisation that we are going to have to deal with more of those events in the future and that we have to act now to make sure that we can cope with them. Science tells us that we are to experience more extreme weather events than we have in the past. There will be more of them. They will be closer together and they will be of a bigger scale than we are used to. We talk about mitigation in terms of climate change, and this is one of the areas that we have to make sure that we have adaptation as well, that we adapt our environment and that we begin to cope with it. Colin Smyth touched on the issues of infrastructure in his constituency, and the fact that we have to make sure is that the Scottish Government is already doing it, but more resource will have to be committed to storm defence, in particular footbridges and the like. I think that we have to start the conversation about the large-scale infrastructure investments that are needed around the grid and energy supply, such as the undergrounding of power infrastructure, both in future expansion but also in the existing network. I do not underestimate the size of that undertaking. I do not think that any of us should, but if we are dealing with the reality of climate change in these extreme weather events, we have to recognise that we will have to feature more prominently in our scenario planning for how we go ahead in those. I hope that the First Minister might reflect on those matters in his summing-up. I thank Evelyn Tweed for raising that on behalf of her constituents and for all of us who have had constituents who have had to deal with such severe problems in recent months. Thank you, Presiding Officer. May I begin by congratulating Evelyn Tweed on securing this important debate and providing the opportunities that Mr Marra has just said for members across the country to reflect on the implications of the very challenging instances of weather around Storm Arburn, Storm Barra, Storm Malik and Storm Corrie that we have now had to face. Evelyn Tweed is absolutely correct in her motion and in her comments tonight to pay tribute to the significant contribution that has been made to the resilience effort by countless communities and community organisations, and I will come on to say a little bit more about that in the course of my remarks. As members have indicated, in the aftermath of Storm Arwin, the Government undertook to review the experience of the handling of Storm Arwin. That review was carried out expeditiously by the Government's resilience division and the report that was published last week. It is a comprehensive report that contains a number of recommendations about how we need to address and improve the resilience effort that is put in place. None of that should in any way detract from the enormous efforts that were put in by a range of different organisations, staff from the power companies who I saw working in atrocious conditions to try to restore supply in very complex circumstances when I visited the north-east of Scotland in Gillian Martin's constituency in the aftermath of Storm Arwin, nor should it detract from the efforts of local resilience partnerships and volunteer groups who put in such an effort to try to improve the situation. However, in all of those instances, we have to be candid enough to reflect on performance and to identify how that can be improved. One of the points that I would reflect on, having spent most of my weekend involved in calls and discussions in relation to Storm Malik and Storm Corrie, is that the pace of the delivery of the—two important factors changed, I think, about the handling of Storm Malik and Storm Corrie compared to Storm Arwin. The first is that the identification and recognition of the scale of the challenge was identified earlier by the power companies to resilience partners. We were clearer earlier in the handling of Storm Malik and Storm Corrie that we had a very significant challenge to overcome in the restoration of power supply. In broad headline messaging to members of the public, it has been clearer to members of the public that they may be off supply for a longer period than was clear in Storm Arwin. That does not help anybody if they are off power, but it allows people to make alternative arrangements and it also commits the power companies to making alternative arrangements for those individuals to support them. The second difference as a result of that notification is that the local resilience operation that has been put in place has been available on a more timious basis than was the case in Storm Arwin. The welfare support, the availability of hot and warm food, the access to leisure centres for phone charging and for showering purposes and just simply for a place to get warm, has been more readily available more quickly in Storm Malik and Corrie than was the case in Storm Arwin. Those are two areas where I would say that the swift review of Storm Arwin has helped us to improve the delivery of a resilience operation to members of the public in the course of the last few days. Having said that, there are important additional areas where we need to continue to build on the very strong foundations that we have for resilience within Scotland. We have well-established and tested resilience arrangements, but we must constantly improve those arrangements because of the nature of the challenges that we are likely to face. Members are right to highlight the fact that there will be crucial tests thrown at us by the weather and the changes in the weather systems that are now becoming all too familiar. In the course of her comments and in her motion, Evelyn Tweed made particular reference to the role of volunteers, and particularly to the Kilin mountain rescue team, to the Trossach search and rescue team and to the British Red Cross. I reiterate those thanks to those organisations, and to the many other voluntary organisations, Gillian Martin and Karen Adam, also referenced those organisations within their constituencies in the northeast of Scotland. Those organisations are making a huge contribution to resolving the difficulties faced by individuals. However, there is an important issue that Colin Smyth raised, which is one that I discussed yesterday with the Scottish Resilience Partnership, which is about the necessity of their being capacity within communities to be able to contribute to the resilience efforts. In some communities that exist today, and it does phenomenally well, it is not quite as mature in other communities. I am interested in the suggestion that Colin Smyth has made about an eighth duty in relation to the formalisation, perhaps, of the role of community capacity building, but in saying that, I acknowledge the importance of that being adequately supported and created to make sure that it can be effective in meeting the needs of individuals in their communities. Lastly, there is a significant issue in the evidence that has talked extensively about this in relation to the work of the power companies. There are power company staff who currently are working extremely hard in very cold and challenging conditions to restore supplies to people affected by Storm Malick and Storm Corrie. I am advised before I came into the chamber tonight that Scottish Power has restored all supplies. SSEN is optimistic that they will get very, very close to the restoration of full supply by the end of this evening, but it may well be a very late evening before that is restored. I thank those members of staff for all that they are doing, for all the communication that is under way. Clarity of communication is essential in all those circumstances to alert people to the challenges that are likely to be faced, but it is important that there is also an acknowledgement that our network has to be resilient to meet those challenges. Mr Smith again makes fair points to Mr Marra about the need to make the network more resilient. We lost power lines because of the degree of overhead cables that we have, and that is an issue that is going to have to be resolved by off-gem and in dialogue with the power companies. I am grateful to Evan Tweed for providing this opportunity for us to reflect on what has been a very stormy period in Scottish weather in very challenging circumstances. A huge amount of community effort and a huge amount of local resilience partnership and a huge amount of power company effort has gone into addressing those challenges, but I want to assure Parliament of the Government's determination to lead a process of constant improvement to ensure that we are building on the strong foundations for resilience that we have and that most of all we are acting to remedy the challenges that members of the public face and to do that as quickly and as effectively as we possibly can do. Thank you, Deputy First Minister, and that concludes the debate, and I close this meeting.