Welcome back, my friend. The first item of business is portfolio questions and the first portfolio is rural affairs, land reform and islands. In order to get in as many members as possible, I would appreciate sync questions and answers to match. Question 1 is not lodged. I call it question number two of the question, which is that Jamie Halcro Johnston is joining us remotely. To ask the Scottish Government what discussions the rural affairs secretary has had with ministerial flu pob iawn o how that the Scottish Government analyses the impact on island communities of disruption to ferry services?" Minister Kevin Stewart. Thank you, Presiding Officer. I am working with the rural affairs secretary and other ministerial colleagues to understand the impact of ferry disruptions on island communities. However, that requires not just ministerial engagement but dialogue with our local authority partners. That is why we took the decision to re-establish the islands transport forum, chaired by myself through the island strategic group. Furthermore, the First Minister's policy prospectus announced on 18 April included a commitment to publish a new rural delivery plan within the lifetime of the Parliament. It will cover the areas critical to Scotland's island, rural and coastal communities, including transport. The minister will be well aware of the serious disruption Scotland's island communities have endured for far too long, with cancellations reduced sailings and emergency timetables, often a very short notice becoming an everyday occurrence for many. Residents often can't leave their islands or go home, island businesses can't operate, get the supplies they need or deliver the services they've promised. Booking trips or stays on islands is becoming a gamble, not worth taking for some potential visitors. On all results of 16 years of chaotic mismanagement of our ferries network by the SNP, when will the Scottish Government finally accept responsibility for the increasing carnage, their lack of investment in new ferries is causing? When will it look seriously at compensating islanders and island businesses for the total mess that Scottish ministers in Edinburgh have caused?  Myself and the Government are committed to investing in our ferry services. We will be delivering six new major vessels to serve Scotland's ferry network by 2026. That is a priority for this Government. Although I am sympathetic to the calls to support businesses through compensation, our focus rightly has to be on building resilience in the ferry network. That includes the charter of the MV Alfred, currently to support CalMac services, and we are also proactively working with Northlink on potential additional capacity on services to Orkney. We will continue to do all that we can to increase the resilience and to add to that fleet so that our island communities are better served. The transport minister will be well aware of the disruption of ferry services across the continent, first following the recent grounding of the MV Pentalina earlier this month. I thank the minister for his engagement with me on that issue. I know that Circo Northlink has been working hard to identify how freight and passenger demand might be met while the Pentalina is unavailable, but I remain concerned about the pinch points on particular sailings and the loss of connectivity to and from the smaller isles in Orkney. Can I ask the minister again to look at increasing to four return daily sailings between Stromness and Scrabster, while that remains the only ferry route across the Pentalina? Thank you very much, Presiding Officer. I am very grateful to Mr MacArthur for his engagement with me on that issue. We will continue to look at the pressures that are on in terms of that crossing. As Mr MacArthur is already aware, because I wrote to him on that subject, we have already increased, thanks to Northlink, the amount of crossings on a Sunday. Northlink is gathering intelligence and looking at other points of pressure to add to the services. I can assure Mr MacArthur and Orkney Islanders that we will continue to look at all the information that we have in this and act accordingly. Once again, I am very grateful to Mr MacArthur, to Orkney Islands Council, who I am meeting directly after this question time for the intelligence that they have provided. To ask the Scottish Government what it is doing to help to ensure that quality Scottish beef is available in supermarkets in Scotland. Scottish beef is an iconic product. I am pleased to say that it is available in each of the main grocery retailers in Scotland, as well as the vast majority of our independent high street butchers. Anytime I meet retailers, the sourcing of Scottish produce, including Scottish beef, is always part of the agenda. In addition, quality meat Scotland meet regularly with retailers and their Scottish beef suppliers to promote and align any marketing campaigns on Scottish beef. It is, of course, important to our agriculture sector that our supermarkets are stocking not just Scottish beef but also Scotch lamb and specially selected pork. It was recently reported that Scottish beef had lost the contract to supply Aldi with beef. Scotch beef is a product of unparallel quality that everyone should be able to enjoy if they wish. Does the cabinet secretary agree that, while Aldi stock other Scottish beef products, it is vital that, during the on-going cost of living crisis, discount retailers continue to provide as wide a range of those products as possible and give people affordable access to the best of Scotland's ladder? I absolutely agree with the member that Scotch beef should be available for everyone and from all walks of life. I know that Aldi has, over the years, really strongly supported the Scottish produce and its supply across Scotland, and that includes offering Scotch beef to their customers. Presently, from my understanding of the situation, I think that there has been a change in suppliers and that has temporarily reduced the availability of Scotch beef in Aldi. However, they remain committed to sourcing Scotch beef and they are in the process of acquiring a new contract and will have it back on their shelves as soon as possible. With the support from QMS, the Scottish beef industry delivers the highest standard of production and animal welfare and wellbeing, resulting in the very highest quality of beef. That is produced at a carbon footprint, which is significantly below the global average. Last month, the CCC spelled out its belief that Scotland would need to slash dairy and beef numbers by 29 per cent and 26 per cent respectively to meet the net zero targets. Can the cabinet secretary here and now rule out any cut to red meat production and assure me and the farming industry that she is a practical and achievable plan to meet the legal climate change targets and protect livestock farming in Scotland? That is exactly what we are trying to do. I would like to give that assurance to the member, as I have done on previous occasions as well. I know that colleagues have raised the reduction of numbers with me in the past. We know that we produce livestock in Scotland, we produce it well in Scotland and there will continue to be a role for that, both now and into the future. That is why our vision for agriculture and our agriculture reform programme, Rootmap, makes clear our commitment to enable the producers of high-quality food to deliver on our shared outcomes for biodiversity recovery and climate adaptation and mitigation, and why we continue to support those sectors. Thank you very much, Presiding Officer. I would like to remind members of my register of interest that I am part of a family farming partnership, and we produce beef. Cabinet Secretary, farmers have a duty to reduce their emissions to achieve net zero, which I completely agree with. However, one of the preventions of doing this is by having to keep livestock on the farm after they are ready for slaughter. This happens for beef cattle, many of which are ready at 11 months, but cannot be sold as Scotch beef till 12. Will she address this with QMS? Cabinet Secretary, I am happy to raise that matter with QMS and to discuss it with the member if he would like to do so. To ask the Scottish Government what discussion the rural affairs secretary has had with ministerial colleagues regarding actions to tackle mental health problems amongst farmers and crofters. I regularly engage with farmers and crofters on actions to discuss the range of challenges that they face and will in turn raise those with relevant ministers as appropriate. The Cabinet Secretary for NHS Recovery, Health and Social Care in his team in the case of mental health. The Scottish Government takes the mental health of our farmers and crofters seriously. Over the last financial year, we committed £50,000 to supporting RSAPI and £50,000 to the National Rural Mental Health Forum. We recognise that the sector continues to face significant challenges and we are fully committed to working with them to address those as and when we can. I thank the cabinet secretary for that answer. Depression and suicide rates for farmers are among the highest of any population tragically. Those figures have been growing and getting worse, cabinet secretary. What steps will the Scottish Government take to not only halt but reverse this trend? Of course that is a really worrying trend and I welcome the member raising this really important topic in the chamber today. I know that it is an item that we will be discussing further during his colleagues' debate tomorrow. Firstly, every life lost to suicide is, of course, an enormous tragedy and leaves devastating and long-lasting impacts on families, friends and communities. That is where the work that organisations such as RSAPI do, as well as the National Rural Mental Health Forum, is so vital and why continuing to support them is so vital. I probably cannot emphasise enough or direct enough people to show the resources that they have available. They have help available 24-7 with a helpline and a web chat as well. I think that it is really important that not just me but other members across the chamber highlight the avenues of support to people so that they know that they can reach out and seek that help and that it will be available to them. What it has learnt from the fisheries note-take zone at Llanlash Bay? Llanlash Bay is an excellent example of the Scottish Government working with a local coastal community building on the voluntary note-take zone by incorporating it into the South Arran marine protected area to support the recovery of the merrill beds within the bay. Since designation, commercially important species such as the king scallop and European lobster have increased in size, age and density. We have continued this approach to NPA designation and management and we are currently working with coastal communities to develop fisheries management measures for the rest of the NPA network. Mark Ruskell? The Arran note-take zone has seen tourism grow while those scallop and lobster numbers have increased fourfold. Given the economic success, can I ask the cabinet secretary how the Government plans to continue to work with coast to collect further data on the impact of this internationally recognised note-take zone? We have set out how we intend to monitor NPAs in our monitoring strategy, and that sets out our approach to the related surveys that we do and how we will continue to monitor that. Of course there are a lot of partners involved in that, so of course we work with them to gather that evidence and to assess the overall condition of the sites, and that includes with NatureScot, and they have recently launched a community-led biodiversity monitoring project to really try and support community groups and individuals who want to participate in that monitoring of our marine protected areas. Coast have also provided a lot of valuable evidence to NatureScot and the Scottish Government about the seas around Arran, which of course we very much appreciate. supplementary Rachel Hamilton? In another note-take zone broad bay, we know that marine biodiversity is almost non-existent leaning on evidence from one example such as Lam Lash whilst ignoring another is no way to go about policymaking. Furthermore, more work needs to be done to establish the effectiveness of the current existing NPA network, so I'd ask the cabinet secretary if she agrees that we shouldn't rush into imposing a new and evidenced marine protections simply to appease the Government's green coalition partners. Instead, we should seek to understand that those that already exist. Could we hear the member who has the floor? In terms of the example that the member raised, of course we would be considering that as well as other examples that we know exist from across the world when we are looking to further develop this work, but I would say at this point in time it's important to remember that we've carried out a consultation, which I believe received over 4,000 responses. It is vitally important that we fully consider each of the responses to that consultation. I know that there's a lot of feeling around this and the concerns that have been expressed by other organisations, so we want to listen to those points of view very carefully and do that in a considered way before setting out further steps from that point. The Scottish Government adopted a national marine plan in 2015 to develop a planning system for our seas, of which no-take zones play a part, but the recent open seas ease the squeeze report highlights the Government's failure to comply with that plan. Will the Scottish Government commit to creating a cohesive spatial plan for our seas with community consultation, engagement and development at its core? I thank the member for raising that point. In relation to the national marine plan, she will of course be aware that we are in the process of updating and bringing forward a new national marine plan, which is work, I'm sure, and I hope that she will engage with it. I'd be happy to write to her to provide her with further information or any indicative timelines that we have around that. To ask the Scottish Government what its assessment is of the welfare of animals used in Greyhound Racing in Scotland. The Scottish Animal Welfare Commission published its report on the welfare of Greyhounds used for racing in Scotland on 9 March. The Government welcomes the publication of the report, and we are currently considering the recommendations. Further to that, we will shortly be launching a consultation on extending the animal licensing framework introduced in 2021, and that will include Greyhound Racing and other animal care services. The responses to the consultation, along with the views of the Rural Affairs and Islands Committee, who are currently considering Greyhound Racing and the Scottish Animal Welfare Commission's report will inform our next steps regarding Greyhound Racing in Scotland. The cabinet secretary will be aware that Shofield stadium in my constituency is the only licensed Greyhound Racing track in Scotland, and no racing has taken place at Shofield since the start of the Covid pandemic. Given my concern about the welfare of Greyhounds that have been raced there previously, I hope that there is no return to it locally. With regard to the consultation on extending licensing legislation to animal care services, can the cabinet secretary confirm when exactly that will be launched, and whether, as part of that consultation, a phase-out ban to Greyhound Racing will be considered by the Government? I thank the member for raising that question and for highlighting this really important subject. Mary McCallan, who was then the Minister for Environment, Biodiversity and Land Reform, had confirmed in October last year during a debate that the licensing of Greyhound Racing would be considered as part of the animal care services consultation. I would say that, in relation to the timescales for that, we are hoping to bring forward that consultation shortly. I know that the committee is considering Greyhound Racing in Scotland, and it is important that we consider all the evidence that it has taken. I believe that it has had a number of sessions so far in relation to the topic. Of course, any recommendations that the committee brings forward, the Scottish Government will carefully consider before we then set out our next steps. I would say that, when it comes to the launch of our consultation, we welcome everyone with an interest in that to respond to it, and we will consider the next steps once we have completed that exercise and once we receive the committee's report too. Question 7, Emma Harper. To ask the Scottish Government what discussions the Rural Affairs Secretary has had with the ministerial colleagues regarding the delivery of the rural crime strategy. The Scottish Government takes all crime, including that committed in rural areas, extremely seriously. While delivery of the rural crime strategy 2022-25 is a matter for Police Scotland and its partners within the Scottish partnership against rural crime, or SPARC, as it is known, the Scottish Government is fully engaged with the work of SPARC and we also receive regular updates on its activity. I know that the member will be well aware that the overriding aim of the strategy is to protect rural communities through strong partnerships, and ministers are looking forward to hearing more about that work as it progresses. Emma Harper. Thank you for that answer, cabinet secretary. SPARC has seen positive results in both reductions in rural crime and associated financial costs in the past year alone. Between April 2022 and March 2023, 284 fewer rural crimes were reported compared to the previous year, as well as an overall reduction in the financial harm to Scotland's rural communities of more than £2 million, which equates to a drop of almost 36 per cent. The approach that is being taken by SPARC is working. Will the cabinet secretary meet me and SPARC to discuss what action can be taken to build further on the reduction in rural crime for our communities across Scotland? I thank the member for highlighting those really important statistics, which I think highlights the importance and just how necessary the work of SPARC is. The member will, of course, be aware that the ministerial responsibility for rural crime does sit with the cabinet secretary for justice. However, the fight against rural crime is one that requires and benefits from the support and input of all our ministerial colleagues. As the member highlights, the reduction in rural crime is really testament to that partnership approach and the vital work of Police Scotland and the other partners that are involved in SPARC too. Of course, ministers would be delighted to join the member to meet with SPARC and to discuss those issues further. I have a SPARC report highlighted that the cost of rural theft of machinery was almost £350,000 in March alone. The north-east was identified as one of the most targeted areas and we are now heading into May and June, which are the worst months for theft. Bold steps need to be taken to tackle that, particularly when such crime makes it impossible for farmers to work. Does the cabinet secretary agree with the Scottish Conservatives plan to introduce immobilisers and regulate the sale of agricultural vehicles to reduce rural crime? That is an issue in a matter that I am happy to discuss further with the member to see what more could be done in this area. Despite the passing of Emma Harper's law, there is still an enormous task ahead of us to stop dog attacks on lambs. The minister I have heard about the recent terrible attack near Kelty, but there has also been a further attack on the west loamond, where more sheep were lost. Both of those farmers are incandescent with rage. Why does the minister think that too many dog owners still have not got the message? It has been absolutely terrible to see some of the incidents that have taken place recently. Especially in a time when we have been trying to increase that awareness and do what we can to ensure that every dog owner is aware of their responsibilities, which are very clearly set out. Of course, we know that the penalties for this crime have increased due to the member's bill that has been taken forward by Emma Harper and some important work was done there, but I am more than happy to consider what more we can do in terms of raising that awareness, ensuring that we are doing everything we possibly can to get that message out there that all dogs should be on leads so that we are saved from some of the really truly horrendous scenes that we have seen in recent weeks. To ask the Scottish Government what discussions the Rural Affairs Secretary has had with ministerial colleagues regarding the role of the Good Food Nation Scotland Act 2022 in promoting a healthier diet. The ministerial working group on food provides that forum for me and my ministerial colleagues to come together and really try and work across portfolios on relevant aspects of food policy as we work towards our ambition of Scotland becoming a good food nation. At our last meeting on 12 January, the group covered issues relating to the promotion of a healthier diet. I am really looking forward to continuing to discuss the next steps in relation to the Good Food Nation Scotland Act with my colleagues. I thank the cabinet secretary for that answer. Partic Farmer's Market in my constituency of Glasgow Kelvin brings into the heart of Glasgow's west end fresh food produce straight from the producers. Does the minister agree that such good models play an important role in educating people about the food that they eat, promoting healthier lifestyles and supporting farmers and food producers? I cannot agree more with what the member has stated there. Farmer's markets play a really important role in supporting our farmers and our producers. They support our local communities and economies but they also do so much more than that because it means that if we are supporting initiatives like that we are shortening supply chains, we are connecting people to our food and where it comes from as well as helping to promote a healthier diet. Through our local food strategy we recognise the importance of connecting people with their food and where it comes from as well as better connecting Scottish producers with their buyers. All of that plays a vital role in our vision of Scotland being a good food nation. The cabinet secretary is aware that from all the time I have been in here I have been pushing the role of public procurement into schools and the hospital. Does the cabinet secretary agree with the Conservative position now that we should be pushing as much as possible to get public procurement to buy local food to increase the health of the nation? I do not think that we have ever really disagreed with that point and I know that this is an issue that the member has raised with me on a number of occasions and that is what I think is really important that we look to try and address that through the good food nation plans that we will be developing because I think that there will be a critical role within that too, but I would also point to some of the other work that we are looking at. We obviously have the Food for Life programme, which has been working with our local authorities in trying to increase the supply of local produce that we have in our schools in particular. We can see the benefit to health, we can see the benefit to our local communities and economies when we take an approach like that as well and that is why we decided to extend that pilot to look at other areas of the public sector that we could make that work particularly focused in Glasgow because I think that that is the kind of approach that we would ideally like to see expanded across Scotland. I look forward to working with the member and I am more than happy to have a conversation about how this can feature within our future good food nation plans. Thank you cabinet secretary. That concludes portfolio questions on rural affairs, land reform and islands and we will now move on to the next portfolio which is NHS recovery, health and social care and I call to question number one Liam Kerr. To ask the Scottish Government whether it tracks how many GP practices are currently being run directly by NHS boards. Public Health Scotland publishes regular data in relation to GP practices including their contractual status. As of 1 April 2023, there were 57 practices classed as 2C out of 905 GP practices in Scotland. 2C status is usually understood to mean that those practices are directly run by an NHS board. Liam Kerr. Thank you cabinet secretary for that answer. The decisions by Inveruri and old Meldrum practices to end their contract with NHS Grampian due to a lack of GPs means that 34,000 patients within a five mile radius in Aberdeenshire face challenges accessing a local doctor. Dr Innes, a partner in Inveruri said that they had explored every avenue to recruit but there are not enough GPs out there. It is clear that GPs are beyond the end of their tether with the lack of support from this Government. What specific measures were put in place by the previous health secretary to address the lack of GPs and when will the north-east have sufficient numbers? Cabinet secretary, there are a range of actions that have already been taken in order to help to support GP numbers. For example, we are going through a programme of recruiting another 800 GPs into the system by 2027. We have also put in place additional measures. For example, since 2027 we saw an increase of some 291 GPs. We now have a record of 5,209 GPs working with practices in Scotland. Alongside that, we have put in place initiatives to help to support GPs, particularly in rural areas such as Aberdeenshire and the area in which the member made representation on. For example, including the Golden Hallow programme and by taking forward a range of actions to encourage graduate entry medical students to go into rural settings through the Scotland GEM programme. There is a range of work in order to increase further recruitment in general practice in Scotland. Alongside that, there is a range of measures to encourage those to work in rural areas. As I have mentioned, we are at a record of 5,209 GPs operating in Scotland just now. However, I recognise the concerns that the member raised on behalf of his constituents. I know that health and social care partnership and the health board are looking at the specific issues in relation to the enveruri practice and whether there is a possibility of others coming in to operate the practice or whether it will require to come under the local health board to be operated in the future. However, it is important that people continue to reassure us of getting access to general practice services, which will be delivered through whether it is NHS or through another practice. I wonder what encouragement the cabinet secretary can give to NHS Tayside to consider directly providing GP services in the village of Envergourie in my constituency, where there is some uncertainty over the future of GP provision, to ensure that there can be convenient access to general practice services for my elderly and vulnerable constituents, given the transport challenges that might exist of accessing services in other parts of the county or in the city of Dundee. It is important that any practice that is looking to change access to general practice services in the local health board area is that it will go through a process of engaging with the health board in order to ensure that patients and those practices continue to have access to a GP as and when is necessary. I would certainly encourage the practice to make sure that they are engaging with the health board and also for the health board to take proactive action in engaging with the practice to ensure that the concerns that the member has been raising or raises regarding his constituents and access to GP services, particularly the transport issues that they face, to ensure that they maintain appropriate measures in place so that his local constituents can access a GP. Jeane Freeman brought in the policy to recruit another 800 doctors within 10 years, or it is Scotland suggested that that number was arbitrary, given that there was about 860 doctors short at that time and at the end of the 10 years, because of wastage, there would still be 660 gps short. Perhaps the cabinet secretary could enlighten us as to why the number 800 was arrived at? As the member has just acknowledged himself, it was a figure that predates me, but it was in recognition of the need for the increase in gps across the country. The good thing that I am sure the member will want to be pleased with is the steady progress that we are making in that recruitment programme, which is progressing at an appropriate rate in order to make sure that we are able to deliver on the 800 figure by 2027. At the same time, we are doing more than we can to encourage more people into general practice as we go forward. A representative of the British Medical Association has said that the closure of inbrewary medical practice in Aberdeen means that no practice is safe and that the crisis in GP care could lead to the collapse of NHS Scotland. What is the Scottish Government doing to support communities that are affected until such measures to increase GP numbers take place? Key to supporting primary care services that are delivered by general practices is GPs, but also the wider support team that assists them in delivering the services that patients require. The provision of advanced nurse practitioners, the deployment of MSK physiotherapists, pharmacists being based in GP practices, all of which can provide a range of primary care services directly to patients. That workforce has increased quite markedly over recent years. We have recruited more than 3,000 additional staff to work alongside GP practices to support them in the services that they offer to patients. However, there is certainly more that we need to do in expanding and developing that further, because primary care is absolutely critical to delivering a sustainable healthcare system, and that wider primary care team, the multidisciplinary team that can support GPs, is going to be critical in supporting and making sure that we can deliver that. Alongside that, it is also about making sure that patients get access to the right services directly at the time when they require it. Much of that can be provided within primary care, with the right support team in place, rather than always having to go to a secondary care setting, which is what happens very often for most patients at the present moment. The GP position at the Hilswick Surgery in my constituency is still vacant after six months of advertising, and Hilswick is also an established training practice for medical students. How is the Scottish Government supporting GP practices in island areas to recruit and retain GPs? As I mentioned earlier on, we are taking forward a number of initiatives to help to attract GPs to rural areas, including through the Golden Hallow programme that we have in place, which is to help to support GPs to take up posts and what are harder to fill rural environments in the way in which the member highlighted. We have also established the ScotGem programme, which is a programme to encourage those graduate entry medical degree level or entering medical degree level to be able to go into general practice in rural areas in order to encourage more people to go into rural areas in the way in which the member has highlighted. To ask the Scottish Government whether it will set out its proposed timetable for implementing the new musculoskeletal pathway, including how it will ensure the views of the third sector organisations are reflected in the process. The Scottish Government is continuing work with NHS 24 and stakeholders to review the musculoskeletal or MSK pathway. Any timetable would be contingent on the outcome of that on-going review work. We expect individual health boards to continue to improve their own MSK pathways for patients with third sector partners at a local level. Pam Duncan-Glancy. I thank the minister for that answer, but having an up-to-date and fit-for-purpose MSK pathway is vital to ensure that patients can access the care that they need when they need it. Third sector organisations are a key part of that, so can I ask the minister would she agree to meet with relevant charities and MSK groups as a matter of priority? I thank Pam Duncan-Glancy for that supplementary question and also thank her for inviting me to the arthritis and MSK CPG last week, where I learned a lot about the various conditions, so I appreciate that very much. As I said in my speech of that, third sector organisations are incredibly helpful. I referenced a couple of my constituency of Argyll and Bute, so I would be very happy to meet those that you have suggested. To ask the Scottish Government what plans it has to put in place to support the palliative care sector in light of reports that a number of people in need and resources are estimated to rise by an additional 10,000 by 2014. We are aware of Scottish research showing a rise in the number of people with a palliative care need, and the Scottish Government is developing a new palliative and end-of-life care strategy to ensure that everyone who needs it can access seamless, timely and high-quality palliative care. We are considering the issues that are raised by the Scottish hospices at their meeting in March with the then Cabinet Secretary for Health and Social Care and then Minister for Public Health, Women's Health and Sport, including funding and long-term sustainability of the hospice sector. Hospices will start closing if health cannot be sourced to match the NHS pay offer. Scottish charitable hospices need to find £15.5 million over the two years to 2024. The time for meetings and discussions is over. What can the Scottish Government do urgently to address this crisis in the palliative care sector? I thank the member for his supplementary question and recognise the importance of palliative care and the importance more widely of us speaking about the end of life stages that we go through. I was at a cost of dying photography exhibition in Glasgow last week and found that incredibly important and thought-provoking. As you know, the 23-24 Scottish Government budget underlines our on-going commitment to prioritise investment in health and social care, providing additional funding of £1 billion. I recognise that there are issues in the hospice sector, and I am working with officials to discuss it. I am the major provider of palliative care in Scotland as a hospice network. St Margaret's Hospice, in my constituency, has contacted me regarding funding pressures. Will the minister meet me and representatives of the hospice to discuss the pressures and how we can assist them going forward? I thank Marie McNair for her question. I would be very happy to meet representatives from St Margaret's of Scotland hospice. To ask the Scottish Government what discussions it has had with NHS Lothian and local groups since March 2023 regarding the reopening of Eddington hospital in North Berwick. My officials are in regular engagement with NHS Lothian and with East Lothian health and social care partnership on a range of issues, and last discussed Eddington hospital in March 2023. The health and social care partnership has recently provided the Scottish Government with an update on the on-going review of community provision, which includes Eddington, and we have been informed that a 12-week public consultation on proposed changes is due to take place. I am very grateful for the cabinet secretary's response to that. As he will be aware, the story around Eddington hospital's closure has been one that has been going back to 2021. However, as the First Minister has confirmed, the responsibility for continued Covid recovery now passes to all elements of government rather than centred in one place. So can the cabinet secretary confirm that he will be able to attend the meeting on 22 May, arranged by the constituents MSP Paul MacLennan, with local groups, including North Berwick community council and Friends of Eddington hospital? I am aware that there is a consultation exercise that has been taken forward by the health and social care partnership board, which is looking at the existing provision that they have in place. I am not aware of the particular meeting that the member has made reference to at this particular point at this stage, but clearly it is important that, as a consultation exercise, it is given the opportunity to go through the process of consulting a local community, hearing what their views are and to take those into account in determining what the final outcome is of any process in going forward. That is what I would expect to happen in this case. By the sounds of it, there is no meeting. That is consistent, because ministers have repeatedly failed to meet local stakeholders following the close of the residential care beds at the Eddington and the withdrawal of minor injury services. However, with access to CTAG services that are restricted in some surgeries, vulnerable older people and young families face long and impractical bus journeys to East Lothian community hospital in Haddington or all the way into Edinburgh to access simple in each services such as having wound stress. Does that prove that the SNP has all but failed and have given up on community-based health services in East Lothian and across the south of Scotland? No, in fact, I think that that is wrong when you considered the particular facility that we have built at East Lothian community hospital, which is providing a range of services to the local community. However, on that side, the member is well aware that the health and social care partnership, along with the health board, is responsible for designing and developing services to reflect the needs of the local community. It has already set out the intention of taking forward a consultation exercise, which will involve the opportunity for even elected members such as himself to participate in that process, to submit his views and to make them known to the health and social care partnership and also to the health board and for that to determine what the future approach is to delivering those services locally. That is the best way in which services are delivered by, through the local process and local consultation, to allow the local community to have a view on what should be provided locally. To ask the Scottish Government what its response is to recent research from the British Dental Association, which shows that 83 per cent of dentists in Scotland expect to reduce the amount of NHS work that they do in the year ahead. The Scottish Government is aware of the survey and understands the concerns expressed, which is why the Scottish Government wrote to all NHS dental teams on 7 February, confirming the continuation of the bridging payment to 31 October 2023, while we prepare for the implementation of payment reform. Payment reform will comprise a new modernised system that will provide NHS dental teams with greater clinical discretion and transparency for NHS patients. It is our intention for payment reform to maintain the confidence of NHS dental teams by ensuring the future viability of NHS dentistry in Scotland. Can I thank the minister? That does sound a bit like a temporary filling to what is quite a long-term cavity in their funding, no pun intended. Can I be frank with the minister on this? NHS dentistry in Scotland is an absolute crisis point, and everybody knows that you need to be living in a cave if you haven't seen your MSP inbox filled with constituents' problems and access NHS dentists, filled with emails from dentists themselves, facing massive funding issues. In my region, not only can you not register for an NHS dentist, they've actually closed the waiting lists altogether. Put simply, minister, some people have no access to a single NHS dentist. My question on behalf of those constituents is a very simple one. If the only way to get immediate dentistry treatment in Scotland right now is to pay for it, what do you do if you can't? I thank Jamie Greene for his supplementary question and I compliment him on his puns. I disagree. I don't believe that NHS dentistry is in crisis. However, there are— Members, please, we need to hear the minister's answer. I accept that there are a number of difficulties. However, we have come far in a reasonably short time. As I said before, through payment reform, that is how we are going to change the system. The Scottish Government has linked clearly ambitions to sustained and improved NHS dental services, and we intend to work collaboratively with health boards to find local solutions. We have expanded funding into local dental services to support that. In addition, we are also working with the other nations of the United Kingdom to improve the pipeline of dentists coming to Scotland from Europe, which was so negatively impacted by Brexit. Last week, dental practices in Langham and Arran announced they were deregistered in 2,000 NHS adult patients. That adds to the more than 10,000 NHS patients deregistered with other practices in recent weeks in Dumfries and Galloway. You cannot register with an NHS dentist and that is a crisis minister. Why does the minister think that the Government's action, including promises of future funding arrangements, is failing so badly to stem what is the collapse of NHS dentistry in Dumfries and Galloway? I do appreciate the issues that there is in dentistry in Scotland. I am working very hard with my colleagues to ensure that we are finding solutions with the dentists. I outlined in my response to Jamie Greene what those are. There is just a single practice in Orkney providing NHS dentistry, showing the particular fragility in the islands in the context of the BDA figures referred to by Jamie Greene. With payment reform now pushed back to November, does the minister accept that its vital dentists have sight of the detail of what is being proposed well ahead of the November deadline? What assurances does she have from the chief dental officer that there will not be any further delay in this process of reform? I thank Liam McArthur for that question. I do agree that it is important to involve the dentistry profession in the discussions that we are having. That has happened to date, and that is continuing at a pace as I stand here just now. The Nuffield Trust in 2022 found that the number of EU and EFTA-trained dentists registered in practice in the UK was halved after the EU referendum and is yet to recover. Is it undeniable that Brexit, along with the pandemic, has been a factor in the current challenging situation in dentistry? Despite the difficult context, can the minister provide an update on the progress being made in providing extra support in areas where there is greatest patient need? It is true that some areas are particularly affected by the present situation, made worse as I have highlighted before by the labour market effects of Brexit, which is why we have expanded Scottish Dental Access initiative grants. Those grants pay out of potential. We need to hear the minister. I will not have all this harping away from a sedentary position. The minister has got the floor. We need to listen to the minister's response. Thank you very much. We have extended Scottish Dental Access initiative grants to wider parts of Scotland, and we have also made available and enhanced recruitment and retention allowance. I am also fully aware of the need to increase workflow force pipelines from overseas. As I have said previously, I am working with and writing to the Department of Health Ministers to ensure that the changes are made on a four-country basis to improve the registration process for overseas dentists. To ask the Scottish Government what action it is taking to increase the GP workforce. We are making good progress to increase the GP workforce. Since 2017, GP headcount has increased by 291, and a record 5209 GPs are now working in Scotland. We have increased medical undergraduate intake by 448 places since 2015-16. We have also increased a number of general practice speciality training posts by 35 in 2023, with further uplifts being considered for 2024 and beyond. Fill rates for speciality training are at a record high, with a 99 per cent fill rate for 2022. Last year, Mr Yousaf launched our GP recruitment marketing campaign, and we are providing significant investment in initiatives that ensure that the setting of a GP remains an attractive create option for those in the medical profession. Ruth Maguire, I thank the cabinet secretary for that answer. Speaking with one of my local GP practices, they have told me that their unsuitable premises are making recruitment and retention difficult. They are currently operating in a building that is too small. Can I ask the cabinet secretary what capital funding is available for building, developing or improving primary care facilities in Ayrshire and Arran? I recognise the point that the member has raised, because I have GP practices as my own constituency who are experiencing similar challenges. Part of the difficulty that we have at the present moment has been the cut to our capital budget, which has resulted in the Scottish Government having less capital available to it, which is restricting the level of investment that we can make across the whole of the public sector, alongside that with projects that are presently in delivery or due to be delivered experiencing very significant inflation as a result of construction inflation being much higher over the course of the last year and a half. All of that is having a negative impact on the expansion of capital investment projects, including in primary care. I want to assure the member that once we are in a position where we have greater flexibility in our capital budgets going forward, we will always look at the opportunity to make more funding available to invest in areas such as primary care in order to support GP practices across the country. GP is a team effort. There is disparity between agenda for change uplifts for NHS admin staff in hospitals and DDBR uplifts for GP, leaving primary care staff feeling devalued. We are hearing staff are leaving general practice from comparable hospital posts. A concerned practice manager wrote to Douglas Ross and myself expressing concern that disparity means they are losing staff, putting pressure on practices to close and patients are frustrated because they cannot contact the practice. I am concerned that the cabinet secretary cares more about hospitals than primary care where 90 per cent of all patient contact occurs. Will the cabinet secretary ensure parity between hospital and GP admin staff uplifts and pay so that primary care providers can recruit and retain the staff that we desperately need? I recognise the issue that the member has raised because it is an issue that I have discussed with GPs in my constituency. We have passed on the recommendation from the DDRB in the uplift for general practice, as was recommended. I recognise the challenges that some of our GP practices face because of the general change agreement for the rest of the NHS, but the reality is that the finances are not available to us in order to pass that on to primary care in the same way. The member will be well aware why that is the case. It is because of the financial circumstances that we face as a result of the appalling management of the UK economy by his colleagues at Westminster. Members, I keep having to say this. The point of the question and answer is that we ask the questions and we get the answers. Cabinet Secretary, please continue. I suspect that it is because I do not like the answer, because the reality is that the mismanagement of the UK economy has resulted in significant cuts to public expenditure, which is having a direct impact on our expenditure here in Scotland. I recognise the challenges that that creates for general practice as well, but I also think that the member should recognise the consequences of his own party's actions at Westminster, which is having a direct impact on public expenditure here in Scotland. To ask the Scottish Government what it is doing to reduce waiting times for NHS Scotland's child and adolescent mental health services. We have set the conditions needed for long-term sustainable improvement to CAMHS. That includes significant additional funding for CAMHS services and new community-based mental health and wellbeing support for children and young people. As a result, we are seeing sustained positive changes in waiting lists with a significant drop in the number of waits over 18 weeks. I recognise absolutely that we must see further sustainable improvement and reduce variation. We are continuing to provide tailored support to the boards facing the greatest challenges, ensuring that robust improvement plans are in place and progress is being monitored closely. I thank the minister for her response. I have a constituent who, as a teenager, is now waiting the best part of three years for a diagnosis from CAMHS. She could well be an adult by the time it comes through. We learned this week that the Scottish Government pledged to recruit an additional 1,000 mental health specialists has not been delivered. This is now a crisis situation facing families like those of my constituent. So when is the minister going to make things better? We are seeing at the moment—I know that that is not much comfort to your constituent, to the member's constituent, who has been waiting for it over three years. I am more than happy if he wants to write to me about that particular case to look into it. At this moment in time, we are now seeing the most sustained positive changes in CAMHS waiting lists that we have seen for over half a decade. The last four quarters have seen each of the four highest figures on record for the number of children starting treatment for CAMHS. The number of children starting treatment for CAMHS and the latest published quarter is comfortably the highest figure on record, 5,548. That is up 11.1 per cent. The overall waiting CAMHS waiting list has decreased by 9.3 per cent since the last quarter, a reduction of 777 people. Children waiting over 18 weeks has decreased by 31.9 per cent since the last quarter, a reduction of over 1,000. Children waiting over 52 weeks has decreased by 41.9 per cent since the last quarter, a reduction of 523. That has been made possible by the hard work of the CAMHS workforce, which has more than doubled under this Government. Addressing the CAMHS backlog is only one part of improving the mental health of our young people research and mental health foundation. Last year, I found that 54 per cent of college students presenting to student mental health teams have moderate to severe symptoms of depression. Will the minister provide an update on when the Government expects to conclude the development of the student mental health action plan and when do they expect it to be published? I had a meeting just very recently with my colleague within Government, Graham Day, and that was the topic of the discussion. We are working closely on ensuring that the commitments meet the needs of the student population and ensuring that there is sufficient financial backing for the commitments that are going to be made, and we will be more than happy to update you as soon as we possibly can. Presiding Officer, to ask the Scottish Government what action has been taken to ensure the long-term sustainability of general practice. We are absolutely committed to the long-term sustainability of general practice. We continue to make good progress to increase GP workforce. Since 2017, GP headcount has increased by 291, and a record 5,209 GPs are now working in Scotland. We remain committed to the GP contract and the delivery of extended multidisciplinary teams, making it easier for patients to see the right person at the right time in GP practices and the community. We have recruited more than 3,220 healthcare professionals since 2018 to support GP practices through our £170 million primary care improvement fund. In Fife, the precise practice has become the latest to go under the direct management of NHS Fife. The medical director of NHS Fife said that the GP partners at Park Road Medical practice are independent contractors of the health board. They have confirmed, following the retirement of one of their GP partners, that they are now no longer able to continue to manage the practice. This follows the news that a total number of full-time, whole-time GPs in Scotland fell by 119 between 2019 and 2022, despite rising patient numbers. I have tried with Fife health board to establish how many GPs are due to retire in the next few years, and that is very difficult to get that information. Does the Government hold that information and what plans are you putting in place? As it stands right now, the information that I am getting is more and more GPs are ready to retire, so the crisis is going to get worse and worse. What are you going to do to deal with that? I hear the point that the member is making in relation to the information that he has not been able to get from NHS Fife, and I will undertake to take that away to see whether we can get that information for him specifically from NHS Fife for him as well. As I have already outlined, we are taking forward a range of different measures, including recruiting more GPs, increasing the level of training places that are available for GPs, and expanding the workforce that supports GPs through primary care services in the way in which I have already highlighted this afternoon. All of those measures are all collectively actions that we are taking to address the very issues that the member has highlighted. Of course, what is important is that we ensure that general practice has been an attractive location for individuals to work in as well. I can assure the member of my determination to make sure that we do everything that we can to help to support general practice and to expand our primary care services, to make an attractive location both for GPs and for the wider multidisciplinary team to work in, and to make sure that patients get the appropriate care in the right place within their local community. I can assure the member that the actions that we are taking are addressing the very issues that the member has highlighted. The cabinet secretary commented on ScotGem, the graduate entry to medicine, a couple of times during this session. Will he recognise the positive feedback that I have had from NHS Fife and Galloway regarding the ScotGem programme, as it is unique to Scotland? The ScotGem programme is proving to be an effective programme that provides a graduate entry medical degree with a focus on rural practices. It is an important part of a wider range of programmes that we have in place to ensure that we encourage individuals into general practice within rural areas. What I want to do is to make sure that we look at building on that. We are also committed to developing a remote and rural workforce recruitment strategy, which will be published by the end of next year. Again, we are helping to do what we can to support employers to ensure that health and social care staff within our remote and rural areas are able to meet the needs of the local community in the years ahead. That concludes portfolio questions on NHS recovery, health and social care. There will be a very short pause before we move on to the next item of business.


BuddyForest here. I'm doing a multi-random from a break from a couple weeks ago. It's 21-22 immaculate basketball hobby. Case number 18. There's a redemption here. It's a dual auto of Ray Allen and Steph Curry. Now the dual auto car number one, Ray Allen is Celtics and then Steph Curry is obviously Warrior. So Celtics Warriors on the random here. Best of luck on this one. That'd be a great card to get. Two best shooters ever right there. Also good luck to you both and thank you for joining the break. Now it'll go, we'll roll the dice here. Got a four and a five. That means nine times, we'll randomize nine times, whichever team is on top. Let's get in the card. And once again, good luck. One, two, three, four, five, six, seven, eight and nine. The Celtics get the card. The Celtics. Congrats to the Celtics. Again, thank you both for joining the break. Do appreciate it.


The Great Barrier Reef is precious, a unique national icon and important to the whole world. But it's in trouble, having lost half its coral cover since 1985. Climate change is the biggest long-term threat. Improving water quality now will help the reef bounce back. Farms are the main source of pollutants. Other land uses, like ports, industry, mining and urban development can also have locally significant impacts. Sediment runoff makes the water cloudy and prevents seagrass and coral getting the sunlight they need to thrive. Nutrient runoff from Fertiliser is linked to outbreaks of coral-eating crown of thorn starfish. The Water Science Task Force has recommended ways to reduce the runoff of sediment and nutrients and priorities for investing an additional $90 million in Queensland Government funding over four years. There have been big efforts over the last decade to reduce runoff, but progress has not been fast enough. We need new technology, innovative practices and land use change to meet the water quality targets. Some ideas have worked, but others have been too complex, fragmented and have been poorly communicated. As part of the Task Force's interim report, we've come up with some solutions. We know that there is no one silver bullet to improve water quality. A range of tools will be required. We need to provide more financial support and incentives to our farmers. We need to provide better education and extension support to farmers. Everyone needs to be part of the solution and we need to more clearly communicate that. Science should be better aligned and funding should be provided for innovative solutions. More reef-wide and local-scale monitoring, modelling and reporting is needed. Better outcomes-based regulations like water quality permits should be introduced, staged over time. We have suggested running two large-scale demonstrator projects, one in the wet tropics and one in the vertical to test the effectiveness of a mix of tools. And we've also suggested some funding priorities. These are our thoughts on what we can do to improve water quality. Tell us what you think. Share your thoughts at gbr.qld.gov.au by the 22nd of February 2016.


Ultimately, did it just come down to you wanted to be a Tennessee Titan and the Tennessee Titans wanted to have you. When I told my agent and my team that, you know, I want to be here in Tennessee, you know, I think the goal was to get a deal done. Just talking to Miss Amy one day in the cafeteria, you know, we're going to get it done, we're going to take care of you here in Tennessee. And that put me so much at ease and I appreciate Miss Amy so much. She cares about you. She's a fan of you. Is that one of the reasons that you're so loyal to this organization? One thousand percent. When I first got here, when I first met Miss Amy, that's when I knew I was like, this is the place for me. Draft night. I promise I won't let her down. And once we, you know, came to a conclusion that I'm accepting this deal and I told her how much I appreciate it. And when she responded, she told me, you promised me that you would never let me down. You haven't done that. One of the moments I'll never forget is the night that you were drafted in 2019. You had such an emotional response. Thinking about that moment, the last four years and how far you've come, are those same emotions coming back? Those same feelings? One thousand percent. Didn't hit me until today when you actually be around everyone in this building and you get up on that stage and you realize, you know, my life about to change even more than it did when I got drafted in the NFL. When I stood up on that podium, like, this is real. I always wanted to be and get drafted to a team where I could call home. October 20, 2019. It's your first game. You had 21 snaps against the Chargers, six tackles. You sacked Phillip Rivers. You had just returned from an eight month recovery that was unbelievable how quick it was. Nobody thought you would play that soon. What do you remember about that day? A lot of goosebumps, I say. I remember talking to Coach Rave. He was like, it's your decision. And I remember sitting in his office and saying, Coach, I'm ready to play. Arriving to that stadium, I just remembered, like, I just kept getting chills. And it's like, I'm about to really play my first in the field game. I get my first set against, to me, a Hall of Famer quarterback. I was just so grateful to Todd and them, their training staff here that helped me get my knee right. Here's another big Jeff moment for you. October 18, 2021, fourth in inches at the Titans three against Buffalo. What do you remember about the atmosphere that night and just how electric that stadium was? First off, I'm gonna say the atmosphere was crazy and unbelievable. Titans fans, we need that every game. That was a long drive. I remember taking the knee and I was like, I was exhausted. But in my mind, I'm telling myself, you have to make a stop.  Because of the film study, I remember they was like, if he doing that walking around, he going to be walking around, he's going to come on in the center. It's a sneak and I tightened down a little bit. The only thing was, go make that play. That's one I'll never forget for sure. And the fans not going to never let me forget it because they always going to bring that one up right there, you know, just that moment. You know, that's what this game about creating them type of moment that you'll never forget. A couple weeks later at Los Angeles on Sunday night football against the Rams, Titans first game after Derek Henry's gone for the regular season. The Titans are given zero chance that night. But it seems like someone forgot to tell you that because you had a monster game, six tackles, three sacks and three tackles for loss against Aaron Donald and the eventual Super Bowl champions.  I think that night, the mindset was, how can Jennifer Simmons play better than Aaron Donald? I'm just going out there on that field. It's like not just for me, but for the whole team, everything just clicking and clicking. I want to give you the opportunity to create the moment that you created April 2019. So here's your camera right here. If you just want to look right in there and tell people what Jeffrey Simmons plans are for 2023 and beyond. Getting that Super Bowl here in Tennessee. It's going to take a lot of work, but I really deep down feel like it's going to happen here in Tennessee because we have the teams to do it. We have the coaching staff to do it. Whatever I say, I mean it. I mean it from the bottom of my heart.


I'm introducing Dr. Michael Millis, the professor of surgery as well as vice chair of global services as well as consultant to the Chinese Ministry of Health and he'll be talking today about living liver organ donation in China. That's the most. Okay, that's working. So first off I want to thank Mark and the organizing committee for asking me to talk today. And I'd also obviously like to thank the board of the McLean Center, those of whom are here as well as those who are not able to be here for their continued support of the McLean Center as well as this conference. So thank you all very much. I am humbled and honored to be listed in that five group of people that Mark noted in his talk. Obviously one person that was notably missing was Mark himself. He has been a leader in the ethical conduct of transplant, the pursuit of the cutting edge of transplant, and he deserves to be on that list far more than I and although I do thank Mark for his support over the years of that. So Mark asked me to give the talk on living donor liver transplantation in China and my first conflict of interest. I have received grants from the China Medical Board for this work. I think it's important also to note what I haven't done and what financial conflicts I do not have and that is I have never performed a transplant in China. There are surgeons in the U.S. and around the world who certainly during the period of time in which the donor source was known to be from an unethical source would nonetheless go over for VIPs in China and perform transplants. And I have never done that. I have also never received money from the Chinese government. So what I discuss is truly what I believe we have accomplished and I'm happy to share with you that. So in every country living donation is linked to deceased donor transplantation. To understand the role of living donor liver transplantation in China, one must understand the history of liver transplantation in China. In 2004, over 2,000 organs were transplanted in China, only behind the U.S. in terms of number of organs transplanted. Essentially all of these organs were from executed prisoners and most were transplanted into four nationals, so called transplant tourists. The transplants were performed in over 600 hospitals with no requirement for quality, qualifications, field strength or institutional support. The system to obtain donors was rife with corruption, paying judges to declare a death sentence, timing the execution according to the need for the organ. Lack of consent of the prisoner, the prisoner's family, kickbacks to the chief of security in numerous cities throughout China, kickbacks to the prison system, etc. The corrupt system generated millions of dollars in revenue to all parties, except of course the prisoner. Human rights abuses have received a lot of negative press and much of it justified based on past practices. It is far easier to criticize a system than to work to reform and develop new ethical systems. In 2006, Vice Minister of Health Jai Fu Wang announced to the world what those of us in transplantation already knew, that the organs China was using were from executed prisoners. What the world did not know was that the vice minister and I had shared a vision of changing the system. Soon after that, Jai Fu and I submitted a grant to the China Medical Board to fundamentally change the transplant system in China. The changes started with transplant center regulation, requirements for quality and experience, banning transplant tourism, requirements for a prisoner of consent, a post-transplant registry, central government and Supreme Court review of all death penalty sentences, among many others. The next step was to determine how to develop a voluntary citizen-based deceased donor system in a country that today still does not have a brain death law.  We instituted a pilot program of the system which was successful and then expanded it to a nationwide system. In January 2015, the government banned the use of organs from executed prisoners and some of those who were involved in the corrupt prior system, including some surgeons, are now in jail. The voluntary citizen-based deceased donor system generated 2,766 donors in this past year, providing 7,393 organs for transplantation and is on a pace for over 4,000 donors in the current year. The changes over the years have had a significant change in living donation in China. Now we'll focus on living donation, liver transplantation in China for the remainder of the talk. So in 2014, I visited over a dozen transplant centers in China. This was following visits to Hong Kong in which I had started to hear about what was going on in China and I wanted to learn more. So I questioned a number of medical and non-medical transplant and non-transplant affiliated people in China during my visit to China. And I asked them about living donation and other sources of organs, etc. And the common response was that Chinese would never accept living donation. The reasons were that they wanted to be buried whole, that Confucianism and Buddhism was not supportive of living donation. But the real reason was that they thought that the prisoner donation system that they had would take care of the need and therefore there was no need to look for other sources of organs. So that obviously did not deter me from working with Jifu to develop a better system. And so this is the first legislative codicelle regarding organ transplantation that China had ever had. And this was effective in May 2007. This followed a very interesting meeting with this document in draft form that was held. We were talking earlier and someone asked the question about getting people in the same room without Skype, etc. This, Mark, I'm sure you will remember this, we had a meeting in my office with Mark, one or two of my other colleagues, my son who had gotten interested in this topic as well and who is now a third-year medical student here. And Jifu and others from China, they joined us by phone and we went through this document, article by article, making sure that it essentially brought China to the level of international standards in as many ways as we could. One of my guiding principles in working with China on this issue was that I did not want to put in harm's way those people in China who needed transplants. And if we immediately excluded organs from executed prisoners, it would indeed do that. So in this article we still allowed organs from executed prisoners because there was no other choice for China at the time. And we went through and we tried to make sure, Mark and others in the room, that it embodied what the international standards were, except obviously for that part, banning transplant tourism, establishing quality metrics, etc., etc. And following this, following that discussion of the preliminary draft, ultimately this final document was passed by the State Council and put into effect in China. So it did address, and other regulatory documents subsequent to that, living donation. And that the rights and outcomes of the donor were the first priority, that the recipient outcomes were second. And despite what was commented on earlier, I have always felt that donors were my patients. They are not just suppliers of organs, they have always been my patients. That there was a comment regarding selection of living donors, and that is that spouses and blood relatives up to the third degree could be reviewed only by the hospital committee before being allowed to donate. If it was suggested that the potential donor only had an emotional bond, then it must be reviewed at the provincial level. Based on essentially the code of conduct based on the WHO and the Transplantation Society. The Ministry of Health continues not to really encourage living donation. And the reason for that is that they recognize that the legal, social, economic and health systems are not in China, are not yet mature enough to support living donation as they require. But it is progressing living donation nonetheless. Health issues, the issues that they are concerned about are obviously health issues, post donation without insurance. In China, health coverage is generally based on the province in which you were born. So even if you are living in Shanghai, you might have more permissive insurance policies for post donation health issues. If you are born in a province out in the western part of China, your health benefits may not be so permissive and you may not have health benefits for any complications of the donation. The Ministry of Health developed criteria for living donor centers and essentially this is a subset of the currently Ministry of Health approved centers. They are much more proscriptive in regards to the potential donors as well as the clinical pathway as we would look at them than we are in the U.S. They have national standards for BMI, hypertension, anatomy, et cetera that would regulatorily be universally dismissed by U.S. centers. Paying for organs and organ brokering is a criminal offense. That was one of the statements in subsequent regulatory articles with penalties against the surgeon, hospital and broker. So does this mean that all organ transplant tourism has ceased or that there are not some people who continue to break the law? It does not. China is 1.4 billion people and there are certainly cases in which have been noted that have either been from organs from executed prisoners, transplant tourism, et cetera. The difference is that when these are brought to the Ministry of Health with documentation, the Ministry of Health does investigate it. And they have investigated a number of them and the summary is there. Of interest, right before the International Transplant Meeting in Hong Kong this past summer, the Ministry of Health received a letter up on the right hand side here, this letter here. Obviously you cannot read it, it's not meant to be read really. It's stating that someone had provided evidence that there had been a transplant tourist who had received an organ in China and that the Ministry of Health needed to investigate. And they did and in the brief time between that letter and the meeting, they had investigated and that the doctor's license was revoked as well as the hospital's transplant license and the criminal investigation was still ongoing. Importantly at this International Meeting, Jifu showed this slide and gave everyone an email that if in fact you see patients that have received organs in China that they want to be notified of that through that email address and they will investigate. So they are committed to developing a system that is ethical. So in terms of numbers, the red bars here are a living donation as you see. This is in 2010 when we started the pilot program for the disease donor program and for the first time in 2015, the number of donors from the disease donor program is greater than the number of organs from living donors. These are all living donors, both kidney as well as liver. And obviously most of them are kidneys but we will talk a little bit about livers. Specifically most of the living donor liver transplants are in pediatric patients and it's interesting the number of pediatric transplants in the U.S. and in China are roughly equivalent, 529 in the U.S., 524 in China. But in the U.S. we only do about 51 living donor transplants with the majority obviously getting their organs through the deceased donor system.  So almost all of the organs are deceased DCD type donors with significant ischemia time and thus not suitable for reducing or splitting that has provided the U.S. and other countries with organs that are of good quality to use parts of them into kids. Since they don't really have a system for that because of their organ donor system, they rely heavily on living donation. So this past year, 358 pediatric living donor liver transplants were performed. Almost all and I'll show in another slide in just a couple of centers. So here we have 817 organ transplants every month. Almost twice as that many people are now listed. There are 36 deaths every month including two pediatric candidates. So their need is clearly there in China just to take care of Chinese patients. Here's the waiting list. The largest liver waiting list is 550 patients and obviously it's increasing. The time of active waiting even though we see here they're not happy with this and if we look at it from a western perspective, these are pretty good waiting times. Over half of the patients who are waiting for a liver transplant get one within a year and essentially 75% or over get it within two years. As a reflection of the special qualifications really needed for pediatric liver transplantation, medical migration which they look at as if patients are leaving their province to go somewhere else for their transplant, 75% of the pediatric patients are transplant or medical migration into essentially two centers, one in Shanghai and one in Beijing. How much does it cost? I specifically asked this at one of the meetings. So for a living donor liver it's about 200,000 RMB which equates to about 30,000 US dollars and it is more expensive for a deceased donor organ in China. In the US it's about the same so it's interesting that in China it's about three times more. So what is the current state? So despite living donation not being promoted by the Ministry of Health that is thriving especially in the pediatric population. Two centers in China are doing the vast majority of them and it counts for the majority of medical migration in China. China has established regulations that attempt to minimize abuses and a living donation found in other Asian countries. Currently Korea and Japan continue to perform more adult living donor transplants than China. So back once again I will refer to a meeting that Mark and I had this time not in my office but in my chairman's office at the time actually mid-2000s in which we were discussing whether the University of Chicago should get involved at all in trying to help China change their transplant system. And in that conversation Mark and I, my chairman of the time Bruce Gowertz and on the phone was Rory Schwartz who was head of the China Medical Board who obviously knew much more about China than any of us and still does. He was in China for many parts of his adult life and to make sure that the people that we were going to get involved with were truly committed in the same way that we wanted to be. And so he gave us certainly assurances that Jaifu and his team wanted to go in the same direction that we wanted to go. And so two institutions are my primary colleagues at Peking Union Medical College in the University of Chicago with the support of the China Medical Board were brave enough to engage and change the Chinese transplant system by establishing a system that allows the 1.3 billion Chinese citizens to be partners in the medical community and one of the greatest advances in modern medicine and in the process improve human rights in China. So this is a photograph at the founding of Peking Union Medical College and this is at the time the president of the Board of Trustees at the University of Chicago. This is John D. Rockefeller and other people who helped establish the Peking Union Medical College. This is a current picture. You still see the Portico. The photo was taken from this direction. And then this is Rockefeller's chapel obviously here on the campus, the logo of the China Medical Board, and then many of the people who have helped make this happen visiting my home several years ago with Jaifu Huang here in the middle and members of his hospital entourage and his academic entourage. Once again, I thank Mark for all of his support over the years for allowing us to do this, to being involved and saying that it's ethically the right thing to do and I appreciate Mark and I appreciate the audience here. I don't know if I have any time. Yeah, that's all right. Yes. Thank you very much, Mike. Thank you.


So, hi everybody, my name is Ana Soreda, I am the head of the Hematology Department at the Catalan Institute of Oncology in Barcelona, Spain. Very much involved for quite a few years in the diagnosis and treatment of patients with multiple myeloma. And I really want to congratulate myeloma patients Europe, MPE, for this 10th anniversary. And I really want to send you a warm regard to all of you. I think that these associations are extremely important nowadays and they have been very important for many years. It's very important to all of us, to the medical community, the scientific community, to have patients with a specific malignancy as close as possible to us. And it's very important for them to understand everything and to be able to make the adequate decision. So in this sense, all the work that MPE has been done for these last 10 years, I think it has been extremely relevant and very important to try to keep the patient population as much updated and as much close as possible to the other healthcare professionals that dedicate sometimes to improve, at the end of the day, the long-term outcome of patients with multiple myeloma. So thank you very much.