The first item of business is members' business debate on motion 10402, in the name of Tom Arthur, on eliminating hepatitis C in Scotland, a call to action. The debate will be concluded without any questions being put, and I would ask Tom Arthur to open the debate for up to seven minutes, please. Thank you, Presiding Officer. I am grateful for the opportunity to open the debate on the report, Eliminating Hepatitis C in Scotland, a Call to Action. I wish to put on record my thanks to all who contributed to the report and to colleagues from across the chamber who signed my motion enabling this afternoon's debate to take place. The report was produced by the Hepatitis C Trust in collaboration with clinicians, support workers, representatives of the pharmaceutical industry and MSPs from each party represented in the Scottish Parliament. As such, it reflects the views of a representative cross-section of those working to treat and eliminate hepatitis C. The objective of the inquiry, as described in the report, was to map progress towards the Scottish Government's world-leading commitment to hepatitis C elimination and to develop recommendations to ensure that elimination is achieved. In both those areas, the report makes an important and considered contribution to our understanding of where we currently stand and where we need to get to if elimination of hepatitis C is to be achieved. Before considering some of the specific recommendations that were made in the report, I will first seek to give an outline of what hepatitis C is, who it affects and why elimination is an important public health goal that warrants our attention and continued support. Hepatitis C is a blood-borne virus which, if left untreated, can lead to degeneration of the liver and severe liver disease, potentially resulting in the need for liver transplant. In Scotland and across the UK, the virus is predominantly spread through the sharing of unsterilised equipment used to inject recreational drugs. Sharing needles for the injection of steroids also presents a risk of transmission, as would the use of unsterilised equipment for tattooing, acupuncture or body piercing. Other means of transmission are possible, such as unprotected sex, however, are less common. In Scotland, it is estimated that there are 35,000 people who carry the hepatitis C virus of which 15,000 are thought to be undiagnosed. That compares to an estimated 6,000 individuals in Scotland who are HIV positive, of whom 800 are believed to be unaware of their status. In both testing and treatment, there have been significant advances in recent years. Dry blood spot testing offers a simple and accurate way to determine one's hepatitis C status. Treatment is now highly effective, safe and of a relatively short duration. However, that was not always the case. Prior to the introduction of all-oral, direct-acting antiviral therapies, treating hepatitis C commonly required a long and demanding regime of interferon, which was often ineffective and could cause severe and debilitating side effects. Therefore, it was not uncommon for people with hepatitis C to be unable to complete a treatment regime. Indeed, some chose actively not to seek treatment due to the potential of an adverse reaction. That is understandable, particularly given that many people with hepatitis C are initially asymptomatic. Unfortunately, despite availability of new treatments, many of the fears about dissuaded people from having a test or seeking treatment persist. It is therefore vitally important that we, as individual MSPs and as a Parliament, send a clear message. If you think that you may have been exposed to hepatitis C at any time in your life or are concerned about your status, please reach out and seek support. That could be to a GP or other health professional or to one of the excellent support charities such as Hepatitis Scotland, Hepatitis C Trust or Waverly Care. Whatever way you wish to engage and seek support, the important thing to remember is that there is no need to worry in silence. This last point that I made speaks to the first area of focus in the report, the need to raise awareness. As I have indicated, it is estimated that more than 40 per cent of those living with hepatitis C in Scotland do not know their status. Some may suspect and others may have no inclination at all. For those who are concerned that they may have been exposed to hepatitis C, one of the key barriers to testing is stigma. While recognising that stigma has decreased in recent years, the report states that stigma was reported as being still highly prevalent and considered more significant among some groups than the stigma attached to HIV. The effect of such stigma can be to prevent individuals from accessing testing for the virus, with some refusing to even consider the idea that they could be infected due to fear of being stigmatised if diagnosed. The stigma stems directly from the fact that hepatitis C predominantly affects people who have previously or currently inject drugs for recreational use. It therefore reinforces calls to recalibrate thinking on substance misuse and understand it as a public health issue. The report also highlights the need for awareness-raising among other less-known at-risk groups, such as users of image and performance-enhancing drugs, men who have sex with men, a group where awareness of hepatitis C is often lower than awareness of HIV, and a South Asian community where there is a higher prevalence within the wider population due to the widespread reuse of needles and razors in some South Asian countries. To address those challenges, the report makes a series of recommendations. First, it asks the Scottish Government to investigate the feasibility of a national awareness campaign. Secondly, it calls for high-profile public figures to use world hepatitis day, which takes place each year on 28 July, as an opportunity to speak out publicly highlighting risk factors, the importance of testing and ease of treatment. Thirdly, it asks to target awareness-raising messages to the less-known at-risk groups, for example in gyms for people who use image and performance-enhancing drugs in sexual health services for men who have sex with men, and in religious and community centres attended by members of the South Asian community. The report also recommends additional awareness training and support for GPs, particularly given that symptoms associated with hepatitis C can be easily misdiagnosed. All those recommendations that I have just outlined would have a positive impact on raising awareness and changing attitudes towards hepatitis C, and they are all recommendations that, in the context of broader public health challenges, would be relatively straightforward to implement. In my remarks concerning the report, I have focused on the issue of awareness. However, the report presents evidence and recommendations on the areas of prevention, testing and diagnosis, linkage to care, access to treatment and funding. I look forward to hearing the thoughts of colleagues from across the chamber on those aspects of the report, and I would strongly encourage anyone who has not yet done so to read the report. In concluding, I wish to make clear my view and that of all those involved in producing the report, that we have a truly great opportunity in Scotland to continue to be world-leading in the treatment of hepatitis C and achieve elimination by 2030, and perhaps even sooner. We must not let this chance slip from our grasp. Let us redouble our efforts, make elimination a reality and constain hepatitis C to history. May I ask all those who wish to take part in the debate to press the request-to-speak buttons? Can I remind members that time is limited for this debate, so it is absolutely essential that you stick to no more than four minutes? I call Miles Briggs to be followed by Mary Gugio. Thank you, Deputy Presiding Officer. I would like to start by congratulating Tom Arthur on securing today's debate. As one of the HIPSE Trust parliamentary champions, I am very pleased to contribute today. I thank the Trust for their briefing for today's debate, as well. It is a very welcome publication of the I Call to Action report, which is a really positive and useful piece of work that makes valuable recommendations around prevention, testing and diagnosis, linkage to care, access to treatment and funding. As Tom Arthur has indicated, it is estimated that around 34,500 of our fellow Scots are chronically infected with hepatitis C and that more than 40 per cent of those are undiagnosed. In too many of those cases, it has been diagnosed and are not connected to treatment services. In 2016, 1,739 people began treatment for HIPSE, which was slightly less than the previous year. The fact that the rate of incidents among people who inject drugs, a key risk group, has risen significantly in recent years, almost doubling between 2011 and 2016, is a real concern. Prevalence among prisoners is especially high, with a 2012 study indicating that almost 20 per cent of prisoners were found to have HIPSE. More recently, the Parliament's Health and Sport Committee undertook an inquiry into prisoner health, which highlighted the number of areas in which we are still failing as a country to help to identify those who are infected and look towards treatment pathways. The Scottish Conservatives welcome and do support the Scottish Government's commitment to a sexual health and blood burn virus framework to eliminate HIPSE. However, the challenge is now that we develop and then expand the innovative solutions and approaches that will make that a reality in the years ahead, given the current treatment rates that are broadly in line with new cases. Clearly, a step change will be needed if we are to meet the new annual national minimum targets for HIPSE treatment initiations of at least 2,000 in this current year, 2,500 in 2019, 3,000 in 2020 and 3,000 for each subsequent year. I know that work is currently being undertaken that will inform and eliminate plan, which the Government has promised to publish later this year. Getting this plan right is vital, and as we seek to extend best practice across all health board areas and roll out successful initiatives to other parts of our country, NHS Tayside, which has not had its troubles to seek in recent months, is a leading part of the country in how we can feasibly look to eliminate and meet that target. Moving forward and moving testing, screening and treatment out of hospitals into a community setting, especially within community drugs and alcohol services, will be extremely important, and I hope that there will be lessons to learn around that. I hope that, in closing this debate this afternoon, the minister will be able to update Parliament on when the strategy will be unveiled and what engagement she and her officials are having with key stakeholders, including patient groups, the third sector providers and pharmaceutical companies, involved. I hope that engagement will indeed include close collaboration with Waverly Care in my own region, which is undertaking an important pilot project that has embedded a community link worker within HMP Barlinnie in Glasgow to engage and support prisoners with HCV, both while in prison and on their release into the community, to make sure that they get that future care. I also hope that the minister will give details of the funding that the Scottish Government will provide to support the elimination plan going forward. Stakeholders are anxious to see budgets protected and, crucially, for the savings arising from the reduced cost of treatments for them to be reinvested into the redesign of services and increased efforts to identify and treat more people with HCV. To conclude, I again welcome today's debate and the focus that it has brought to tackling HCV in Scotland. We have a genuine and rare public health opportunity in Scotland to effectively eliminate a disease, and we need to grasp that. We eagerly await the anticipated elimination plan being published, and I, another HEPC parliamentary champions and other colleagues across the Parliament, look forward to scrutinising the plan and working with the Scottish Government to ensure that it is delivered on the ground in reality. Scotland used to lead the world in our determination to eliminate HCV. It is time that we did the get-go. Can I remind members that they may be disadvantaged in colleagues if they go over their time? I would also like to start by thanking Tom Arthur for bringing this debate and this important topic to the chamber for discussion. For the work that I know that he's done, as well as to all the other contributors to the report, eliminating hepatitis C in Scotland, and for his role, and I know other colleagues' roles, as Scottish Parliamentary Champions for HEPC. We have parliamentary champions across the chamber from all parties today. I read the report with great interest and have followed the work, because I represent a constituency half of which rests in the NHS Tayside area, so I was glad to hear Miles Briggs raise that today. Now, like others in this chamber, as elected representatives, we have regular meetings with our local health board. It was when I was attending a meeting with NHS Tayside last year that they gave us a presentation on the work that they'd been undertaking into hepatitis C, and I really found that work just incredible, and that's really why I wanted to speak about that today. We've already heard that Scotland has been considered a global leader in this area, and NHS Tayside has very much been at the forefront of that work. Like I said, NHS Tayside has been leading that work, and it has been under intense scrutiny of late. It has the issues that need to be resolved and we have to give credit where credit is due, and that is particularly to the team who is working on it and recognises what they have achieved so far. Just to give an idea of the impact of that work, Professor John Dillon, who is a consultant hepatologist at NHS Tayside, stated that the project that is being undertaken there is on course for Tayside to be the first region in the world to have eliminated HCV. That is huge and vitally important, and that is largely due to the pioneering approach that they have taken to tackle the virus, which uses treatment as prevention in the project, testing and treatment of hepatitis C through community pharmacist-led care. That is an approach that has won the team a number of plaudits over the past few years. As has already been outlined, hepatitis C is a blood-borne virus that can be contracted in a number of ways, but most commonly through the sharing of needles via intravenous drug use. The largest single group that is most affected has been those prescribed opioid replacement therapy. We are treatment for hepatitis C previously relied on those who came forward for treatment because they had either been identified as having used drugs in the past or were accessing other health services. The NHS Tayside project focuses on preventing the spread of the illness by looking to those who are most likely to pass it on, and that is the act of drug users. Professor John Dillon attended the Parliament's health and sport committee at the start of the year where he outlined the rationale behind it. He stated, in your career as an injecting drug user, perhaps you inject for several years before moving on to recovery. If you become infected with the virus during that time, you will potentially interact with six or seven other people whom you will pass the virus on to. If you can offer treatment at a very early stage while people who are infected are still actively injecting when they have contact with other drug users and share equipment with other drug users, their chances of transmission disappear because they are not infected anymore. It is the idea of treatment as prevention. Given that those on opioid replacement therapy received that from a community pharmacist, the team focused on community pharmacies as a means of engaging with patients to access testing and treatment. It is now estimated that around 80 per cent of those with hepatitis C in the Tayside region have been diagnosed, and transmission rates, which currently sit at around 5 per cent and 10 per cent, are expected to reduce to just 1 per cent over the coming few years. As it says in the report, hepatitis C is preventable, treatable and curable for the vast majority of people. New treatments are now available, with short treatment durations, limited side effects and cure rates upwards of 95 per cent. Scotland is a world leader in this area, but with current testing and treatment rates suggesting that we may not hit the target of eliminating hepatitis C by 2030, we need an elimination strategy. We have the projects that are working in Scotland. We have the capacity to do it, but we need the focus and strategy to get us there and to help us to maintain that world leader status, but, more importantly, to eliminate the virus itself. I recognise that I have a long afternoon in the chamber, so I will not incur your wrath and stay strictly within my four minutes. Can I start by thanking all the people who have Tom Arthur for bringing forward this important debate? I also thank the Hepsie Trust who have supported all the parliamentary champions and in putting the risk report together, and I thank the collaborative and cross-party approach that has been taken in this important work. That is something that unites us across the chamber, and I suppose that is the purpose of this debate today, how we can unite behind eliminating hepatitis C in Scotland. I think that it is an ambitious report. I think that it is right that we should try and meet the Government's target of eliminating hepatitis C by 2030. We have more than 35,000 sufferers of hepatitis C in Scotland, but the moment that we are treating less than 10 per cent—far less than 10 per cent—so, while I agree with the Government's target to eliminate by 2030, I think that it is important that we have a full, detailed strategy on how we do that elimination, but also behind that, a deliverable strategy about how we achieve that elimination. A big part of the challenge is the fact that up to 40 per cent of cases are still undiagnosed in Scotland, and less than one of five people in Scotland are receiving the treatment that they need. Finding, testing and treating patients and locations that are accessible is absolutely essential, particularly because there are issues with substance misuse more generally. Given that 90 per cent of hep C cases are people who are previously injected or are currently injecting drugs, I think that how our drug strategy relates to our hep C strategy is also extremely important. This report says that Scotland is falling behind. None of us wants Scotland to fall behind. We want Scotland to be the beacon and the pinnacle of eliminating hep C. That is why we should look to England and France, who have set targets of 2025, to look at where there is best practice to learn from, but also where we can improve on their strategies. It is a deliverable strategy so that we can eliminate hep C in our own right here in Scotland. We want a strategy, a detailed strategy, a deliverable strategy, a strategy that focuses on two areas, firstly on finding and diagnosing a greater number of cases, working collaboratively with the organisations to find new patients, and secondly, removing barriers to treatments with clinicians having the freedom to select the most appropriate treatment method. It is important to look at how we can partner with prisons, because quite often there are patients who start treatment or could potentially start treatment who are in our prisons. However, because of the length of their sentence, they perhaps fall off that treatment or they do not begin the treatment because there is not that support base that comes from when they leave prison and what happens in individual communities. How we have that work collaboratively with our prison service, with our NHS and also with community facilities is absolutely important. We also know that the cost of treatment has fallen significantly too, so that should encourage us to go even further in terms of being able to treat more people for less money. We should recognise that if we eliminate hep C, if we treat people early and eradicate hep C, that will provide a net saving to our NHS in terms of all the associated conditions that go together with having hepatitis C. I promised that I would finish well within my four minutes. I hope that we can continue that collaborative work and bring forward a meaningful strategy. I hope that the minister can set out in more detail what that strategy will look like, when it will be published, what funding will be behind that and what measurable targets we will have over the course of that strategy to make sure that we can test whether it is actually being delivered, so that we can eradicate hep C from Scotland. I would like to first congratulate my colleague Tom Arthur for bringing this important debate to chamber today. Mr Arthur has been very involved as one of the cross-party hepatitis C champions that led to the report, Eliminating Hepatitis C in Scotland, a call to action with the Hepatitis C Trust. I would also like to acknowledge the other champions, MSPs Anna Sarwar and Alison Johnstone-Miles Briggs, who are in the chamber today, as well as the other champions. The report brings together views of leading clinicians, services, charities and patients who participated in the inquiry. I thank everyone who is involved in the work. The report is not lengthy and I would encourage folks across health and social care and wider society to read the report so that everyone can be further informed of ways to tackle and reduce rates of hepatitis C in Scotland. The report's 30 recommendations support proposed work under eight different categories, namely elimination, awareness, prevention, testing and diagnosis, linking to care and access and treatment and finally funding. Those areas are all clearly laid out in the report. In the time that I have, I would like to address the testing, screening and diagnosis aspect of the report. Testing or screening has been done previously using simple blood samples that are tested to look for antibodies to the Hep C virus, which is the body's response to exposure to the Hep C virus. There is also a PCR test that establishes whether the virus is still active and needs treating. I note that the dry blood spot testing that Tom Arthur mentioned is now available and NHS and Frees and Galloway offer the dry blood spot test service. It was interesting to read that testing rates have increased in recent years, but the number of persons diagnosed has decreased in 2015 and 2016. That may suggest efforts to find undiagnosed patients may be stalling. I am especially interested in the hard-to-reach persons. Most new blood-borne hepatitis C viral infections are the result of sharing or injecting equipment among people who inject drugs. Since problem drug use is the national public health concern, the chamber recently debated and passed a motion proposing the introduction of an SDCS, which is a safe drug consumption site in Glasgow. The report supports innovative approaches, so I would like to suggest that SDCS is one of the potential innovative approaches to finding undiagnosed persons. That is action number 16 under the recommendations. As outlined by the minister in the previous debate, such places would help to reach some of the most marginalised and at-risk people in our communities who inject heroin and have potentially shared injection equipment, even once. Even sharing equipment could lead to hepatitis C infection. That would enable the offering of screening and testing leading to diagnosis and treatment for hep C. Add-equipped provision of sterile injecting equipment needs to be made available in places such as community pharmacies and substance misuse services. The report supports hep C screening in GP clinics in areas where there is a high hep C prevalence. Finally, as Tom Arthur has said and the report states, through a combination of implementing the recommendations, there is an extraordinary and achievable opportunity to eliminate hepatitis C by 2030. I would ask the Scottish Government to analyse the report's recommendations and support the motion. I too would like to thank Tom Arthur for securing this debate. This is absolutely a public health issue, and I am very proud to be a hepatitis C parliamentary champion. With colleagues, I strongly believe that it is time that we did as much as we possibly can, much more, to diagnose and to treat people. It is thought, as we have heard, that around 45 per cent of people in Scotland with hepatitis C are not even diagnosed, and that is unacceptable, not when treatment is so effective and can play such an important role in prevention. I too would like to thank all the experts who have taken part in hepatitis C meetings who have contributed evidence to this report, which is indeed a call for action and action now. I would particularly like to thank those patients who have shared their experiences with us. I would like to share my sincere admiration for the incredible work that the Edinburgh access practice does to diagnose, treat and care for people with hepatitis C. By building fabulous relationships, strong relationships between staff and patients with the help of their fantastic outreach specialist, they are able to get people the diagnosis and treatment that they need in a setting that suits them. I learned that this specialist even knows which sofa a patient is sleeping on on a particular night of the week. That is what I call outreach. I think that that is really important. We often hear a lot about treating people who are hard to reach. I understand why people use that phrase. I am sure that I have used it in the past myself, probably too often, but I am reminded today that people are not hard to reach. It is our services that can be hard to reach. Stigma is still a barrier, and some people who are not diagnosed have many other complications in their lives. I will never forget meeting a patient at the Edinburgh access practice who told me that their joy at recovery now felt clean. The clear impact that it has had on their mental health and wellbeing and the feeling that they did have a productive life ahead of them is really important. We cannot underestimate the opportunity that we have to make that difference to many more people in Scotland. When the health and sport committee heard evidence on treating bloodborne viruses, we were told time and time again that we need to get out into community settings to make sure that people are diagnosed and treated. We have heard from Tom Arthur and colleagues that previously treatment was so notoriously debilitating. It was pretty scary and off-putting, and it would be avoided, but we have come a long way since then. The more people that we can diagnose and treat, the better. It is not long since we had an important debate on the need for safe drug consumption facilities in this chamber. Those facilities would provide another opportunity to test and treat people. When I prepared for that debate, I read NHS Greater Glasgow and Clyde's report taking away the chaos. I was really alarmed when I read that people who injected drugs considered hepatitis C ubiquitous and therefore inevitable. Sharing communal batches of drugs or needles stored at public injection locations was commonplace. We need safe drug consumption facilities to reduce new cases of hepatitis C and treat those who already have it. Dr Ken Oates raised a point at health and sport committee, which we would do well to consider today. He suggested that, although there will always be diverse views on ring-fencing, some protected funding can be of real benefit to vulnerable people. He gave the example of funding streams for alcohol and drugs partnerships. Anna Sarwar is right that prison testing rates remain too low. We should have an opt-out basis for testing there. When people are released from prison, that treatment should follow them where it has started. I really think that Parliament has a fabulous opportunity here. I associate myself with Mary Goujon's comments. In my view, the NHS Tayside treatment model should be rolled out as quickly as possible. We have already made a commitment to eliminate hepatitis C in Scotland. That is achievable. That is an area where Scotland could easily be leading. Let's lead and I look forward to hearing from the minister how Scotland is going to take action now to eliminate hepatitis C. The last two open debate contributions are from Ivan McKee, followed by Brian Whittle. Thank you. I would like to take this opportunity, as members have done, to thank Tom Arthur for bringing this important debate to the chamber today and to all those who are involved in the preparation of the hepatitis C trust report. It is not often that we have the opportunity to eradicate a disease in its entirety, but today we are debating the possibility to do just that. If the correct steps are taken over the coming period, Scotland could be at the forefront of the global efforts to eliminate hepatitis C, making a huge difference to the lives of thousands of individuals and their families, current sufferers and those yet to be diagnosed or to contract the disease. In addition, elimination would save the health service many millions currently spent on treatment and care that could be diverted into other priorities. There is much talk and healthcare of the preventative agenda, the concept that spending extra money now results in lower costs to the system later. Often the problem with executing on preventative spend opportunities is the difficulty in understanding and demonstrating the link between the extra upfront spend and the consequent savings, which often, for many reasons, do not materialise as anticipated. However, in the case of hep C elimination, the relationship is much more clear-cut. Every year a number of cases are treated and while new medicines have significantly reduced the cost to treat the total spend, it is still high. Increases in treatment rates delivered now will result in lower rates of incident going forward. The numbers can be modelled and the resulting future cost of treatment in both scenarios is evaluated. Over and above the savings from lower future treatment costs of the condition itself are the savings and cost of consequent conditions, for example, liver disease and care. Often preventative health measures can exacerbate health inequalities with the middle classes listening to healthy lifestyle messages and acting accordingly. However, the elimination of HCV, however, will reduce health inequalities as often affects vulnerable and deprived groups in society. I would also like to take this opportunity to raise awareness of the work that has been undertaken by Waverly Care and Abbey in Barlinny prison in my own Glasgow Proven constituency, a project that I have visited and witnessed at first hand. The prevalence of hepatitis C amongst the prison population is estimated as high as 19 per cent. As part of the project, a community-alink worker is embedded in the prison. They engage with and support prisoners with a hep C diagnosis whilst in prison and upon liberation into the community. That ensures that there is continuity of care and that the individual is not lost to the system as often the case. Otherwise, the pilot is proven successful and has now been extended to other prisons. The report makes proposals for inclusion in a Scottish Government implementation plan for elimination of the disease. That plan needs to provide robust modelling of the numbers required to be treated on an annual basis to reduce infection rates to report where elimination is achievable. It also needs to model the financial impact. How much more needs to be spent each year and for how many years to increase treatment levels and how much that will save in the long run. It has been estimated that elimination can be achieved within the existing budgets for hep C, but it will require a different approach. Adopting flexible budget models that support NHS boards to deliver multi-year budget plans and having ring-fence budgets for hep C with a minimum rather than a fixed treatment target. Negotiations with drug suppliers for a fixed cost for elimination over a given period could dramatically reduce cost per treatment. There needs to be a whole system approach to ensure that implementation and funding are co-ordinated at a Scottish level and that savings are monitored and then reinvested to accelerate the elimination process. By taking those steps, I believe that we can look forward to the day when Hepatitis C has been eliminated in Scotland. The final open debate speaker is Brian Whittle. I can see that he is really keen to respond, minister. Thank you, Presiding Officer. I add my thanks to Tom Arthur for bringing this debate to the chamber. The work he has undertaken and other MSPs, such as Miles Biggs, Alex Cole-Hamilton, Alison Johnston and Anna Sauer, to highlight the cause of eliminating hepatitis C. I also want to add my congratulations to Hepatitis C. Trust for their report, a call to action, which both highlights the challenges that are facing us as we work to eliminate hep C in Scotland and shows how we can get there. I am aiming to eliminate any disease that is a big ambition, but as we see in this report, it is achievable not by a single grand gesture or proclamation, but through targeted interventions backed up by a political will from this place. As has already mentioned, the Health and Sport Committee has done quite a lot of work in this area and has heard exactly what was talked about by Mary Gougeon in the Tayside application and the way in which they are looking to eliminate hep C up there. It was also raised in the debate in this chamber when we discussed safe injection houses, as Alison Johnston mentioned. The chamber is prepared to stand up and debate some really hard topics. It is clear from this report that one of the biggest obstacles in eliminating hep C is in the area of diagnosis, particularly early diagnosis, because people infected with hep C can show few or no symptoms for years. It is more difficult to detect the virus before it causes serious liver damage. That increases the risk of people unknowingly spreading the virus to others, as has been mentioned today. The majority of new hep C infections result from intravenous drug users sharing injection equipment. Many of the contributors to this report felt that the best way to address that was through preventing drug taking in the first place through supporting opioid substitution therapies such as methadone. Again, we have had that debate in the chamber. I would like to caveat that by saying that methadone in itself is the solution, but it is certainly part of a much bigger solution. I think that the importance of raising awareness and providing opportunities for testing. When we are discussing prevention, I think that the peer-to-peer awareness programmes in prisons and in substance misuse services is really key because, again, when the health and support committee were out in the communities discussing this particular looking at drug use, it was very obvious then that the most effective way of persuading people from taking the drug and injecting drugs was peer-to-peer. That is a really important service that continues. I also highlight the lack of symptoms to encourage people who may have, in the past, engaged in a behaviour that could put them at risk of having the condition that is really important. That debate is part of that. In testing and diagnosis, I think that the report identifies a fall in the number of patients being diagnosed in 2015 and 2016, despite increasing testing rates. I think that that only emphasises the need to ensure that testing is being targeted effectively. We know where to look for that. Clearly one of the biggest opportunities for testing comes when drug users visit needle exchanges or addiction support services. I would like to hear from the minister how the Scottish Government is going to look to continue that kind of support. However, we can only be a viable option if we combine that with awareness programmes that seek to normalise testing and ensure that no one has put off those services as a result. I think that the stigma has been mentioned several times in this chamber. Lastly, I would like to address the need for the barriers to testing to be brought down. I think that the need for more testing in non-clinical settings where staff have a strong personal relationship with clients can actually be a better place to encourage them to be tested and support them in the event of a positive diagnosis, as Alison Johnstone highlighted. I am going to sit down at that point. Thank you very much, Mr Whittle. I call Eileen Campbell. Seven minutes, please, minister. No more on that. Thank you, Presiding Officer. I thank my colleague Tom Arthur for bringing this important matter to the chamber. It has provided us with an opportunity to reflect on Scotland's track record in tackling Hep C to respond directly to some of the recommendations of the Hep C trust report and to outline the Government's strategy to limit the Hep C as a public health concern in Scotland, which is very much in line with today's motion. Over the past decade, Scotland has been at the forefront of efforts to tackle Hep C. In fact, that is recognised in the Hep C trust report, which recognises that Scotland has long been regarded as a world leader in tackling Hep C. Indeed, to Scotland's Hep C's action plan was a model that informed the World Health Organization's approach to national action plans for viral Hep C. A Scottish NHS expert was seconded to the World Health Organization to help them to develop their thinking on that. That directly led to the first-ever World Hep C summit being jointly hosted by the Scottish Government and the World Health Organization in Glasgow in 2015. It was also in 2015 that we announced our intention to eliminate Hep C as a public health concern. That intention and ambition is something that the Government remains committed to. Hep C disproportionately impacts on some of the most vulnerable people in Scotland, but it is a disease that can be cured and effectively prevented. That means that we can't eliminate it—a point forcibly made by Mary Gougeon. Indeed, in response to Mary Gougeon and others who raised the work in NHS Tayside, I'll be visiting NHS Tayside on Tuesday. I'm meeting with Professor John Dillon and other professionals involved in that board's leading work. We'll be able to understand a bit more what learning we can share and replicate as we work on that issue. I recognise that there is a clear desire for a strategy to eliminate hepatitis C infection in Scotland. Our current focus is on eliminating the serious disease associated with the virus, and we have seen real progress with that. I have recently asked Health Protection Scotland to provide recommendations on how we might eliminate the virus. On receipt of that advice, I will make sure that members are updated as that work continues to progress. In the meantime, in January of this year, I increased the annual treatment targets for hepatitis C to 2,000 per year for 2018-19. We will keep them under review over the coming years, but it is important to recognise that the figure represents the minimum number of patients who should be treated. I know that others mentioned that this afternoon, but that is not a cap. That is the minimum that we expect to be treated, and we will keep that figure under review, because we are treating more people and we are treating them successfully, but we must also increase treatment capacity in a safe and sustainable way in order to keep us on track to do the good work that we are all celebrating today. I agree with hepatitis C trust reports' emphasis on the importance of combating stigma around hep C. Tom Arthur eloquently articulated the barrier's concerns and fears surrounding the stigma associated with hepatitis C. In the 2015 update to the sexual health and bloodborne virus framework, the Government reconfirmed its commitment to tackling stigma and the negative attitudes towards those affected by bloodborne viruses. That is why we are providing £1.9 million over the next three years to third sector organisations to support innovative work to tackle sexual health challenges and reduce bloodborne virus transmission. That includes work to challenge the stigma and activities that specifically target the most at risk groups such as vulnerable young people and those who inject drugs. Members recognise the recommendations around awareness. In response to some of that, the Scottish Government is actively considering the feasibility of a national awareness campaign, and funding has also been given to Hepatitis Scotland to lead national awareness raising activity and to do work in raising awareness among professionals, including general practitioners. I hope that that gives some comfort that we are actively going through recommendations from the trust and where we can and where it is feasible, we will consider the recommendations fully and make sure that we act upon them. The report also notes that prevention measures are a crucial element of any elimination strategy. I wholeheartedly agree with that point, as we know that those infections are primarily passed via injecting drug use, so it is crucial that we tailor our support and interventions to that vulnerable and complex group. We are funding third sector colleagues to better understand the population's specific needs by engaging directly with them. Miles Briggs, Anna Sarver and Ivan Key absolutely correctly mentioned concerns around prison. I have also witnessed some of that great work that has been undertaken through Waverly Care at Barlinnie and the support that is given to prisoners who face incredible challenges. We still have a lot of good work that is going on, but we still have a lot to overcome. We will continue to work with Waverly Care to understand what more we can learn from that as that work progresses. Miles Briggs, I thank the minister for taking this intervention. Throughout the debate today, we have heard the progress that has been made in NHS Tayside. How has that been rolled out across other health boards and what learning they can take from what is happening in NHS Tayside to date? I am visiting NHS Tayside on Tuesday to make sure that we can properly understand the good work that is going on. It is worth pointing out that this morning I was at the National Sexual Health and Bloodborne Virus Advisory Committee meeting that has representatives from David Goldberg, who has given us a presentation on the work that has been happening across the country, specifically citing the work on NHS Tayside. Of course, that work, that group, is populated also by—I forget her name though, but it is people from NHS Tayside who are continuing to make sure that we understand the work that is going on there to ensure that we can, through their advice to me, understand that and make sure that that can be effectively taken forward in other parts of the country. Others have mentioned the issues around the work that is being taken by Glasgow City Health and Social Care partnership around the safe consumption rooms. That is absolutely why we need to ensure that the work that is going on around hep C absolutely is complemented by the work that we are taking forward around the substance misuse strategy. I think that a point raised by Annas Sarwar is that we are making sure that things are complementing one another. It is important to recognise that we are building this work on from a position of strength. Recently, for example, Scotland Scotland recognises the 2018 international liver congress with the success that we have had in reducing serious hep C-related liver disease. Health protection Scotland data shows that we have delivered a 39 per cent reduction between 2013 and 2016 in the incidence of— You must close, please. —composacus cirrhosis in those with chronic hep C. A clear indication that our approach of targeting those most unwell is working. Again, I congratulate all the members for speaking and we will look forward to continuing this work. Thank you, minister. That concludes the debate. We now move on to the next item of business.


The Experience Innovation Cafe, or XIC as we call it for short, is a space where team members, frontline leaders, patients and anybody can come to look at some themed opportunities for improvement. They have presentations that are done for them that we call X Talks and then they have opportunity to engage a little bit deeper during what we call X Play. At the end we collect surveys or scorecards and we bring that to the Human Experience Committee in order to help us bring the voice of the frontline to our decision-making process. The day Wambi presented at XIC, they were talking about bringing the voice of the patient, the voice of the family, to the survey. So now that team members, frontline caregivers, EVS, clerks, are all hearing from the patient how well they're doing. Growing up I spend a lot of time in hospitals when the care providers were burned out or stressed or didn't really have the time to do the work that they wanted to do that really impacted the patients and families. When there were no systems that just took customer satisfaction leading to employee recognition, that's when I sought out to develop it. Wambi is a care provider recognition and performance system that is powered by real-time patient family feedback. It starts with the patient family providing those real-time reviews and then care providers are given access to their own individualized gamified dashboards where they are empowered with their patient satisfaction analytics, they get incentivized, and they get rewarded for the great care that they deliver. It enables the patient to directly give information back to the person that's caring for them so that they can adapt that care to further provide an exemplary patient experience. We introduced Wambi to Hack and Sac Moravian Health, team members, leaders. We had them present at this experience innovation cafe. Everyone that was there pretty much the next day was emailing and asking if they can participate in having Wambi come to their hospital or site. Wambi is currently engaged in a pilot where we have launched in five hospitals and units within each of those hospitals. We had a day with the Wambi team where we had a reveal day for the team members so they can see their individual dashboards. The team members for the first time were able to see their picture and what the patients were saying about them and how the patients were rating them. When I saw it I just thought that it was nice to see our team members' faces and know that our patients are rating us and that points, it just was nice to see that. It's a game changer because it's really the only tool right now that has patients that are recognizing their caregivers. It motivates those caregivers to continue to provide that level of care, sensitivity, empathy, and service to our patients. Really there's an amazing synergy between Wambi and Hack and Sack Meridian Health and sort of our values. We're really honored to be a part of this partnership and we're really looking forward to seeing where it goes.


Russia said on November 17 that its forces shot down three Ukrainian MiG-29 fighters while Ukraine claimed its armed forces struck Russia's command post, according to official briefings from the two countries. The Russian Defense Ministry said in a briefing released on Friday that in the past week, the Russian army repelled the attacks of the Ukrainian army in many directions including Kupinsk, Krasnyi Lyman and Donetsk, Zaporizhya, Kursyn and attack Ukrainian artillery system and command post. In addition, the ministry claimed that the Russian air defense forces had shot down three MiG-29 fighters from the Ukrainian side and intercepted 22 Vomars rockets and 198 drones. On the same day, the general staff of the armed forces of Ukraine claimed that over the past 24 hours, 53 battles took place in the frontline area. Meanwhile, Finnish President Sali Niinistus said on Friday that they had decided to provide Ukraine with a new military aid package estimated at 100 million euros.


Great. Well, hi, everyone, and welcome to this month's Patient Safety Movement Foundation webinar. Today's topic will be focused on patient medical and legal perspectives of unsafe care. Before we get started, my name is Sarah Miller. I'm our director of partnerships with the Patient Safety Movement Foundation, and I'm very excited and honored to facilitate today's webinar. So we'll jump into the objectives really quickly. So these are the objectives for today. I will read through them for you all. The first one is understand the different priorities and perspectives of patients, families, clinicians, administrators, and attorneys when dealing with medical harm. The second is recognize how medical areas have historically been handled and why there are such disparities in the way different roles typically respond. Third, consider the impact the current methods of dealing with medical error has on patients, families, and others. The fourth one, discuss the expectations that patients and families should have of healthcare organizations in preventing harm before it occurs and how they can participate in keeping themselves safe. And finally, summarize the steps everyone can take to improve communication, transparency, and respect for each other in dealing with harm when it occurs. So moving on to the CE slide. So today we're really excited to offer board certified patient advocates, CE credit, BCPA. Again, if you are in the live webinar, you will receive one CE hour. So please feel free to email education at Patient Safety Movement with any questions you might have regarding the CE. And again, it will take about five to seven days to process. So a few housekeeping items before we get started. At the end of this webinar, we will have about 10 to 15 minutes of discussion. So up here you'll see we have a chat feature at the very bottom and a Q&A feature. I did want to show the differences between the two. If you do have a question that you want one of our panelists to respond to at the end of this webinar, please shoot it into the bottom right where it says Q&A. It's where the red boxes. And if you have, you know, a comment, a question throughout the webinar that you'd like to kind of have side discussions with other panelists and attendees, you can pop that into the chat. But again, any questions that you want our panelists to answer, please pop that into the Q&A for the end of this presentation. So moving on to this slide, we do have a fun interactive polling feature for today's webinar. It's called Slido. So during this time, I would really encourage all of you that are on this live webinar to log in and there are two ways to log in. You can scan the QR code directly from your cell phone, which is on the right hand side, or you can go to your browser on your phone on your computer and go to Slido.com right here on the left. And then it will prompt you to add in this code. So pound 875-992. Once you type that in, it will take you directly to the live polling teacher. We have two questions throughout this presentation that will give you all the opportunity to answer live. But again, you will need to log in. So again, two options. The right hand side scan your QR code and it will take you directly to this link or join us at Slido.com and put in the code pound 875-992. Okay, so with that said, I will go ahead and pass it over to Luis. I'm very excited today to have him be our moderator. So Luis, would you like to introduce yourself? Yeah, thank you so much, Sarah.  My name is Luis Torres Torija. I'm a physician and quality and patient safety coordinator at the Hospital Español in Mexico City and fellow of the Health Care Safety Fellowship of the Patient Safety Movement Foundation. I've been in this role for the last couple of years, and I'm really excited to continue learning and facilitate ways to give a better attention to our patients. So with that, I'm going to introduce our fabulous panelists. I'm going to ask everyone to briefly introduce themselves. Do you want to start calling? Sure. Thanks Luis. So my name is Colin May. I'm a lawyer in Calgary, Alberta, Canada. And I practice primarily in state planning and corporate law. However, I also do some work in professional discipline. And I currently am a commissioner with the Alberta Human Rights Commission and Tribunal, as well as a member of the Provincial Council of the College of Physicians of Surgeons of Alberta. So I deal with the regulatory element for doctors here in Alberta. And I've become, through a family event, I became involved in patient safety from numerous aspects, regulatory, dealing with adverse events, and from the legal side. Thank you Colin. How about yourself, Elisa? Good morning everyone. My name is Elizabeth Caveny. I'm an attorney as well. I'm the managing partner and senior trial lawyer at Caveny and Crow Law Firm in Chicago. I specialize primarily in medical malpractice. So deal with the eight issues of improper medical care or unsafe medical care very often. I have been an ambassador to the Patient Safety Movement Foundation for a little over a year now, and I'm working to improve patient safety in multiple venues. Thank you Elisa. And Regina. Hi, I'm Regina Holiday. I am a patient rights activist. I've been working on this field for 11 years at this point, due to my husband's medical care in 2009 and his subsequent death. I started a series of murals about how to improve healthcare in 2009 and became part of the affordable healthcare debate. And then I began painting hundreds of jackets with people's patient stories. I'm currently in the walking gallery in an attempt to change healthcare policy on a local as well as national scale. I'm currently in seminary and I do serve at four churches, and I'm currently in my chaplaincy at WVU medicine in Morgantown, West Virginia. I live in Grantsville, Maryland in Western Maryland, by Pennsylvania and West Virginia. Wonderful. Thank you all for this excellent presentation. And I'd like to begin by asking our audience to go ahead and use the chat box if they have any questions during the webinar, and we will review it in the final part of the webinar. And with that in mind, let's point ahead and get started. Well, as you know, the term medical error is a preventable adverse effect of care, whether or not it is evident or harmful to the patients. This might include an inaccurate or incomplete diagnosis or treatment of a disease, injury, behavior, infections, or any other type of ailment. Medical errors often harm and sometimes cause death. So we as clinicians, patients, administrators, families, lawyers, all have different priorities when something happens. And I want to ask Colin, what do you think are the organization's priorities in this matter. Thanks, Lisa. I think for organizations, when an adverse event takes place, sometimes they have conflicting priorities, sometimes it is to learn from it. But often, what you'll find is that the priority is to get over it, get beyond it as quickly as possible, with as little pain as possible to the organization, which often means not disclosing very much about what occurred, and not being that forthcoming with the patient or with the patient's family, unfortunately. And you'll often find that that might conflict even with the clinician. Sometimes you'll see that, you know, the clinician who may have caused the adverse event or been involved in or the group of clinicians are looking. They often do want to resolve it. They want to apologize. They don't like the fact that this has happened. This wasn't their intention, you know, and, but unfortunately, often the organization will try, will quiet them down. You'll end up with management bringing in legal who will tell them, don't talk about it, don't reveal anything, let us deal with it. And so you end up with clinicians being quieted, often families and patients not being given the information they need to find out what happened. And unfortunately, even for the organization, if their goal is to move beyond something as fast as an adverse event as fast as possible, what they often do is end up dragging it out because they force it into a litigious sort of environment. And unfortunately, what that does is it does drag it out for everybody involved. So often the organization is its own worst enemy in dealing with these matters. Yeah, you're completely right, Colleen. And really, in the part of the patients priorities. What do you think are, are these Regina. Well, as far as patients and families when it comes to this regard. There are so many opportunities now due to open data access. I'm a big proponent of the open notes project which has been taking off nationwide and in parts of Canada, where we open up the medical records the family and caregiver can see it, which allows us a little bit more access to what's actually happening in real time, or close to real time. So we get to dealing with these problems much more quickly than the traditional litigious way that was done in the past where it was shut down defend. Don't let the family or patient know what's going on, which caused harm because honestly in the cases of most patients, folks don't do because something went wrong as much as they sue because someone thing went wrong, and they were treated badly at the same time. And that was the kind of frustration that makes people hurt for the rest of their lives honestly. You're completely right Regina. And with that, I'm going to turn this over to the audience members and just like Sarah told you before you can log in into Slido for answering this question. I want to share with you what happened to you. How confident will you feel in knowing that appropriate next step to take. This is a scale of one to five, and being five, the most confident. So you can answer in in real time. I want to share that available evidence from the OECD and the WHO suggests that 134 million adverse events occur due to unsafe care in hospitals around the globe. This contributes to 2.6 million deaths every year. We took an account for example in the US. It is an estimated that more than 200,000 people die each year, making the medical error the first living cause of the precovid. It's now the fourth. And for what I'm seeing in the responses, we really do not feel confident at all about what is the next step to take when an unsafe care happen. And this is worrisome, but this is something that is happening around the globe. And yeah, it's important to take actions about this. And Elizabeth, I would really like your opinion on why is medical error the third living cause of death. Does medicine has become some kind of business. Well, I think it's important for everyone to know that medical errors are the third leading cause of death in the United States. And that's just death that doesn't include medical errors that lead to injuries that and this is only what's reported. So the amount of medical errors that patients are subjected to is an insurmountable amount. And I think it's twofold. I think that the old physician patient relationship no longer exists, where the physician knew the patient kind of from head to toe, all their health issues managed their health, managed consultants that they saw. And that there was one person that cared for a patient. So I think that's the way of the past kind of the old days of house calls are long gone.  And so we as patients keep becoming smaller in a bigger and bigger world that our care might not really be the main goal of the end person, which is a large corporation and a board of shareholders. I completely agree. And finishing the question, we can see that there's really, there's a lot of less confidence and well, very confidence is more percentage and taking this from an account, calling historically, what happens when patients point out errors, and how do they typically respond. In this case, there's, there's sort of two parts to that there's immediately in the moment. When you point out an error, perhaps to a clinician, and then there is the response as you move on at following the error. And as Elizabeth said, what can just kind of tweaking off what she mentioned is, because you don't have the same access to a single doctor who may be your family doctor in the same way you used to. Clinicians often work in large teams. Sometimes they don't communicate well with each other and pointing out errors can result in sometimes they'll blame each other. So jousting will happen amongst clinicians, and sometimes they'll blame the patient or the family they simply start off by saying well you didn't do this. You didn't follow your treatment or they'll, if it's in an acute care setting sometimes they will simply say well you're being abusive to me as a clinician, and do I'm to call security or I'll call the police you know, there's a there's often a very visceral reaction that happens. So it can be difficult even in the moment to respond. And then down the road historically what has happened is there is an effort to shut down the clinicians who may want to talk to the patient about or the family about what happened. And it usually involves sometimes that d'arvo acronym of deny attack and reverse victim offender applies while here, because you have a situation where it's often you often look to blame the patient or the family for something that happened. And instead of providing the information to them. So, as Regina said that will get you very, very rapidly into a situation of litigation it's often not the adverse event that leads to litigation, but the denial of the effort to prevent families and patients from experiencing what happened so that's, that's often been what happened. And as that combining with what Elizabeth talks about the sort of more contemporary and more recent situation, where you don't have access to a family doctor who can sit down and speak to you about what happened results in patients and families being left in the cold, so they have to find another solution which often means ending the end up going to a lawyer, unfortunately. And that's a very important point, the, the culture of denying the, the finger pointing the, who's to blame in this kind of situations. And with that, Regina, I would love your opinion about the progress that we have made up today. Well, it's been a challenging time and it is a time of transition, which the beautiful thing about a time of transition is we can do amazing things. As it was mentioned earlier the hospitalist versus the primary care situation. A lot of people in the hospital setting have absolutely new idea what these terms even mean. I don't even know who can be their advocate. What privileges are, you know, where, where can a doctor go in and advocate for you. So, so part of this is on learning with patients in the primary care setting about the wonderful resource of primary care doctor is within the family. One of the reasons you want to have a pediatrician prior to actually having a baby, because that pediatrician can be your advocate understanding that the old system is actually still in place in areas, and they can be someone who could help you. Well, as we go into hospital engaged networks and when organizations that are more focused on hospitals care, then it does become much more important that you be a caregiver advocate or a patient advocate for yourself, and understand the situation that you're currently in. We do need to keep in mind that right now there is a movement called direct primary care. Those are doctors who do not work within the traditional insurance structure. We still do house calls a lot of those folks do. So, so it's one of those things that there are that's another model that's being looked at nationwide. And of course with COVID right now that has changed practice as well. So a lot of people are doing unique care directions like you didn't used to see nurses go out to people's cars and provide care in a car setting. Now think about how many accidents occur when a patient's just trying to leave their vehicle and get into the doctor's office, how many hips are broken just because of a curve that was how to be reached right. So, the fact that we're in this point of chaos to some extent within health care is allowing for us to have some positive change. I also wanted to point out social media that was not really a thing like 1012 years ago. A lot of patients have realized that if they get on Facebook or Twitter and directly from their hospital bed sent out a tweet or post about the care that they're getting, they will get almost real time response to the situation that they're in, which is pretty amazing. When, when you can push your nurse call button and get no action, but when the Facebook manager realizes somebody's yelling to the world about the care, and you get action, then things have changed. So, there's a whole bunch of things going on right now I do also want to focus on electronic medical records. So at this point, most of the nation is using electronic medical records. They're using different systems within those records there are pilot projects right now going on about how we could be include audio files about this patient. It's actually effective for COVID patients where the patients often intubated and unable to talk, but that audio file can give a glimpse of that person's reality, and help the entire team provide better care. The same thing goes for pictures.  So we're utilizing technology in ways that can provide better care and less than errors. Well, Regina, that's, that's really interesting because you're touching this point of the information, the, the transparency, and I can say in the healthcare organizations, the, the current data on patient safety is only estimates. We don't really know how many people are affected each year, because we don't have an accurate measurement method. There is really no requirement that the public being formed of the frequency and severity of all medical errors, or the resulting patient outcomes organizations and physicians often feared being transparent with patients and families about medical issues that have occurred due to a fear of litigation or fault. There's really the certificates do not list the preventable medical error as a secondary or primary cause of death. It's only focused on diagnosis and physical causes such as cardiac arrest or sepsis, for example. And with that in mind, I want to ask another question to our audience. You can log in again to the, to the slide of polling question. And on a scale of one to five, the same five being the most confident. How confident will you feel in being able to get adequate information about the air. And I, you can start responding and we will review this, these results. And I want to ask Elisabeth, what does deny and defend mean for the patient who is hoping to see cancers. And how does it impact everybody. Well, look, I think we have to look at it in a couple of different ways, really to give the benefit of the doubt to the clinician. They have an inherent bias because of who they are and how they're trained. They're trained for instance surgeons, they're trained to do a certain surgery, a certain way, and to take certain steps, and they do a BCD E and the result is F, and that's what they're trained and every day they do a BCD E and F results and they do it 10 times a day. And so they have an inherent bias that I don't know what happened. I didn't do it. I didn't do anything wrong, because number one, they did a BCD E, and F didn't happen something untoward happened. And two, how could they continue to go on? How could they go to the next surgical room if they truly thought they did something in room A that led to the death of that patient. They have to think it wasn't my fault. I didn't do it. I didn't do anything wrong. I was able to go to the next surgery and able to be able to wake up the next day and continue to practice medicine. So I think we have to recognize that clinicians have an inherent bias to admitting fault and admitting medical error. That's the first thing. The second thing, you know, I tell, I spoke at a conference of laparoscopic OBGYNs. I was asked to speak about how plaintiffs attorneys evaluate medical negligence cases. I was the least popular person in the room. I can assure you of that. But one of the things that I said to the physicians is if you would spend more time in your patients room, they would never end up in my room, in my office. They will go to you first for answers to their questions before they will come to me. It is only when they don't get answers to their questions and they don't understand that they will come to a lawyer to try and get answers in questions. Very few situations are situations where the patient comes. They absolutely know what happened. They know what the error was. They know what the basis for a lawsuit is. They're not all wrong wrong site surgeries, you know, or amputation of the wrong leg. They're not. They're often very complex cases that take some time to figure out what occurred. But when they don't get that answer from the clinicians, they will come to an attorney like myself and you might not like the answer that I come up with. It might not even be the right answer. But I will make the time and go through the education and the medical literature and the records and talk to the as many people as I can and try and figure out for the patient what it was that happened. So the lack of transparency, whether forced onto the clinician by the organization or their insurer, or because of their inherent bias to believe that they didn't do anything wrong. The lack of transparency is what will drive them to litigation, or at least to seek legal counsel. I completely agree and in the part of the clinicians is normal that there's some fear regarding the repercussions of error that it can be from this accreditation legal problems to even lose their jobs. The hospitals have traditionally follow a deny and defend strategy providing limited information to the patient and family and avoiding admissions of fault. But there's also I want to share this that there's a growing number of institutions that have implemented a communication and response strategies that emphasize early disclosure of adverse events and a more proactive approach to achieving an amenable solution. We have second victim programs to give support to clinicians after an error where the focus is really on the system and not in the individual. And about the organizations, I will love your, your point of view calling about what does this deny and defend culture mean for the organization culture as a whole. I think for the culture as a whole. Just the learning piece is not there. If, as you mentioned there it has there has been a move to sort of quality assurance reviews that sort of thing on a systemic level. There's been a good element to that and a bad element of we've seen here in Canada, because there, they, there is an effort to learn from these experiences. But often you'll find that that effort itself will cover up some of what happened for the families and the patients because in Canada, for instance in my province in Alberta, under the evidence act. I've brought forward through a quality assurance review which is a systemic look at what happened not about individuals can't be used in any other forum so it's protected information. And when the meeting will happen between the, for instance, maybe the health services or some other organization that is responsible for the care. And when things held with family. They don't discuss findings of an investigation but outcomes of what they're going to do so often you'll find patients and families are looking around staring at each other thinking, well we know less now than when we came in and it gives you a sense that there is still a cover up going on that they're not giving you the information. It's the same thing in the United States and that whenever there's an adverse outcome. Most hospitals will require that a conference and more ability and mortality conference takes place, where some of the greatest minds at the institution will meet will review the records will interview the doctor interview the nurses and make conclusions about what happened and how can we prevent this from happening in the future. It's a beautiful thing, but the patients not invited to it, the patients families not invited to it. They're not, it's completely not discoverable in the United States, anything that's generated or done at that conference is kept confidential from the client and attorney is entitled to find out if an M&M conference took place, but we're not allowed to see any of the documents or any of the conclusions that were reached or changes in protocols that resulted. So it doesn't advance the cause that we're talking about today which is transparency. Yeah, that's exactly what we're seeing here in Canada as well. In an effort to learn. And perhaps a good, I think a good faith effort to learn. Organizations are still perhaps intentionally and sometimes intentionally shutting the family out from that process of learning by turning it into a systems error. And of course, so that will mean families may have to go to a regulator to complain about certain clinicians. And it really, what I'm finding is it, it actually prolongs the problem, because the patients and their families don't feel they've gotten enough information from this systemic review. So they end up dragging doctors and RNs before their regulator. So it just gives this product just extends the process. So I think as Elizabeth mentioned, there has to be a way to bring patients and families into those reviews that make them feel as well that they're a part of it they're contributing to it. But their concerns are heard, and that they're not feeling shut out so that, again, as I said it, we need to avoid that prolonged conflict that goes on, which just harms clinicians as well. Yeah, you're completely right. How can we align really all the efforts of all the, the persons involved in this kind of events. And I want to ask you, Sarah, if it's possible to review the results of the question. Thank you. This is important because this is one of the main things that we want to have with our patients. And really, all the health care system that we have in our different countries, of course, taking an account, the different context is the trust. So what happened when we do not think we're getting the adequate information about an error, and we can see here in the response that 0% feel very confident about the information that they're receiving about an error. And the most percent is really the part of the less confident side. And related to the information, according to studies like the one published by the patient safety movement foundation in their annual poll in US, for example, 87% of the general public have heard a little or nothing about medical error or patient injuries. And overwhelming support about creating more public information about this problem with 82% approximately having more focus on promoting patient safety. So with that in mind, Regina, what can patients, families, and the general public can do about it. So of course, we're somewhat limited in what tools we have a part of it is just embracing the fact that mistakes do happen. So in facilities around the United States for at least the past 10 years I'm aware of there's been the zero harm campaigns, and you'll see all these signs up about zero harm zero injuries, and is that a realistic goal. Truly, do we make mistakes. Yes. So right now this average is one medical error per day during hospitalization. So it's happening consistently. So when we ask people have zero harm zero mistakes, then I don't think we're realistic and what's going to cause understanding of reality. If we let the caregiver in the family and the patient be part of the care team, which honestly prior to COVID they actually were in many cases they were providing care in the room. Hospitals are understaffed. Now of course due to COVID visitation has been limited. So family caregiving in the hospital setting is not what it once was. So if we're truly viewed as part of the care team, then we need to be part of these meetings, we need to be part of the m&ms. As we go deeper into a world where telehealth is a standard of care. Thank you cove it for making that more possible. Then we truly are part of the care team, and we have to be part of all the same information and same documents. When charting occurs, it shouldn't just happen from the care professor professionals, but also from the patient and family themselves, because they are an understanding part of that team. When we talk about systemic problems within healthcare. It's important to remember that this information is not being shared often beyond the hospital system in which it occurs. Patient communities like patients like me and other Facebook groups are doing their best to spread information about systemic harm far beyond the current hospital system in which they are being treated. So we have great hope of progress and change due to what the patient voice can provide within a wider care paradigm and due to access to information. So it's great to spread more of that, which is really important. Yeah, you're completely right Regina and yeah, how can we change this paradigm about this kind of culture that normally we have in our country so it is a bit. How can patients and family members prioritize their goals in the short term and long term. Their term goal for any family or patient obviously is to prevent a medical error right so not even to get into this what we're talking about. And the best way to do that is to have a patient advocate with you when you're dealing with significant medical issues I don't mean when you're going for your annual physical or when you're going for your mammogram but if you know something's wrong. If you have been diagnosed with cancer or you've had a biopsy done and you're going to get the results. Take someone with you. I've been a patient advocate. I'm not a certified patient advocate and I don't mean take a certified patient advocate with you I mean, take someone that you lost that can take notes and can listen. I've been an advocate for both a medical malpractice attorney, a defense attorney and a judge on on two occasions gone with them to their medical appointments. And the questions I hear them say and the misinformation that they walk away from I think, who are you were you in the same room that I was and I was so thankful that I was there taking notes for that person because they were a patient. They weren't with medical knowledge they weren't a judge they weren't a medical malpractice attorney they were just a patient, and I was so glad to be there to be able to take notes and information so always if you're dealing with something, something important, or something important. Take someone with you a friend a family member somebody you can trust. If you don't have somebody hire a patient advocate and make the investment and have somebody go with you that can walk you through the process and help you find consultants and go to the next step. If a medical error does take place, if you've done that but yet something does go wrong. Try to go to the doctor first, talk to the nurses the nurses are often your best friends and the ones that cared for you while you were in the hospital. Talk to them if they're available to you often hospitals and organizations will pull them. And all of a sudden you won't see those same nurses that you had ever again. The surgeon doesn't come to do the follow up appointment and to see how your stitches are coming along. It's a resident only that does or it's an attending or one of his partners so you can't go back to your original doctor but try. Try and talk to the people that were involved. I think going to the organization is a complete and total waste of time. Contacting the organization asking for a meeting with their general counsel or their legal counsel or writing a letter about the doctor or telling them you want some questions answered complete waste of time in my experience. The next step is to talk to an attorney and and get or get your medical records and have them reviewed by a nurse or a physician if you if you have the benefit of somebody like that in your family, or in your circle of friends most people don't. But if you do that's a choice, you know to have your records reviewed, but find a qualified competent attorney. If you have a nurse employed full time I used to have to, I would have them go through the medical records with the patient, and so that they can look through them together and understand them, and they understand our decision on whether we're going to go forward with a lawsuit or we're not. Those are my suggestions on short term and long term fixes, although it's really a system that's broken it needs to be fixed first but if you end up unfortunately in that system. Those are some steps you can take. Exactly. So how do we prevent to this process happen how we developed this trust more than the normal physician and healthcare personnel with with the patient how can we improve this this communication. The patient can be filled as a part of the team, this patient center care attention that is is is really useful. And with that, Colin what should patients, families, and really the general public expect healthcare organization should do about it. I think something that Elizabeth has mentioned is, and this, we are seeing this more we see this in Canada and Alberta we've seen this. You're able to access your electronic records more easily. But as Elizabeth noted, most people look at their like their records and they have no clue what they're telling them. I think that is one of the areas where organizations should be more proactive. If you're looking at your records you want to find out what they mean. They're for most people they're very difficult to understand. There's a lot of jargon there's a lot of acronyms that you will never know what they mean. So watching, you know, medical show on TV a drama is not going to get you there. So I think that's one of the things is just being more forthcoming with the information, but also explaining it to patients and families they need to know what it is now. That doesn't mean you don't end up going to a lawyer, ultimately, to find out more because they may not tell you everything they want you to know that you want to know or that you need to know. I think having that access to the information is important. And as Elizabeth also said, in my experience as well. One of the least helpful things you can do is to go to the organization and complain. The complaints processes often are very opaque. And they will not give you the information again that you need, or they will be very cursory in their investigation without and not look to, to, to lay any blame or to even explain what happened. So you're often better. And Alberta, we have various agencies, you can certainly go to the regulator so that we are physicians board, the College of Physicians and Surgeons does investigations. There are other agencies set up recently Alberta just went through a process where we reviewed the entire complaints process across a number of organizations, including Alberta Health Services, which is the key provider here. We have public health here in Canada, and Alberta Health Services is pretty much it in this province. They are, they are the universal board that provides everything. Not necessarily in primary or long term but what I would say is, you know, we need to have, we should expect organizations to be more forthcoming, more proactive and giving us information. So, when they, they, I think what they need are complaints processes that are independent in many ways, the way you might have an internal auditor and a company, you need a complaints process or an office that is not controlled directly by management and legal stepping in to allow people to make complaints and to get a fair hearing. And that's that those are the things I think we need to look at going down the road. And I mean I'm happy that Alberta has done that where that goes right now that's just sort of in the consideration phase, but I think those are the things we need to see. And more, more ability to see what's going on immediately, more access to those records as Regina said, you can now go online you can make a Facebook complaint and get faster at reaction. And they are end down the hall and tell you're unhappy about something. And that that can be different, a bit different in Canada, maybe from the US because we do have government run healthcare so the reaction is somewhat delayed, perhaps but I have seen many people make a complaint on Facebook, or on LinkedIn or somewhere. And the next day, somebody from Alberta Health Services is is responding to that complaint and saying sorry what did we do wrong let's find out some more information. So I think those are the things that we need from these organizations, and move, we need to move forward with those, and we need to I think to get a sense that you don't want to. You know you don't you don't want to be attacking the family you don't want that to be the culture we need to have that culture of, as Regina has also said, their family was a caregiver patients had to have to be involved in their own care the person centered model of care, which also means the doctors and nurses are also persons ever they're all involved in this care as a team. And you want to protect everybody because of course doctors and nurses don't go to work, generally, saying I'm going to harm somebody. As Elizabeth said, they have a bias to, and in many ways to continue working and to maintain their health, they have to believe that they're doing the right thing. If something does happen, jumping all over them, and harming them doesn't help the situation either. So I think are we need that. We need that from organizations for both patients families and the clinicians. Just to add also, you know, at least half of the people that come to my office, come with a with the mindset that we just want to make sure that this doesn't happen to somebody else. They want to know that there's a check and a balance, and that if something went wrong, it's going to be rectified, not necessarily compensatorily to them, but that it's going to be rectified for the next patient for the next child for the next parent, so another family doesn't have to go through it. You hear about it in criminal cases that families who represent the families of the victim very often don't want the families of the offender to get the death penalty because they don't want that family to be just as ignored as they are. And it's the same kind of thing very often families of victims of medical error, don't want anything horrible to happen to the doctor, they just don't want another family to go through what they went through. And hospitals and organizations very often are doing checks and balances, or making a change in their flow sheet, or adding a box that needs to be checked or adding a stop in the surgery where everything has to be checked time out. But patients don't know that that that's happened as a result of their parents death or their child's injury and how good they would feel if they knew now, you know, call it Trevor's correction or, you know, and Sandy's time out and it would be such a benefit to families to feel like they lost something but it was at the, at the cost of a greater good, a greater good came from it. I think that'd be something really wonderful to see from organizations. Yeah, you're. Yeah, I was going to say I think Elizabeth has hit the nail on the head there. You know, certainly there are situations where people need compensation. They've been harmed. They have maybe permanent injuries that require lifelong care that is expensive and they need to be paid for that. But I think she's absolutely right. Most people are looking at this is what happened, apologize to us, be transparent about it, and make sure it doesn't happen to somebody else, or at least try to diminish the likelihood that it happens to somebody else I mean, as Regina said, you know, mistakes happen, you can prevent every mistake. But if you if an adverse event occurs because there is a flaw in a system or technical flaw, that can be fixed that can be addressed, and that should be passed on throughout the health care system to other organizations to, to other hospitals. And that's what a lot of people are looking for they feel that at least as upset as they are with what happened to them that they're you know humans have this sense that if we can help if we can learn from something that went wrong, and make sure that people are safe and protected, then that's that's an important. That's a very important thing for people to feel that what's happened to them has produced a fact where maybe 100 other people will not now go through that 100 other families will go through that. Yeah, you're making excellent points and really you're talking about the culture, you're talking about patients, families, clinicians, people. So, we all have fears, we all have a different ways to respond. And yeah, I've seen some of the comments about yeah, if a healthcare worker say something about a medical error they will get punished, something like that. This is mainly sadly things that happen right now, and that it does not help to align all the efforts of all the, the people involved to give the best attention possible. Let me see the part of the chat box. We have some questions. I have a question from Edith. Somebody commented on the imperative if that's the right word to not outright lie to the patient after a medical error, our physician denied any role in the action that cause an injury. We got a copy of the medical record a few weeks later from which we learned her claim was untrue. That's when the real rage at what happened began. What do you think about this. Yeah, I think in the United States, there's no law that requires a healthcare provider to confess an error to a family, or to provide accurate information. If they if they know it there's no requirement that they do so. If you've ever seen the movie bleed out, you know that a doctor will say one thing off the record and another thing on the record. But the lies will definitely incite rage and distance the parties from ever reaching any kind of a resolution short of litigation. And we have another question related to this deny and defend culture in the healthcare context is per safety, and we talk about the roles of the patients and the clinicians and the roles from this. How do we actually make the next necessary shift away from defensive and secretive responses to towards a relation restorative and healing response. How do we humanize the response to help her car and what role do non disclosure agreements playing this, who want to answer this this question. Oh, I'd be happy to just address it and if or Regina if you'd like to go ahead. Can we do it together. Sure, sure. The thing that you know you have to look at is, we've got, as I said there's legislation that prevents. We have these quality assurance reviews in Alberta, in Canada. As Elizabeth said they have the same sort of meetings and systemic look reviews in the US. I think one of the things we have to do is just change legislation that allows that to that information to be used more readily to involve patients and families in those discussions in those meetings to give feedback. And other things we'd have to look at is just the training. For instance, I'm involved here at the University of Calgary, our Cummings Medical School working with Hasking Business School is involved it has a course on precision health and medicine, part of which is a quality safety piece, and we were able to present and speak to them in their first week, and I'm continuing to work with them in their ethics and law course about about how to implement person centered care in educational roles and so and that's management as clinicians. That's even their IT people are attending these courses. So I think there's certainly the educational piece, there is changing laws about keeping things quiet. And if you've been incited, for instance, as Elizabeth said, if you're not, if the doctor says one thing and privately and then tells you something else, and then you find out later and you're angry about it. There should be ways and mechanisms to still go back to the organization or to, to the, you know, whether it's the regulator, and to still get a full response where they say well sorry this is an explain why that happened to you. There are a lot of stages through the process where the patient and the family's anger can be brought under control and because they're given the information they were looking for maybe they don't get it first initially, but they that that's a process I think that needs to be put forward is bring make it happen at any time, anytime to this process make sure these people are getting what they need. And if you fail at one stage, do it at the next step. So moving into that. The one thing about non to close disclosure agreements says you never have to sign one. You don't. What's your goal is your goal change in the world is your goal to stop systemic arm. Then it may be more valuable to share your story, all over the world. Talk to reporters, go to meetings. There's oftentimes a place at a place at a conference where you got that chance to ask a question, ask that question in front of 1000 people and watch how fast change can happen. What I love about the current open notes project is now the narrative note is coming before the clinical data flow. So in that narrative note, instead of saying 64 year old man or aggressive wife. It says Bob, or Sally, it's their name. And if you name people and you actually do that, they become real again, and we have the ability through doing that to change things. Yeah, I completely agree. And, and of course we need to take an account, the different countries, the different context of the countries, the societies and how they impacting in the different responses of these kind of things for the a clinical part for the organizations for the, the patients by itself. Well, discussion to have about how everybody's role and how we all fit in together when it does happen. But I think we can't lose sight of the fact that it is the third leading cause of death in the United States. And that's really where the fix has to come first. Perfect. Thank you, Elizabeth. Well, this was a very enjoyable. Thank you to all the panelists for being here and have this important conversation. Thanks to the patient safety movement foundation for this opportunity. And also to the audience for being so engaged and join us during the webinar. If there's some questions that were on respond, we will try to do it and publish after after this. I'm going to turn it over to Sarah to give the final details of the webinar. Thank you, Louise and just to echo what Louise said, if we didn't get to your question. I do see that there were a few in the chat and we'll be sure to hand those over to our panelists after this webinar and they will respond to those and we'll send that out shortly. A few housekeeping items I just want to remind everyone here at the patient safety movement we strive to present the highest quality educational content completely free of charge. And as a non profit that relies on donations from individuals we do ask that you consider helping us keep these webinars going by visiting our website and donating what you can. And then last but not least just to reiterate the continuing education credit information. This webinar does provide one C e credit for BCPA so please email us if you have any questions at all if you attended the live webinar. I think it's about five to seven days to process but again thank you so much to everyone that joined us and we hope you enjoyed this webinar and have a great rest of your day. Thank you Sarah. Good luck everyone. Thank you.