Can I call meeting to order? I welcome everyone to the sixth meeting of the Public Petitions Committee in 2019. We apologise from Brian Whittle and Maurice Corry is attending as committee substitutes. We are welcome. Before we begin, I would like to congratulate Maurea Lyle, who is part of our clerking team and also a world and a Paralympic medalist a'r griffwys edrych i'n cael ei ffordd i eu hwn yng ngyflaen i'r ffordd. Rydw i'n ffordd o'r ffordd y gwaith sydd wedi'i gweithio'r iawn i gael o'r gwybrig yng Nghymru, ac mae'n gweithio'r ffordd o'r ffordd i'r Gŵr Eysbyd, ac mae'n gweithio'r gŵr i'r ffordd i'r gŵr eysbyd. Rwy'n gweithio'r gweithio'r skleidwyr maen nhw'n gweithio'r gweithio'r gwaith o'r gweithio'r gwybrig. The first petition is petition 1667, lodged by W Hunter Watson, which calls for a review of mental health incapacity legislation in Scotland. At a previous consideration of this petition in October 2018, we agreed to invite the Minister for Mental Health to give oral evidence. Members will be aware that on Tuesday of this week, in advance of today's evidence session in this petition, the Minister for Mental Health made a statement to the Parliament announcing an overarching review, which will examine the full legislative framework that supports and protects people with a mental disorder. The minister has also written to the committee with further detail on the review. That appears to deliver on the action called for in the petition and also appears to pick up on concerns and regular comments by members of this committee about the number of mental health-related petitions that we have seen recently coming before us. The petitioner has subsequently indicated that he very much welcomes the minister's statement and hopes to be given an opportunity to respond to the forthcoming consultation about the reform of the 2003 mental health act so that he may raise the many issues that concern him. Members have a copy of the petition as emailed to the clerks to that effect. Notwithstanding his statement to the Parliament and her letter to the committee, the minister is here to give evidence to the committee this morning, and this might allow us to draw out some further information on the review. The minister is accompanied by Theresa Meadhurst, deputy director of adult mental health, John Mitchell, senior medical adviser and Kirsty McGrath, head of the adults within capacity review team. I thank you all for attending this morning. The minister has given that he delivered his statement to the Parliament on Tuesday. I wonder if he wished to add anything further by waiving an opening statement to the committee. Thank you very much, convener. With your indulgence, I will give an opening statement. As you mentioned earlier, I announced to Parliament on Tuesday that in order to strengthen support for people with mental health conditions, we will undertake an independent review of the mental health act. Taken together with the on-going work on capacity and adult support and protection legislation, we now have a comprehensive programme of activity amounting to an overarching review of the legislative framework affecting people with a mental disorder. The vast majority of people who access mental health services do so on a voluntary basis. Relatively few people are ever treated for a mental disorder against their will. If they are, it is because it is necessary to protect them or to protect the public or other people. People with a mental disorder may also be affected by the adults within capacity or the adult support and protection act. Depending on their needs, a person may be subject to one, two or all three of those acts. This may be confusing for the individual and their carers and also create barriers to those caring for their health and welfare. Although huge advances have taken place in relation to mental health in terms of treatment and changing social attitudes, we have also always been clear that we will continue to keep the changing context under review to ensure that our legislation is fit for purpose. In recent years, there has also been an increasing focus in all areas of public life on the importance of protecting and promoting human rights and on recognising the rights of people with disabilities. That has provided us with an opportunity to look again at our legislation to ensure that the rights and protections of those with a mental disorder are fully respected. The Scottish Government is absolutely committed to bringing change to people's lives and ensuring that mental health is given parity with physical health. This review of the Mental Health Act will take this a step further, reaffirming our commitment to creating a modern inclusive Scotland that protects, respects and realises internationally recognised human rights. I mentioned that we have already begun work to review incapacity law and practice as well as the review of learning disability and autism under the Mental Health Act, and we will shortly be undertaking work on the Adult Support and Protection Act. This latest review will build on and be complementary to the on-going work, resulting in an overarching review of the legislative framework affecting people with mental disorder. I just want to take a minute to outline the principal aim of the review of the Mental Health Act. It is to improve the rights and protections of a person with a mental disorder and remove barriers to those caring for their health and welfare. It will do that by reviewing the developments in mental health law and practice on compulsory detention and care, care and treatment, since the Mental Health Act came into force, making recommendations that give effect to the rights, will and preferences of the individual by ensuring that mental health, incapacity and adult support protection legislation reflect people's social, economic and cultural rights, including UN, CRPD and ECHR requirements, and considering the need for the convergence of incapacity, mental health and adult support and protection legislation. We intend to announce the chair of the review shortly and, clearly, it will be for them to determine how the review is best taken forward. I want to be clear, however, that this work will be stakeholder driven and evidence led. I am determined that, throughout the process, the views of service users, those with lived experience and those who care for them are at the front and centre of this work, so they can help us to shape the future direction of our legislation. Each stage of the process will have to create an engagement strategy showing how the review will seek to gather as wide-ranging views as possible, including those that I have already mentioned, professionals and people with a more academic interest. The third sector in particular will be key to making this happen. It has a wealth of knowledge and understanding concerning the impact of legislation on people's lives. I very much hope that you will welcome the announcement of this review, which complements the work that is already under way and which will ensure that Scotland's mental health legislation continues to lead the way in ensuring rights and protections of our citizens.  That includes the mental healthcare and treatment Scotland Act 2003, the adults within capacity Scotland Act 2000 and the adult support and protection Scotland Act 2007. You also referred to reviews of other work that will be undertaken, which might improve practice without requiring legislative change. That has also been addressed in your letter to the committee, but I wonder if, for clarity, can you confirm how many separate reviews or distinct pieces of work will be taken forward as part of the overarching review? As you outlined, there is already work on going, which will help to feed into the overarching review. There is work on going in relation to people with learning, disability and autism. There is also work on going in relation to the adults within capacity act. We are all anticipating work in relation to the adult support and protection legislation. Often, as I said in my opening statement, people find this quite confusing because they can find themselves under several pieces of legislation at one time. We need to ensure that those work streams continue and that we ensure that our work is clear and concise in a very complex area. Under the chairmanship of the review of the mental health act, that work will feed into the overall review. Kirsty is probably able to tell you a bit more about the work that is already on going in relation to the adults within capacity act and how we envisage ensuring that that work fits in with the current work streams that are on going. Yes, minister. I am happy to speak to the committee on that. As the committee will be aware, we have been looking at the adults within capacity legislation over the past year or so. It has been quite clear that there are distinct areas of crossover between the adults within capacity and mental health legislation, namely the way capacity is assessed and the definition of mental disorder and the use of an individual's mental disorder as the gateway to intervention under both the adults within capacity legislation and the mental health legislation. That is an area that could not be looked at in isolation under a review solely of the adults within capacity legislation. When we have been out meeting with stakeholders, there have been many calls for us to take a wider approach and to consider more holistically the crossover between mental health and capacity law, and that is what will be happening with the review that was announced on Tuesday, which has been widely welcomed by all of the stakeholders that we have been meeting with over the past year. What has also been very clear, as we have been meeting with stakeholders, is that there are concerns around some areas of the process around adults within capacity legislation. There is a strong desire to ensure that, in looking at the act, we do not throw away what is very good about the legislation. When the act was first came into force, it was groundbreaking. In many areas, it still remains so, particularly with regard to the principles under the legislation, which are the principles of least intervention of ensuring that the wishes and preferences of the adult are taken into account. We have been told time and time again by stakeholders that, if the practice around adults within capacity adhered more closely to the principles of the legislation, it would be far more close to adherence with the UN convention on the rights of persons with disability that might currently be considered the case. As we await the outcome of the review, which will impact on possible legislative changes to adults within capacity, we will proceed with a comprehensive programme of non-legislative changes to practice and guidance. The principle is developing a strategy for supported decision making to enable people with impaired capacity to have the support that they need to make their own decisions about life and care. That is a fundamental aspect of the UN convention on the rights of persons with disability, enabling people to exercise their legal capacity on equal footing. In addition to that, we are seeking to improve the training for professionals across health, social care and the law to ensure that those who require to know about the adults within capacity legislation are fully aware of the range of options and the principles that they need to act when doing so. Our first priority is to look at revising guidance and course of practice on powers of attorney. That work will highlight the need for every adult in Scotland to consider appointing an attorney while they have capacity to do so, and it will also provide information on the rights and responsibilities of attorneys and the safeguards that are in place to protect individuals and the sanctions that can be imposed for misuse of power of attorney. If the committee requires any further information about that work, I would be happy to write in detail. I think that we have some questions around that, which I will tease some of that out, but it is helpful if you can provide further information at the end if you feel as if there is anything that we have missed. It does feel very complex to me and complicated, and I wonder how you see it being co-ordinated and managed. Will the chair of the review manage all of that? Is there some kind of timeline that is visible so that we can check or the Parliament? What is the parliamentary engagement with the process? How visible is the... I mean, I did hear the minister in the chamber on Tuesday saying that you didn't want to be... You didn't use this term, but I understood it being constrained by a fault, you know, putting a date on something which then things become too complex and you don't want to be driven by that and understand that completely, but how do you see it being managed so that we don't go overwhelmed by the complexity of it, that it's still visible to everybody so that we can understand what you're trying to do and what is... Do you envisage the parliamentary engagement so that we can see as the process is going on how progress has been made? Absolutely, I can completely understand, convener, why you would be concerned about the complexity of this because it is very complex and there are several work streams going on currently. As Kirsty had indicated, it's become evident that we can't just have those work streams working in isolation that we actually need to pull all of this legislation together and have an overview of mental health legislation and capacity legislation, and that's what's brought us to this point. We will have processes in place and regular reporting from those work streams to ensure that they are co-ordinated. Trisa will be able to explain exactly how we're going to manage that process, convener, with your indulgence. Thank you. Each of the work streams will be provided obviously with a briefing on the work of the different elements so that they can fully understand what's happening, particularly important for the new chair person who's going to come in for the review on the mental health legislation. Then what we will do is, through officials, we will maintain oversight of where each of the reviews are and provide informal opportunities to meet together and share information, as well as put in place a structure of more formal engagement for critical stages of each of the pathways for the reviews that are being conducted. We're very aware that we are spinning lots of plates here and so we're really keen at the outset to make sure that we have structures and processes in place to ensure that there is good communication and that we're ensuring that everyone is co-ordinated in their work. Angus MacDonald. Okay, thanks, convener. Good morning, minister. Good morning to your officials. We know that the Scottish Government consulted last year on the Adults Within Capacity Scotland Act 2000 in its paper, Proposals for Reform. The paper stated that, at the same time, a scoping exercise was to be carried out to find out what is currently happening across Scotland by way of support for decision making for those who need it in supporting persons to exercise their legal capacity and that working groups with a range of stakeholders would be set up with the aim of establishing a strategy for support for decision making that would underpin the Adults Within Capacity legislation. Again, for clarity and further to your statement this week, can you provide any further information about the consultation and outcomes and can you confirm that this is something that will be included within and help to inform the overarching review? Thank you very much, Mr MacDonald, for that question. The work that you refer to regrettably was delayed due to difficulties in recruiting staff to carry out that work or carry that work forward last year. We have now resolved those staffing issues, and I am pleased to report that the Scottish Government officials met with people first, which is a learning disabled organisation this week, to learn from their law and human rights group about the work that they have been doing to support decision making. We are in the early stages of planning workshops with a range of stakeholders to learn from them what is needed by the way of support to exercise legal capacity. Following on from that, I will be looking for volunteers to support us in further developing the strategy and to test it out. I would like to assure the committee that the work is a priority for us this year. Clearly, you stressed in your statement the need to engage with stakeholders, including many others in the third sector. It is good to hear that you have met people first, but how would you ensure that you will achieve that level of engagement that you have committed to? It is far better for me to tell a chair how to conduct a review, as we have been appointing someone to do that. I am very clear from the outset that the voices of lived experience, service users, carers and their families have to be front and centre of this entire review. I will be very clear when a chair is appointed that that would be my expectations and the expectations of the Scottish Government. We have been very clear in reviews that have been commissioned, that we need to have the voice of lived experience at the heart of that. Giza, do you want to come here? I am sorry, but there will be engagement. Stakeholder strategies will form part of the work packages that the delivery of the review will have in place. We will ensure that the chair is provided with appropriate support to not just inform those different engagement strategies but to have oversight of the work going forward. Through the engagement at an informal level of the chairs, we will also ensure that there is engagement at that programme level to fully understand and be able to evidence the appropriate evidence that is being used, whether that is academic or other evidence, as well as the engagement strategies that are in place to ensure that not just organisations but people with lived experience and carers themselves are engaged with that strategy. Okay, thanks. That is encouraging to hear. If I could move on to the issue of, well, in May 2017, the Mental Welfare Commission for Scotland and the Centre for Mental Health and Capacity Law published the report, Scotland's mental health and capacity law, The Case for Reform. One of the recommendations in that report was that, I quote, there should be a long-term programme of law reform covering all forms of non-consensual decision making affecting people with mental disorders, end quote. Can you confirm that this will be included within the review and how that might look? Yes, I can certainly confirm that that would be an area that would be covered by the review. That might be an area that John Mitchell might be able to add a bit more information on. Those sentiments echo the original milling committee, which I think foresaw the needs to create what we're calling convergence in terms of these different legislations and how they protect the rights of people and the fundamental idea of how we protect decision making and involve people in their own care. The most recent report talks about a longer-term vision, but I think that that would be a fundamental aspect of what we would be expecting from this review. As explicitly, as the minister said, the third point in the purpose of the review is looking at the convergence of those legislations around decision making. We understand that the UNCRPD rights are not legally enforceable in the same way as EHR rights are in Scotland, but that is something that you have referred to to providing an impetus for this increased focus. Will the review be looking at the enforceability of the range of rights in Scotland? As I said in my statement, we are taking this opportunity to look again at legislation to ensure that the rights and protections of those with mental disorder are fully respected. The review will make recommendations that will give effect to the rights, will and preferences of individuals, making sure that mental health, incapacity and adult support legislation reflect people's social, economic and cultural rights, including the requirements for the UNCRPD and ECHR. There is an issue concerning the legal standing of personal advocates for people with mental health and capacity. Is that going to be covered in the review? All the legislation of mental health and incapacity will be reviewed. Kirsties might be able to give you a bit more information on specifically adults with incapacity legislation and the issue that you raise. The question of independent advocacy and its place within supported decision making is part of our development of strategy of supported decision making. We are well aware of the importance and value that independence advocacy has. The very positive reference that having an independent advocate can make to a person. It is part of the work that we are taking forward. I have one concern on that very subject. The legal standing of that advocate in relation to decision making seems to be a big grey area at the moment. I agree with you that it is a grey area. It is one that requires clarity. The petitioner refers to article 12.4 of a convention on the rights of a person with disabilities. He considers that the appropriate and effective safeguards to prevent abuse in accordance with international human rights law are set out in that convention. Are lacking in the Scottish mental health and incapacity legislation, how is this being factored into the overarching review? It is worth noting in my opening remarks that most people who use mental health services do so. They receive that treatment voluntarily, so there are very few people who are subject to an order or certificate under the mental health act. For some individuals compulsory treatment is used to provide the person with the medical treatment that they need to alleviate suffering and protection of both the person and others. Compulsory treatment is only allowed under mental health legislation in Scotland in very strict circumstances. There are a number of safeguards, including independent advocacy and independent mental health review tribunal, which grant and review orders for compulsory treatment. There is also the independent body, the mental welfare commission, which monitors the use of Scottish mental health law, including compulsory treatment. The commission also has the power to intervene in cases if there is evidence of improper care treatment or practice. Under the 2003 act, any service user has the right to support from an independent advocate and the right to appoint a named person to represent their interests, and the right to make an advanced statement sitting out of how and what treatment they would like and would not like when they are unwell. The 2015 act introduced further changes to ensure that people with a mental disorder can access effective treatment quickly, and it also strengthened support for decision making and promoting rights. It is widely recognised that people living with dementia are in certain circumstances denied their human rights and sometimes physically or chemically restrained. The petitioner considers that the lives of elderly people with dementia will be shortened in breach of the article to ECHR, and that is due to the chemical restraint. However, will the Scottish Government intend to amend Scotland's health and social care standards? In the petitioner's words, it would no longer condone the use of chemical constraint. Will that be something that can be addressed without legislative change? Improving care and support for people with dementia and those who care for them has been a major ambition for this Government. Our legislation follows a rights-based approach. The Code of Practice, which companies the adult within capacity act, explains that the use of covert medication is permissible in certain limited circumstances. For example, to safeguard the health of an adult who is unable to consent to treatment in question, where other alternatives have been explored and none are practicable, John Mitchell would be best pleased to explain how that works in practice and some of the difficulties that families, carers and clinicians face in terms of providing appropriate care and treatment for people with particularly severe dementia who require medication but are not able to give the consent for that medication. Yes, I think that this is a real concern and I am grateful to you for raising the issue. There is a fundamental challenge between protecting the rights of people but also protecting them from ill health and the consequences of ill health. The legislation is quite clear and practice is quite clear that nobody should be forced to have medication without their consent if they have capacity. The challenge is that if they do not have capacity in the current legislation, the Adults in the Capacity Act allows treatment for physical disorder and the Mental Health Act for mental disorder when capacity is not present. All medications have side effects and the concerns about the use of, for example, antipsychotics in elderly people and the increased risk of falls, the effect on blood pressure is a very real risk and clinicians on a day-to-day basis have to weigh that risk as they do with any treatment, the side effects of it versus the benefits of it. When somebody with dementia, for example, is in a psychotic and distressed and agitated state, there may be more risk to their health, for example, from falls for them not being treated than them being treated. Thank you, Mr Mitchell. I understand that, obviously, it is a very important decision that the clinician must make in that intervention. The petitioner particularly asks whether the Scotland's health and social care standards could be amended without going down that legislative route in order that we do not condone the use of chemical constraint. The use of chemical restraint, as the minister said, is authorised under certain circumstances and there is very clear guidance for clinicians. The Mental Welfare Commission has explicit published guidance on the use of covert medication as do the Royal College of Nurses and Psychiatrists. There is detailed guidance for practitioners on considerations of consent and capacity and on the use of covert medication already that is available in Scotland that people are aware of. I am not aware if any further amendment would be needed beyond the necessary consideration of that as part of the total review. Is there a difference between giving someone their medication without their consent because it is part of their medical condition or some slightly different which is chemical constraint? We have heard it, maybe, anecdotally called, the chemical caution, which is just about managing people. Do you think that that is something that the petitioner is trying to address and I wonder how you would respond to that, which is quite different from somebody not being able to consent to the medication that is required for whatever their condition is to somebody just managing somebody? Yes, there are two issues that the petitioner has raised. There is the discussion about covert medication but I think that convener should quite rightly say also about what clinicians might call rapid tranquilisation. The situation where it is quite clear that a medication is being administered but it is against the wishes or without the consent of the individual having that and that might not be necessarily in a demented situation but indeed with young, psychotic and dangerous individuals who may have to be in hospital. The two are different and there are again different guidance on principles for both of those different situations. The situation of emergency tranquilisation with medicine is a very common situation that unfortunately is required in some circumstances and again the mental welfare commission lays out explicit guidance on that but the act also contains in it particular safeguards so that for example if a patient is subject to compulsion then if a medication is administered without that person's consent which is a section 243 issue then there is a legal responsibility for the clinician to document why they are doing that and inform the mental welfare commission who are the overarching watchdog independent from government promoting and protecting the rights of people in Scotland with mental health problems. I meant that this is maybe more a question for the minister but the petitioner is also I think at the heart of the petition is this concern about the human rights of the person who may be treated against their will and he describes he asks why the minister made no reference to the absolute right of patients not to be subjected to human or degrading treatment and he references the Robert Napier case against the Scottish ministers but he also talks about you know he asks will the Scottish government study the definition of inhuman and degrading treatment provided by the European Court of Human Rights in paragraph 52 of its judgment in the pretty versus UK case and consider whether forced treatment might at times fall into the prohibited inhuman category as he believes that it did in an example that perhaps is provoked or prompted. His petition so there is something slightly different there which is about in terms of human rights legislation is this kind of treatment in itself in humane or degrading and should that there for be is that being taken into account by the government. Eight minutes is certainly convenient our legislation is compliant with the European Convention on human rights and fundamental freedoms and it's never been found in part or in whole by the European Court of Human Rights to be incompatible with the convention. We are obviously conducting or commissioning this review so that it takes account of developments and changes in human rights legislation and so it would be looking at where what the current human rights legislation is whether that be European or or UK human rights legislation at that point in time none of us know where we're going to be at that time but of course we also make sure that we are abiding by the appropriate case law that emanates from the European courts of human rights and I think that hopefully the petitioner can be assured that Scottish government do indeed take cognizance of article one of that convention ensuring that everyone and within its jurisdiction have the rights and freedoms provided by section one of that convention. I'll specifically look at this question of whether some of the treatment that's been used may fall within the absolute right on not to be subject to in human or degrading treatment. As I said, convener, we certainly the legislation we have not has not been found in part or in whole of being in breach. I think that's specific and I may be incorrect here, the lawyers in the room will tell me. That's specific legislation related to slopping out practices in Berlin and was not a mental health legislation. The point that the petitioner is making is if that case can be founded on the idea of inhuman degrading treatment, will the review at least consider the possibility that in view of the petition and others, I'm sure that some of the things that happen to folk in terms of the treatment could also fall within that category and what reassurance can you give that you would actually be looking at that? I mean, I don't have a view one way or another of what that review or consideration would establish but it's clearly an issue for a petitioner and it would want you to reflect. I can understand that. I have met the petitioner in the past and heard his views and concerns and certainly I would be expecting that the review would be looking at all human rights legislation. I think that Dr Mitchell wants to come in at this point. The absolute and qualified human rights are a complex area and I'm not a lawyer and I think that the evolving story of that is why we are having this to review to some extent but article 2, which is the right to life, is an absolute right and what that means is that there's a duty not to take away a name of life and a duty to take reasonable steps to protect life and article 14 is the right not to be discriminated against and that could be interpreted in terms of people having the right to the same effect of treatment as other people and article 25 is the right to the highest attainable standard of physical and mental health. So I'm really just saying these are illustrations that show the counterpoint between these different articles and how then an individual is protected while still protecting their absolute rights is a challenging one and I think that with the two decades now we've had with the current legislation and the experience of rights and consideration of that is the reason why this review is really timely for an expert consideration of these issues. You would accept, as we've said earlier, the distinction between effective treatment for the individual and a means by which the system manages patients and therefore when you're looking at those you would look at them differently in terms of human rights. Thank you very much. Following on minister and panel from the previous question and response, will the review itself consider what advice regarding informed consent of people with disabilities should be given to psychiatrists and other medical practitioners? Yes, so we're developing a strategy for supported decision making to enable people with impaired capacity to have the support that they need to make their own decisions about their lives and care and we'll provide a comprehensive training programme for professionals across health, social care and the law and we're improving the provision of support for guardians and attorneys and we're revising current codes of practice and guidance to provide clarity on the law as it stands. Okay, thank you for that. Two last questions from me. I wonder if you've got an idea of what outcomes might come from the review in general terms obviously. For example, do you think the possibility of consolidating legislation as opposed to new legislation? Well, I'm glad that the caveat is not that slightly convenient because I don't want to pre-empt the outcomes but there is certainly the possibility that there could be convergence, as I said in my statement in Parliament, that there could be convergence of the mental health and capacity legislation. However, as I said, I don't want to prejudge what the outcomes will be or what the work will recommend. And obviously you've already highlighted that announcement on the chair will be made soon. A ministerial definition of soon can be sometimes quite flexible. I wonder if you have indicative time when that might be. Also, you talked about the work being supported by a short-life working group. Have you got an anticipated lifespan for the short-life working group? So, I appreciate your house in soon. If you speak with my officials, you know that soon, when they speak to me, is yesterday, when I'm asking for something. So, yes, we need to get the right person. This is a really complex review. It's a really important review and so we need to make sure that we get the right person but rest assured that I will be not resting on my laurels and that I will be doing this as speedily as we can in terms of appointing a chair. In terms of the short-life working group, it will include representation from service users, patients with lived experience, relatives, the mental welfare commission, representatives of those who have mental disorder and third sector organisations, Scottish human rights commission, mental health review tribunal, health boards, local authorities, a principal medical officer, Scottish prison service, the courts and tribunal service, so a wide-ranging views and people contributing to that. We're anticipating that the initial stage will be about 12 months but, as I say, there's also work on going and we're anticipating that the learning disabilities and autism review of mental health legislation and how that affects those populations. I'm expecting to have them bring back their recommendations by the end of this year and so that will also feed in to the work that's on going. So, there are lots of different works going on. That's just a point of clarification, convener. A question to John Mitchell, if I may. You made reference to the article 2 of the convention giving individuals an absolute right to life. If the review of the legislation took into account the full field of human rights, would that then be the case that doctors could no longer prescribe drugs concealed in food? For example, would there be a change to the current practice? I think that that's a matter for the review and it's a matter for legal interpretation and application of the rights. I think that I wouldn't be able to anticipate the outcome of the review. Last question. This committee has done quite a lot of work around mesh and, of course, there's a whole questionnaire about the independent review and then there was work done by Professor Britton to look at the effectiveness of that independent review. Will you be looking at her report in terms of some guidance about the highest standards of how these reviews are operated? Absolutely. We will be looking at the best practice for carrying out a review, as I'm sure you would expect to do, convener. The big issue then was the extent to which some of the stakeholders felt excluded, so it's a huge challenge even describing the membership of the short life working group in itself challenging. Absolutely, but I hope that the committee has heard, as I hope Parliament has heard and the wider community, that service users and patients or people with lived experience in their families are at the front centre of this review. They will be at the heart of what we do. Thank you very much for that. I think that that's been very useful. Of course, the committee is taking full credit for the timing of the announcement, but I'm sure that the petition and others, and far more broadly, will welcome the decision by the minister to take that forward. We have to think about what we want to do next with the petition. I think that the suggestion is that we perhaps reflect on what has been said today and afford the petition or the opportunity also to reflect on it and anyone else who may want to make a comment on it, and then we can perhaps come back to the committee at a later stage and see how we will actually manage the petition. It does feel to me as if the petitioner's request has been met, and I'm sure that he's pleased with that, but we can decide at a later stage if that's agreeable. Thank you very much and thank you minister for that. Can I just suspend briefly to allow a change of our witnesses? The next evidence session relates to the committee's inquiry into mental health support for young people in Scotland. As you know, the inquiry was launched in connection with petition 1627, consent for mental health treatment for people under 18 years of age, raised by Annette Mackenzie. As you'll also be aware, the committee wishes to understand where young people can seek help at an early stage before they've reached crisis, and to the extent to which young people are aware of how they might support their peers in generally increasing public awareness around what we've already established is quite a complicated landscape. At its meeting on 21 February 2019, the committee considered thematic analysis from the call for evidence, and we again are very grateful to all those who have responded. We did get a wide range of evidence, and that wide range of evidence received through the inquiry is clear that the Scottish Government is undertaking a wide range of work in the area of children and young people's mental health services. To assist the committee in determining where it could focus its work in this inquiry, an update has been requested from the Minister for Mental Health on the progress of Scottish Government policies. To this end, the minister is here to give evidence to the committee, and she is accompanied by John Mitchell, a senior medical adviser, Hugh McElwain, deputy director of children and young people's mental health, Philip Reigns, head of the children and young people's mental health delivery unit, and Lindsay Wilson, senior policy lead of suicide prevention of the Scottish Government. I welcome the minister and the officials to the meeting, and I invite the minister to provide a brief opening statement of up to no more than five minutes, after which we will move to questions. Convener, I am happy to set out the Scottish Government's approach to improving the support for our nation's mental health and address any issues that you may raise. Let me start by describing our vision and how that shaped the work that we have set out. My vision for children and young people's mental health is that, presented in the 2017 mental health strategy, children and young people can get the right help at the right time, expect recovery and fully enjoy their rights free from discrimination and stigma. We know that, in order to achieve that, decisive change is needed in the way that children and young people are supported. The Audit Scotland report on children and young people's mental health highlighted that there is often too great a focus on crisis and specialist services at the expense of early intervention and prevention. You will have seen the recent report from the Public Audit and Post Legislative Scrutiny Committee on that Audit Scotland report, and we welcome that report and its recommendations, just as we did the report by Audit Scotland. That is why we are taking action in several areas. First, we acknowledge that performance in specialist services needs to improve. Recent statistics show that improvement is happening, however I am clear that we need to remain focused on driving sustainable and faster improvement. Steps are being taken to drive that change. We have invested £4 million in improving the capacity of CAMHS with the recruitment of 80 additional staff. Discussions are under way to support performance as part of the development of the annual operating plans of NHS boards. We are increasing resources to support improvement in health services in every part of Scotland, and lastly, I have established a new strategic board for mental health, which I chair, to monitor and drive the necessary improvements. Secondly, sustainable performance will only be possible if we drive wider system change. Our 2017 mental health strategy set out the key framework for achieving this, and this has been backed by ambitious commitments to action and resources in the programmes for government for 2017 and 2018, and we are committing a quarter of £1 billion to that work. We set out our detailed plans in Better Mental Health in Scotland, which we published last December. Key to that is not simply improving the capacity of our health services but all services that can support mental health. That is why we are making significant investments in the capacity of education to support children and young people. Thirdly, we are looking to key independent groups to highlight where reform needs to go in the future. For the issues today, the work of the children and young people's mental health task force and the chair of Dr Dame Denise Coyer will be vital. The task force will set out detailed recommendations to the Scottish Government and COSLA this spring, and those recommendations will drive our future work. Similarly, the national leadership group for suicide prevention under the chair of Rose Fitzpatrick will make recommendations on how we can more effectively make suicide everybody's business. Both those groups set out their delivery plans last December. At the same time, we are undertaking major reviews of key issues within mental health. In the past month, we have announced a major review of forensic mental health services as well as a wider-ranging review of the mental health act. Lastly, I want to highlight the critical importance of reducing the stigma around mental health and ensuring that young people are comfortable about speaking out if they experience poor mental health. Mental health is one of our key public health priorities, and we will work with the new Public Health Scotland body and other partners on how to drive that priority across all our work. One of the things that we are interested in is focusing on early interventions around a young person's life and the support that they can draw on. In the Scottish Government's 2018-19 programme for government, there were a number of announcements that were made in relation to mental health service with that kind of perspective. I wonder if you can give the committee an update on the progress of the goal to have counselling services in every secondary school, the additional 250 school nurses and the training for teachers in mental health first aid to be offered in every local authority? I know that that was not a commitment, but the idea of mental health first aid training not just for teaching staff but for other staff within a school, is that something that you would consider? If the convener allows, can I take those points individually? In terms of counselling services in every secondary school, we set out our commitment to ensure that every secondary school would have access to counselling services, as you say, in the 2018 programme for government. The work in introducing counselling in schools is progressing well. We are continuing to work in partnership with COSLA to establish a delivery model for the commitment, and my officials have been working very closely, as you would expect with officials in education portfolio. Officials continue to work in partnership with COSLA and local authorities to establish a formal joint agreement, and they have completed two of the four stages required for this. Further work has been undertaken to establish the appropriate funding model for the distribution of resource to education authorities, and it is anticipated that that will be considered by COSLA in April. It is also key to highlight—perhaps it has not been highlighted—that the counselling service that we are putting into secondary schools is a year-round service, which is not a term time, because we need to recognise that young people, their needs do not stop when the school closes for recess. On the additional school nurses, we set out a commitment for an additional 250 school nurses in the 2018 programme for government. As a first step in rolling out that commitment, a survey of the existing school nursing capacity in every NHS board has been completed, and that will inform the development of an action plan for rolling out the additional capacity, and the necessary upskilling of the existing workforce, which is due in late spring. The relevant training and coursework materials have now been developed to ensure that the existing workforce now has the necessary skills to carry out an extended role or a differing role. With regard to training teachers in mental health first aid, the current programme of mental health first aid has been offered to six local authorities who are undertaking the training for staff, who work with children and young people and who are on track to ensuring that the offer has been made to all local authorities within the original timescales that we had outlined. We have also convened a joint project to design and develop a specific training course that will be made available to all school staff, so I hope that that answers your last question, convener. That all sounds interesting, but it is all process. It is all about setting up what the funding model is going to be and how we are going to get an agreement. When can we reasonably expect a school to have one of those counsellors, and when can we expect all schools to have one? I answered a similar question to that in chamber, not so long ago. We have committed that we will have our first tranche of school counsellors in schools at the start of academic year 2019-2020. What proportion is a tranche? We anticipate 50 per cent. I appreciate what you were saying about the process, but we obviously need to ensure that the mechanisms are there to deliver those interventions on the ground. I think that sometimes systems create a business that does not actually have outcomes to them, but if you were asking for things to happen yesterday, that is maybe going to move the thing along a little, but we would want people to take comfort in the process. What people want to see as a consequence of the policy is that there is a difference on the ground in our schools. Absolutely. I would not disagree with that. Action is absolutely what we need to see, and I hope that that will be demonstrated. You will be aware, minister, that the convener of the Public Audit Committee stated last week that the absence of basic data in relation to a whole range of factors in mental health provision for children means that it is not possible to say whether public spending is making a difference to young people's mental health. Given the additional funding commitments that have been made by the Scottish Government, for example, the £60 million investment in the school counselling service, how are the impacts of that and similar investments to be measured in the absence of basic data relating to young people's mental health services? The Children and Young People's Task Force has a dedicated workstream to addressing finance issues and data, so it might be helpful at this point to ask Hugh Mackleon to give you some details about how the Children and Young People's Task Force is carrying out that work. In its delivery plan that was published in December, the task force laid out how it is specifically going to take forward its work on finance. It is seen as a very complex area, while looking across a whole range of different services and different players. However, I think that what the task force did was actually take it down into some three fairly simple tasks. That is identifying the full investment in children and young people's mental health. It is something that has come up before and that is something that is difficult to measure, moving beyond the health service into universal children's and family's services, including schools. However, it has set itself the task of doing that. Ensuring that investment lands where it is intended. When money is invested in children and young people's mental health, it is making sure that we have a way of tracking that and making sure that it lands where it is meant to land. Thirdly, the most important part is developing a consistent and agreed approach to ensuring that investment delivers for children and young people and their families and for the taxpayer, and gives that return on that investment. That is quite a simple way of describing the work at that workstream. It is helpful that it is so simple, because it really cuts to the core questions. Linking across into the data workstream, there are significant elements and interdependences between the finance workstream and the data workstream. All of those questions can only really be answered by an improvement in the quality of data across the entire system. As an area that I am reasonably new to, this is one where there is no shortage of data, but information seems to be something that is hard to pull out of a lot of that data. I think that there is gaps in the data, so they are looking very much at the bits beyond NHS, where there is a lot of data on what is going on, but it does not tell the full story because it does not reach back into universal services. The interaction between the data workstream and the finance workstream of the task force is going to be really important. I would anticipate that a lot of that work will be informed by the other workstreams. The workstream that is looking at universal generic services within communities is going to be looking at an approach that brings together health and other integrated children's family services in a way that probably has not been done before. The data requirements to monitor that and to monitor the effectiveness of that will probably emerge as the recommendations from that workstream emerge. Similarly, the work that is going on in the specialist workstream, which is looking at a new and reformed approach to CAMHS, will throw up questions about how you measure progress and effectiveness of that different approach. The whole thing fits together, but the three key questions about identifying the level investment, making sure that it lands where it is meant to land and developing a consistent approach to the return on that investment is something that runs right through the task force work. We anticipate that the recommendations that we will get will provide clear direction on how we take that work forward. That sounds like quite a task, so we will clearly monitor it as it progresses, thanks. Minister and panel, the Audit Scotland report published in September 2018 concerning mental health services for children and young people highlighted that mental health referrals for children and young people increased by 22 per cent over the five years from 2017 to 2018. I think that it was a very important statement that the minister made just now about making suicide prevention, for example, everybody's business. What are the factors that have driven such a significant increase in referrals? As Dame Coyer had already noted in her initial recommendations that were published last September, which led on to the formation of the task group, the rise in referral signals and increased demand and services by those with emotional distress. The rise in demand partly reflects the success of campaigns and awareness of mental wellbeing. It is important that we recognise that as a society, we are much more willing to admit that we were perhaps not feeling well, that we are in distress, and that we are seeking help. It might also reflect some of the increasing pressures that we hear about from young people. I hear this when I go into schools and I talk to young people, I talk to my own family, not least of which seem to arise from social media and the pressures that are putting on to that particular generation. I think that those are pressures that our generations do not appreciate. We grew up in a very different world. Mitigating those issues is a fundamental rationale for the programme for government investment in the work of the task force and in the drive to increase the range of early intervention and prevention services that we need to ensure are there to help children and young people. Some of the work that we have spoken about in ensuring that our school teachers have mental health first aid training and have adequate skills there, the increased number of school nurses that we are putting in with a focus on mental health and wellbeing, the introduction of school counsellors in every secondary school and the work that the task force is doing in looking at early intervention and community wellbeing and so on are all really important in getting that early intervention in there. We talk about young people here. Young people are looked after by their parents, hopefully. What are you doing within your review in connection with parental guidance on this issue? Sadly, it is missing at the moment. We have a lot of peer pressure from children getting younger and younger. It might be mobile phone use or whatever it might be in social media. I do not see anything about the parents and how they might help them to educate them. You may already be aware that the four chief medical officers around the UK issued guidance last month in terms of giving guidance to parents in terms of screen time and social media. Much of that guidance was also about modelling good behaviour, such as not using mobile phones at the dinner table, keeping screen time out of the bedroom and the importance of sleep. John might be able to add a little bit more to the specifics of the guidance that the CMOs put out. As the minister said, there is specific guidance about social media. The other aspects of our interventions with parents are at very early ages in terms of the psychology and positive parenting programmes. In relation to the emerging concern about distress in young people, the true finding that something for it is happening with our adolescent female population is something new about their presentations and expressions of distress. We are expanding the distress beef intervention programme from the summer of 2020 to include people under the age of 18. Already, in the thinking about what that will be, it will be in terms of working with families, not just with an individual young person on their own. It is good to hear that. It would be helpful for you to hear about how we are involving parents in the task force. Joanna Murphy is the chair of the National Parents Forum for Scotland's member of the task force. With Joanna's input, the task force is establishing a parents network that reaches out to parents groups across Scotland at early stages, but that will be something that the task force will use to inform the development of its recommendations. Young people at the centre of the task force talk a lot about that, but parents as well. We are also looking at the potential for the development of some form of digital platform, which provides advice and support for young people and children, but also for their parents. That is key. What we are looking at within the task force is how that fits in with other things that are out there. If there are other services out there that parents use, is there something that we can do to integrate whatever advice and support that we can provide on mental health into that? Finally, the task force's work on community hub-based approaches to earlier intervention and support around mental health is very much at the forefront of Denise's mind that we look at support for parents. She spoke to a lot of parents, particularly of children who were rejected for CAMHS, and the constant thing from parents is that we need someone to talk to to help us through this. It is very much at the heart of what I would expect to come out of a range of recommendations from task force. I think that we are on the right track with that. That is the case. I am glad to hear it, because that is music to my ears as a parent. It is something that I have seen a lot of. Of course, we are mindful that the petition was prompted by Annette MacKenzie losing her daughter and not being aware that her daughter had medication. Of course, that whole question about when is it confidential, but when is it wise to ask somebody to share what they are doing with the people around them? I am very conscious of how difficult that has been for their family. Can I ask David Torrance to come in here, because he has some questions on Denise Coyer? I think that we will be going back to this question in social media. Thank you, convener. According to a chair of the Children and Young People's Mental Health Task Force, Dr Dame Denise Coyer, the following changes are required to reform and improve the system of children and young people's mental health services. A stronger focus on prevention, social support and early end invention, a wider range of more generic, less specialist interventions to free-up specialist services to see those in most need, and a better information and understanding for the public and all agencies and services of where emotional distress and mental health and mental wellbeing problems are best supported. Do you agree with this assessment? Absolutely. Those are the themes that are underpinning the work that the task force is doing. Denise Coyer set out in her initial recommendations on what have informed our commitments in the programme for government. What current mental health policy initiatives address Dr Coyer's recommendations reforms and what more needs to be done to do so? In terms of the work that is already on-going, as we have already spoken about, our commitment to school councillors—I put in a school councillor in every secondary school in Scotland—is the additional support that we are providing in terms of additional school nurses, the training that is being offered to each local authority for all teachers to receive mental health first aid training. We cannot look at schools in isolation, we do not train someone in first aid and expect that they are only going to use those skills within perhaps their work environment or when they are volunteering, but that will equip a whole population of people with skills that they are able to use in their everyday lives. I think that there is a broad range of policies and commitments on-going that will help to improve the knowledge and skills that people have in terms of dealing with mental wellbeing and mental distress, but it will also help to raise awareness of those issues throughout the population. I do not know if Hughes wants to come in here with specific things from the task force. Maybe just to describe a little bit of the process of the task force that might be helpful. We have a team within our division that is exclusively providing support to the task force, but the task force is independent of government and we will use to do that sort of thing. I have been involved in this sort of thing before around youth employment, and it was more traditional in that the independent group would go off, come up with recommendations and the Government and Causal would consider them and implement them as a whole. This time round it feels a bit more interactive, which I think is important because we are looking at a set of issues out there that are live right now for children, young people and their families. In some ways, it is similar in that there will be independent recommendations coming to the Government and Causal for consideration and, if agreed, subsequent implementation. Rather than waiting until the end of the task force in 2020, we are anticipating that the task force will just, at various intervals, provide recommendations for consideration as it goes through its work. Rather than waiting until everything is ready, if there are areas that want to make recommendations that are ready to go, then those will come in. We probably all agree on what needs to change. I think that Denise describes that really well and why. A wider range and easier access approach that is built on prevention and alien intervention is largely underdeveloped at the moment and why that needs to happen. The waiting times are too high and the level of rejected referrals should not be a feature of the system at all, but it is far too high. The distressed language for children, young people and their parents goes with that. That is why we are doing it. I think that the task force's role is not about endlessly describing that but about how we change that. I would expect the task force's recommendations to be challenging because it would be a surprise if they weren't challenging and we know that the status quo needs to be challenged. As we go, I would hope that what we would be able to do is work with our colleagues and local government to take forward some of the recommendations, even as the task force is continuing with its work. That is something of a feature that I would anticipate seeing over the next year and a half. We talked earlier about social media and its important strand of the committee's work in our inquiry into mental health. Mr Mitchell mentioned the chief medical officer, Catherine Calderwood, who said that there is no evidence of causation of harm, but she stated that there has been a rise in children's depression. She also says that the quality of life—children say that the quality of their life is lower if they have long periods of time on their screens. We welcome your announcement recently on your new guidance on the health use of social media and screen time. A couple of questions specifically about that. What work is currently being done to undertake the development of that guidance? Secondly, has the Scottish Government done any work on the impact that social media is having on the wellbeing of young people? Rachael Hamilton would agree that we grew up in very different worlds to the ones that our children are growing up in. Sometimes, as parents, it is quite difficult to understand the pressures that young people are under. The work that you refer to is the Scottish Government-commissioned work, so we are developing advice on social media use. That will be produced by young people, for young people, and that is really important in understanding the landscape. The world that they live in but also the credibility of that advice. That is currently being commissioned. I am sure that we would be happy to inform the committee of further timelines as we have those, if the committee would be interested in that. There was a research commission last year, and we will be publishing that research very soon. I wondered whether you would have had any collaboration or discussions with social media platforms such as Facebook or Instagram, as in the Scottish Government, because there are recommendations that, of course, age verification could be improved. The sharing of data could be useful with regard to the research that you have undertaken. I presume that that is part of that and that industry has a duty of care, too. There was a suggestion that there was a voluntary code of conduct developed as well. I presume, minister, that some of the points that come out of the work that has been going on with the young people getting involved will be involved. It sounds very much like that. Some of the things that would be getting done in terms of background preparation for the commissioning. I do not have that detail to hand about what the exact detail of that is, but, again, I am happy to write to the committee to provide them with that information, if that would be something that they would be interested in. Minister, I might add that much of this starts to move into the territory of what is UK Government. We would have to work very closely, because clearly there is a lot of work that UK Government colleagues are doing in that area, and there are many of those discussions on-going. It is a question of pulling our efforts to make sure that there is a collective effort across all the nations in having those discussions with the relevant platform providers or whoever to be able to do that. It is a question of where we best lend our efforts to support that work. A number of the submissions received by the committee is part of inquiry into mental health support for young people in Scotland, referred to a need for a change to the approach of mental health services. That was a change from biomedical model based on medicating children and young people to an approach based on levels of psychological distress, trauma and recognising social, psychological and biological factors. Can you fix a view of mental health that people are advocating something different from that? Do you agree that such a change of approach would be helpful? What policy initiatives are planned or are currently under way that would encourage this change? It is a mindset thing. I think that we need to recognise that young people's mental health extends across a spectrum from wellbeing to mental illness, just like it does for all of us. A whole system approach to change and improvement is the intention of the task force, as we have heard right across that from wellbeing right through to treatment for illness. We would challenge the idea that there is a single biomedical model. For the few children with mental illness, they must be able to access evidence-based treatment. That must include medications. We would not question the need for some children to receive medication for a physical illness, so we have to be very careful about how we approach that. I absolutely recognise that people have concerns about the use of medication and children. The 2017 UK NICE guidelines on treating depression in children and young people clearly states that antidepressant medication should not be used for the initial treatment of children and young people with mild depression. It provides information on the use of that particular medication in more severe conditions. That would be the prescribing guidance that we would expect clinicians to follow. John Mitchell might be able to give you a bit more information about the safeguards that there are in terms of the use of medication. That is a really important issue. It is an issue that has raised when the number of children prescribed medication is published each year. I absolutely understand why that can cause some people alarmed, but the vast majority of children would have a psychosocial intervention or a talking-based therapy, a play-based therapy, to treat their illness or their condition. One of the questions at the core of this petition is the question of at what point someone is prescribed medication and to what extent GPs and others are under pressure. Therefore, it should not be the first port to call, but there are pressures on—I am not saying that this is a universal experience—that there has been some work done in that, where the straightforward option is prescription when, in fact, the guidelines themselves say that that should be further along the line before that happens. There has been a lot of work done over recent years, and John Mitchell will be able to provide the committee with the detail on that. I think that, thanks to the energies of the petitioner—I think that it is an important issue that the committee will be aware of—I wrote out to all the GPs in Scotland and to their all colleges a very detailed letter explaining the issues in the petition and the importance of awareness of guidelines and following those guidelines, as well as issues to do with consent and capacity. As part of the work in the task force in terms of the specialist subgroup in the task force, we have had conversations with the all college of general practitioners and about the prescribing of medication with GPs. That conversation is on going at the moment to look at if there is perhaps an opportunity through the emerging single nationally Scottish formulary for medicines to actually lay out if there are shared care arrangements or what exactly, who should be prescribing what when. Those conversations are happening at the moment. As the minister said, we have an annual publication that gives us data on the prescribing of medication for mental health problems in people, including in children. That is broken down into health boards. There is also primary care data that is produced for discussion at practice level about prescribing not just about mental health medication but about other medications. Is this the first port of call or, rather along the line, is that monitored? There may be circumstances—I am not a clinician—where a GP feels that it is the most appropriate decision at the first stage, but is that monitored? As the minister said, the nice guidelines are very clear that antidepressant medication should not be used for the initial treatment of children and young people with mild depression. The nice guidelines say that, but we know that it has happened, so is it monitored? Will we monitor the use of antidepressant prescribing in children? Will monitoring establish at what point in the journey of the child it was prescribed? It is not at that detail, but we would expect prescribing of antidepressants to be supervised by specialists in specialist, child and adolescent mental health services. Does that mean that you would not expect a GP to prescribe antidepressant for a child? No, not at all. The initiation of prescribing would be a specialist function. The on-going prescribing, the provision of a prescription, would be something that GPs would be asked to do, and that is why there is a conversation with the Royal College of General practice at the moment about the precise arrangements for that. So it is specifically on antidepressants as opposed to other related medications that might be around somebody experiencing anxiety? Well, I think that, as happened with the tragic case that the petitioner has come to us with, it was not an antidepressant that was the medicine that was used. Was it a medicine that was prescribed for anxiety? It was, yes, with a primary function for another purpose. The information on prescribing in primary care, as I say, is genetic information, but there is not a specific measurement for children and young people of exactly what is prescribed for those conditions. Does that mean that you would not know if that was something that was prevalent in the system, that young people were, I am not saying that they are, but they routinely prescribed antidepressants at first appointment? You would not know that? Well, they would not be prescribed an antidepressant at first appointment in going to the GP because the nice guidelines are clear that we would not prescribe that, and if a child was presenting a young person with moderate or severe depression, there would be an expectation that that GP would seek specialist help, specialist involvement, and if there was any prescribing, it would be initiated through that process. But the system still would not identify prescription for anxiety, which was not an antidepressant but was something? Not across the total range of medicines, just in the same way for physical health conditions. Thank you very much for that. I think that we have concluded your question, when somebody has any further questions. Just on that point, the pathway, is that data collected, the pathway of, say, we were talking about here, the GP prescribing tablets for anxiety, is the pathway that the previous recommendation that that young person went to a therapy, a different therapy, is that data collected so that there is a distinct correlation between what pathway is working and what pathway isn't working, before, of course, they referred to a specialist? We would expect that the young person in distress that if they presented to their GP, if they presented to a health service, the GP would use their clinical skills to assess and look at. In the first order of business, we would be looking at support and social prescribing opportunities. That information would be documented in the primary care records, but there is not a national amalgamation of that information as such. Do you think that that would be a useful way of taking forward? In extreme cases where suicide happens, if there is a distinct pattern happening within that pathway of recommendation from a GP? Certainly, when a very serious incident happens like a suicide, critical incident processes will mean that there will be a detailed exploration of the previous historical narrative of what has happened with that person, which will lead to recommendations. We have a lot of information on suicides and the prodromes to suicides. The challenge is more in the generality of ordinary practice when we recognise that presentations of distress are relatively common, not just to primary care, but to schools and to other services, employers and other things. The hard data on exactly that story is not present and it is not really possible to pull it together. We are working, as I say, with the Royal College of GPs about the issue of prescribing to try and get a better handle on that information. However, I think that the comfort that there has been a narrative with the young person in distress that has explored the environmental supports that are available to someone is not necessarily as clearly documented and measured, just in the same way that, for example, middle-aged men with high blood pressure who have an earlier narrative of not necessarily about the medicines but about sports memberships and advice about their weight and about smoking, that that is not necessarily measured to the same degree as, for example, we know about anti-hypertensive prescribing in Scotland. I wonder whether the process that somebody who may be prescribed antidepressants has to be done by a specialist. Should that apply to other forms of medication that are being given to address forms of mental health, such as something for anxiety that was not an antidepressant? Is that something that you would be looking at? We have to allow clinical judgment and fundamental clinical decisions to be made. There are a wide range of different medical treatments used. Some of those are reserved for specialists and some of those are not. It is fundamentally up to the clinician who is assessing a situation and then initiating prescribing if that is of medicine. I think to say that all prescribing of everything under any circumstances for mental health problems could only be done by specialists would not be possible, because I do not think that that is possible in physical health. We also have to remember that prescribing is not necessarily done by doctors. It has to be proportionate. I think that we have to accept that GPs may choose, for example, with somebody who is saying that I am anxious. The problem that I have is that my heart is beating so fast that it is troubling me to think about using a medicine that would maintain their heartbeat at a regular level rather than going to an antidepressant or to a sedative medicine. To limit the ability to prescribe the broadest range of medicines for clinicians, I think that that would be impossible. The question is whether physical distress is a consequence of emotional distress, but that might be something that a clinician would be able to identify and perhaps apply the same caveats or precautions that there are in relation to prescribing of other medicine, which is really at the heart of a lot of what has brought this petition in front of us. I thank you all very much. I think that that has given us a lot of information around how we would want to take the inquiry forward. We are obviously going to reflect on that. The number of times that we have made the offer of providing more information, I think that any information that you think that would be useful to us, we would certainly welcome that. I think that some of the issues around Dame Coyer's work are something that we might want to look at further. I think that we will have an opportunity to reflect on what we have heard. I do not know if there are any specific points that people want to make at this stage. This is not something that we are undertaking lightly and we recognise that it is something that we would. What we want to try and think about in the next stage is what aspects of this do we focus on in order to assist and strengthen. The work that has been done elsewhere and we are very conscious of the work that Dame Coyer is doing and how substantial that is. Possibly at a later stage, we will have the opportunity to reflect on that. I just wanted to make a point that Hugh had talked about a digital platform. I think that getting a bit more information about that might help with our inquiry too, if that is possible. We can provide that separately if that is okay. Yes, not today. I am not seeing you out of the stage, but you are welcome. You have certainly provided us with a substantial amount of your time, and we appreciate that. We have given us plenty of food for thought. We are conscious of the need to try and do work that bolsters and assists in what is a very challenging area. We will get an opportunity to reflect further on how we take the inquiry forward, but I thank you all very much for your attendance, and I will suspend briefly until I witness to leave. If I can call the meeting back to order, our final petition for consideration this morning is petition 1626 on the regulation of bus services lodged by Pat Rafferty on behalf of Unite Scotland. At our previous consideration of this petition in April 2018, we agreed to write to the Scottish Government asking it to respond to questions raised by the petitioner. As the clerk's note sets out, the Government responded to the effect that it would be bringing forward the Transport Scotland Bill in due course, and the petitioners would be able to participate as part of that process. The bill has been considered at stage 1 by the Rural Economy and Connectivity Committee, which has recently published its report on the bill and has identified some concerns and provided some recommendations for the Government to consider in advance of stage 2 of the bill. I wonder if members have any comments or suggestions for action, and we have not had a further response from the petitioner. Okay, thanks, convener. It's unfortunate that we haven't had a response from the petitioner, given the importance of the petition. With that fact, I think that it would be low to close the petition, to be honest, given its importance, and given that we have the Transport Bill going through a committee at the moment. I would suggest that we should refer the petition to the REC committee for consideration as they go through stage 2, rather than close it. Does that give the petitioner the opportunity to put a further response to the REC committee at that stage, when it is passed over? In terms of stage 2, it would be individual members who would be bringing forward amendments. It would afford the petitioner the opportunity to make the case to the committee in writing or lobbying in relation to specific amendments, but it would also be an opportunity for individual members of that committee to reflect on what the petitioner says and decide who they want to bring forward a petitioner. My understanding would be that, if we refer it, it would not come back to us. If we refer it to them, they would deal with it. I am very conscious of the issues that are highlighted in the petition. It is one that interests people in United Scotland, but, if you remember, at the time, there are a number of other campaigns, including the People's Bus campaign by the co-operative party. I know that, across the party, people have highlighted issues around bus services, the frequency, the reliability and their cost. It is of interest across the Parliament, and it would be something that would be lost in the process or in the system if it was referred to the Rural Economy and Connectivity Committee and, certainly, because so many of those issues will be getting addressed at stage 2. I do not know I guess that you are on the committee. I keep thinking that you are on the committee. You should be on it in order to assist our deliberations. I think that it is incredibly important that the situation with bus transport and the squeezing on local authority budgets, the subsidisation of transport and, in particular, in rural areas. I think that the Rural Committee would be the best committee to look at that as well considering the nature of the geographical locations. I think that my understanding is that the Rural Economy and Connectivity Committee are addressing a lot of those issues. They have looked at this in the stage 1 report, and I think that there are some recommendations on that as well. Yes, it is a rural issue, but I would also argue that it is an urban issue, particularly in areas, say, for example, in one city, where the key commuter routes are sustained, but the routes within communities can stop at 6 o'clock at night. In Glasgow, there are places where it is not possible to get a bus after 6 o'clock at night, in part because of the way some of the funding operates, and it is simple. It is not possible to run the number of subsidised routes that you could argue for, and there is a questionnaire about the industry and how we regulate it. My sense is that those issues will be being addressed in committee, and in referring to the petition, we are perhaps flagging up to some of the issues that I do not think the committee itself has taken on board around the level of regulation, the level of powers that we have given to local authorities and the resources that local authorities would be able to take on that role as well. My sense is that we do not want to close the petition. We recognise the importance of the issues, but we feel that it would be useful to refer it to the rural economy and connectivity committee. I agree entirely with that chair. I think that your point about urban is absolutely right, because I have seen that in my area as well. Little routes being lost, which are key to older people. I had one case in Rolston near Paisley and exactly that. Maybe that could be flagged up to the rural economy committee and the connectivity committee, because I think that that is something that is very important, because that might get lost. In referring to the petition, we would be expecting that the committee would be aware of the deliberation of the committee through the course of including the original statements by the petitioners and so on. I am quite happy with that. We agreed that we would then refer the petition to rural economy and connectivity committee for consideration at stage 2 of the committee scrutiny of the Transport, Scotland Bill. We would like to thank the petitioners and others who provided submissions on what has clearly continued to be an important issue in many of our local communities. Is that agreed? In that case, I thank everyone for their attendance and we will close the meeting.


I am Dr. Sagarika Mukherjee. I am a consultant endocrinologist at Manipal Hospital in Phukata. We will be mainly talking about whether insulin is good or whether oral medicine is good for diabetes. Now you are aware that there are two types of diabetes. One is called type 1 diabetes where the body does not have any insulin on board. And there is a second one called type 2 diabetes where you have got a lot of insulin inside your circulation. But that insulin is not working properly. So for type 1 diabetes as the definition goes that you do not have any insulin on board. So there is no treatment option for type 1 diabetes. So insulin and insulin is the only treatment option for type 1 diabetes. Type 2 diabetes, yes. Type 2 diabetes you have got lots of insulin on board. But this insulin is either not secreted properly or the insulin is not working properly, insulin is not entering your cells of the body properly. So therefore you need medication which will help your own insulin to work or which will enhance your own insulin's action. Now when type 2 diabetes develops there is an odd factor which is created inside the body called insulin resistance. There are a lot of medications available nowadays which then address the insulin resistance and reduces the insulin resistance which helps your own insulin to work. So for type 2 diabetes once your diagnosis with diabetes you start off with diet and exercise. Whether you are type 1, whether you are type 2 diet and exercise goes hand in hand for whatever your diagnosis is and that goes on till for the rest of the life. There is no daily relief from diet and exercise. Lifestyle adjustment must and must be followed for management of diabetes. For type 2 diabetes you get started on medication. Initially we start on one medication and then if it is not working then many a times if your blood sugar control when diagnosis is made with a test called fasting and pp blood sugar, post-pandial blood sugar that is after a meal and a test called glycosylated hemoglobin or HPA1C. Depending what your HPA1C is your healthcare provider might provide you might give prescribe you combination medicine that is medication which are complementary in action. They complement each other in the mode of action and they reduce your HPA1C together in a very very robust way. So that is possible as well. So and once the medication are not working once the medication are failing to work that is not providing you adequate control for your HPA1C in spite that you are compliant with diet and exercise then healthcare providers think of starting you on insulin. Now starting someone on insulin on diabetes is not a curse at all. Remember insulin is a life saving medication. Insulin was discovered 1921 and it had completely revolutionized the way the diabetes is treated. Prior to that people with diagnosis of diabetes used to really pass away with diagnosis of diabetes because there was no treatment. So insulin had revolutionized treatment. So in taking insulin is not a curse at all. Insulin can be taken with a simple pen. Those can be adjusted very easily. The modern pen devices are very very handy today. And there are some complementary medications as well which goes all along with insulin. Hope this was very helpful. Please stay tuned for more information on diabetes management.