Welcome everyone to the Health, Social Care and Sport Committee's first meeting of 2022. Let me take this opportunity to wish everyone a happy new year. I've received apologies from Stephanie Callaghan this morning, but all other members are here. First item in our agenda is to decide whether to take items 5, 6 and 7 in private. Looking to my colleagues now for their agreement on that. Thank you. Our second item today is an evidence session from our inquiry, first session, in our inquiry to health and wellbeing of children and young people. I welcome to the committee Professor Heazel Borland, the interim chief executive of NHS Ayrshire and Arran. Heller Connelly, the health psychologist for the division of health psychology Scotland from the British psychological society. Mary Glasgow, chief executive of children first. Thirsty Louise Hunt, senior policy and public affairs lead for Bernard of Scotland. Jackie Peffer, chief social worker for Perth and Kinross Council. Suzanne Shields, occupational therapy and care group lead for occupational therapy for children and young people at the Royal College of Occupational Therapies. The clerks have allocated one member from our committee. It is a lead questionnaire on each of our themes, but if other members want to come in, then we have a chat function on this platform. If you just put an R in the chat box, I will try to take as many supplementaries as time allows. It would be also very helpful, particularly when asking supplementary questions, if members could direct their question to one of our panellists in the first instance, because that means that everyone is clear as to when they speak. Of course, our panellist, if you want to come in on anything in particular, but you have not been asked by your committee member, you can use the chat function as well, and let me know that you want to come in just by putting an R in the chat box. If we do all of that, then it should all work beautifully. I will start things off by going round the panel quickly to ask what issues you feel that children and young people are facing with regard to an impact on their mental and physical health and wellbeing at this point in time. Of course, right in the middle of the pandemic started 2022 Omicron on the rise and two years now of this pandemic. If I go round everyone in the order in which I introduced you and start off with Professor Borland. Many thanks, convener. Much appreciated. That is a huge question, I have to say. It is enormous. My colleagues across Esher have pulled together a range of picks. We are concerned about a number of developmental delays in infants. We are concerned about the impact on childhood obesity. We are also concerned about the interaction with dental services and the impact that that can have on the broader health and wellbeing of children of all ages. There is a significant impact on their mental health, which tragically is also resulting in an increase in suicides across the country. There is also a range of other issues about making sure that we deliver person-centred services, the stigma that can be connected with being care-experienced, the impact of poverty and some concerns that at times we seem to be compartmentalising poverty in our language. We talk about child poverty, period poverty, food and fuel poverty—it is all just poverty. We need to tackle it in that way. The impact of Covid-19 on education and the impact of that on the attainment gap. When you look at the broader issues in social media, thinking about all those things and their impact on some of our public health priorities in terms of breastfeeding, smoking in pregnancy, gender-based violence and the impact that that can have in particular on young people and a particular focus on young girls. There is a whole range of issues there, convener. I am more than happy during the course of the evidence-based answer questions on a range of those things in more detail. I did not want to go into too much detail right at the beginning, but I am more than happy throughout the meeting to respond to any questions that colleagues may have. I appreciate that. It is a very wide question. My colleagues are ready to dig into some of the detail of that. Of course, our inquiry is a big theme, but with a very short timescale, but I am hoping that it will be a springboard for some more focused work. We will be inviting you back as we do that. Can I come to Heather Connolly now? Good morning, convener, and thank you for having me here today. I am representing the division of health psychology. That is much more a focus on general health and wellbeing of the population and individual level and how we support systems that we are all supported into to think more psychologically informed in the way that we provide support to people. That is less on the specialised mental health aspect. As Professor Borland gave a broad array of the difficulties and the challenges that children and young people are facing just now, that emphasises the wider determinants that are impacting our children and young people, but in all humans, particularly in the Covid-19 pandemic, and reiterating what Professor Borland said, a lot of things around our mental health and wellbeing for children have been impacted significantly. Our obesity, diet, nutrition and physical activity are social connectedness, the relationships that we have with people and the relationships that we have with children, or they might not have been attending as much as school or nursery, and some people have been taken out of school because of fear of Covid-19 and things like that. The relationships and taking it back down to the relationships that we have with our children and young people and how we engage them in all the fantastic services that we have out there is really important as well. The biggest one, I think, again reflecting on what Professor Borland said, was that about child poverty. I think that that is one of our biggest difficulties right now in our society about poverty. Unfortunately, that is only going to get worse given our energy crisis and everything like that. I think that trying to tackle child poverty gets down to the core of some of the difficulties that children have growing up and that young people growing up in terms of access to certain services, in terms of ability to go to community groups and have those relationships with other children and young people. I think that tackling child poverty and poverty in general is really important. When we think about all the wider determinants that impact our health and wellbeing, poverty is in the middle of that, because if we do not have the ability to access stuff, if we have that stress and burden of worrying about financial difficulties, then that impacts on all of our health and wellbeing. I think that that is going to come out very strongly in the questions around child poverty. As you said, those outside determinants that are affecting the household incomes are adding additional stressors. Mary Glasgow, can I come to you? First of all, thank you very much, convener, and the committee for the opportunity to submit written evidence and also for the invitation to appear this morning to speak on behalf of the children and families that we support at Children First. It is very similar to colleagues who have already spoken to their very broad themes by any measure. Every aspect of children and young people's development has been impacted by the pandemic and the associated restrictions. We hear and we see children, young people and their families who are isolated, who are struggling with general levels of anxiety. We take a whole family approach and we know that when parents are anxious, parents and carers are anxious about money, when they are anxious about restrictions, about relatives, about what is happening and the broader context, then children pick up on that. We have seen a huge increase in the level of anxiety and pressure on family. What that is meant for children individually is often a rise in their own level of anxiety and sit alongside the loss of peer and social relationships. The loss of time at school, which for many of the children that we support, is a place of safety when home and family relationships are not always safe. We have seen children lose out on sports activities and unity activities. Normal developmental milestones over the past two years have been lost for a whole generation of children and young people at whatever stage that we have been at. We have got teenagers who have had far less opportunity to take risks, to mix with others outside of home. They have lost opportunities to go off and do Duke of Edinburgh awards or experience other aspects of normal things that children and young people need to do. There are general aspects of their development that have been delayed. We have seen a very specific increase in the level of distress, anxiety and harm that children have experienced because of the losses that they have come across. One of the single biggest things has been the difficulty that children, young people and their families talk to us about reaching out and getting support in a timely fashion. It was really difficult before the pandemic. There was a lack of support to recover from the impact of trauma. It was very difficult to access quickly good quality support for children who were experiencing emotional distress or mental health difficulties. That got a lot worse through the pandemic, so we have seen children's challenges around their anxiety and their mental and emotional health being exacerbated made worse. Parents and carers are really at the end of their day, they are very distressed, not known where to turn. When universal services are not available as a first step into support, they have really been at a loss to try and access timely help for children, so we have seen that get worse. One of my big concerns is that it was bad before in that sphere, before the pandemic has been made a lot worse. Of course, the biggest thing, as other colleagues have said, is the growing impact of poverty and the anxiety and uncertainty and the difficulty that that places on family relationships and family relationships. We always say that children and young people do well when families do well, when parents do well and feel safe and secure. Right now, we are seeing an incredible amount of anxiety, pressure and worry about poverty and the impact of poverty on families generally. There is a general issue, and then there are very specific issues for some of the children and young people that we support and children first. I thank the opportunity to be able to speak to the committee today on behalf of the children and families that Bernardo Scotland supports. I echo a lot of what has been said already, particularly what Mary Glasgow said about the concerns on the impact of poverty. What we have found, especially since children have returned full-time to school after the disruption of lockdowns, is that there has been a lot of anxiety and concerns around children's mental health and the disruption that has been caused over the past 18 months, almost two years now. We had put out a survey to Bernardo Scotland staff that are based in schools on what they are seeing in the children and young people that we work with. What has come back from that is that the vast majority of staff, 94 per cent, came back and said that they feel that children and young people have a lot more worries now than they did pre-pandemic. There is also a great level of concern about the impact of financial hardship that has been made worse over the course of the pandemic. I echo a lot of the issues that are perhaps not new. They are issues that we have known about before the pandemic, but the impact of the pandemic and the social isolation that has been caused by that and the impact on developmental milestones has just made that so much worse. Over 83 per cent of our staff came back and said that they see families with more financial hardship now than they did prior to March 2020. That is a really, really key concern for us. Mary Glasgow had also picked that up. Children will get overwhelmed and stressed if the adults that are caring for them in their lives are also experiencing difficulties. That is the key thing that we want to see. We want to see a whole-family approach to supporting families and children and young people. We would like to see much more investment in focus on that early intervention and that whole-family support that is available. Jackie Peckard Thank you for the opportunity to speak to the committee this morning. I am the chief social worker officer for Perth and Canoes council, but I am also representing social work Scotland as chair of the standing committee for children and families. The children and families standing committee have met monthly throughout the pandemic and more often if required. There has been pretty close monitoring of the issues that families are facing. I echo all of the comments that you have received already, but I would like to pick up on some key issues for particular groups of children, if I may. For example, young carers and the impact of caring responsibilities in the initial phases of the pandemic with lockdown and the withdrawal of universal services. The impact on the mental health of young carers has been significant in that those are young people who face isolation and they often lack the support that other children can engage in. That has been a concern for us. I would also highlight care leavers for young people who are care-experienced and are living independently, often without the support of families and key relationships. The isolation and lack of support that young people who have left care has an impact on their mental health in particular. We have seen an increase in the likelihood of self-harm. I think that we also heard earlier about that there has been an increase in suicidal attempts and suicide. I demand for mental health services at an acute level. To reflect on what has been said earlier by other contributors, where mental health and the wellbeing of parents are affected, it is likely to have a direct impact on children and young people where their family circumstances are impacted by drug and alcohol, misuse, depression and poverty. Poor mental health has a direct correlation with the wellbeing of children. I would also highlight the needs of children with disabilities. We are seeing a linkage to poor mental health in parents because their packages of care have perhaps been either withdrawn or they have withdrawn themselves from it, so they have become more isolated. Although those things are beginning to be reintroduced, they are tired and they are still experiencing the distress of everything that they have experienced over 18 months now. One of the things that we have also seen just by seeking information from our members is an increase in the young people who require care or residential school provision because their parents are unable to manage or they are unable to be managed within mainstream provisions. An increase in concerns and an increase in young people in some instances is moving into care provision. I would also echo the comments that we have made about the need to look at the whole family and the whole family to tackle issues of poverty, health and wellbeing, because anything that positively impacts on families will positively impact on children and where it comes in and inextricably linked. That is where I would start. We are very aware of the fact that this is not just a health issue that goes across a whole lot of disciplines. With that in mind, we have reached out to other parliamentary committees to work with them and all the different drivers that are affecting the children and young people's mental and physical health. Finally, on the initial question that I have put to you, can I come to Suzanne Shields? Thank you for giving me the opportunity to speak today. I am the occupational therapy lead for children and young people in Lanarkshire, but today I am representing the Royal College of Occupational Therapists. I echo pretty much what everybody else has already said, but the key things from an occupational therapy point of view is that we have all experienced the loss of our roles over the last year in our occupations. That is the key thing. We have lost our routines, our activities and things that we take for granted. That is no more so than for our children. They have lost access to education, the opportunity to play, to meet, to socialise and to learn the things that they need to progress through life. From an occupational therapy point of view, the children that we already support are the children who have a level of need with a range of disabilities, life-limiting conditions, developmental needs and autism. The range is vast, so they are already children who have a level of need. That has been compounded by the Covid pandemic. We know that children thrive on a stable start. We know the issues around poverty, poor housing and the lack of education. The lack of support that education gives young people and their families the routine of getting up every day and going to school. We want the children and young people to have access to play. Play is a main occupation of children and young people. Access to green spaces, outdoor activities, leisure facilities and everything that has been stopped. However, there were already issues before the pandemic for children access and some of those as a result of some of the poverty issues, access and travel. It has been compounded. One of the key things for us in the NHS is the threat of redeployment. We are beginning to see the significant fall-out of the children who services were stopped when all their services were suspended. Staff across the whole of occupational therapy were redeployed into acute sites, which was what was essential, but we need to prioritise the needs of our children and young people going forward. We are seeing the evidence of developmental delays. Children who did not have good nursery time and are now already in school have lost that opportunity to develop those early social skills. We need to make sure that we are supporting the parents around these children. We work very hard to empower parents to self-manage and to support the children the best they can, but that is very difficult when, as we have all said, these parents are struggling with their activities, their routine, levels of stress, levels of anxiety and poverty. I think that that probably covers everything from an occupational therapy point of view that has not really been covered already this morning. Thank you very much to all of you for giving us that overview. Sue, you have put an R in the chat box and you want a supplementary on any particular point. It is directed to Jackie Pepper. You spoke at length about some of the drug and alcohol issues that parents might have impacting directly on the children. I want to ask about to what extent are you getting a sense that young people are at risk of more adverse childhood experiences or have been, whether it be abuse or physical abuse or any sort of adverse childhood experience? Thank you very much for that question. Again, this is a topic that we could probably spend the whole session on, I think. Can you hear me okay? Yes. I think that one of the things, just to look at trends and patterns, and it might be helpful for the committee to be aware of this, that what we saw across Scotland in the first six months of the pandemic was, or probably into the first nine, 12 months, a higher referral rate into social work services. Once universal services started to return, once families were being seen, we were seeing many more concerns being referred to social work services in the first instance. Primarily from education and police services, so that will give you an indication of what has been happening there. I do not think that we have seen that go down, so that is continuing. What that has not necessarily done is worked all the way through the systems to mean that more children are being registered in the child protection register, but it has meant much more activity at that investigatory stage and ensuring that all services are working around families as best as they possibly can to provide the intervention that is required to ensure that those children do not end up within the child protection or the statutory system in terms of care. From my own perspective, the vast majority of those children will be affected to some degree by mental health, parental substance misuse and domestic violence. Those three features significantly in the lives of those children. I think that because families have been less visible for a period of time, it is very difficult to quantify what that has meant, but it is certainly their significant features. It is certainly an area for inquiry for the committee to look at a bit more depth. I am happy to see what I can do in the future to provide a bit more information for you. That is great. You want to lead on our theme on persons-centred services, if you want to continue then. Thank you, convener. We have heard a lot from most of you today about the whole family approach that is needed. In our procession before this, we spoke with Audit Scotland that it will have held NHS Ayrshire and Arran up as a beacon of good practice. How could services be organised to provide a more joined-up experience for children and young people? Are you able to give any examples? That is relevant to anyone who is here today. Can we start with Professor Borland? Thank you very much for that and no pressure. I would absolutely be proud of the work that is happening right across Ayrshire and Arran across our whole system. From a children's services perspective, we work in an incredibly integrated way. The relationships that we have between health and social care and with our other multi-agency partners such as Police Scotland are very strong, so that has given us an incredibly strong foundation. We are keen to support the voices of children and young people, and the entramen of the United Nations right to the child has given us a basis for that to build on. We have established a strategic corporate parenting group that works closely with the corporate parenting agencies and groups across our local authorities. Obviously, we have taken a very strong account of the promise, and we have developed a corporate parenting promise that takes us from 2021 into 2024. We have a dedicated workstream as part of that promise, which aims to ensure participation and consultation. For example, with our care-experienced population of children and young people in an on-going and systematic way, rather than ad-hoc, on-off elements, we really want that to be a systematic approach. Our public health teams have aimed to undertake some bespoke local research so that we can inform our needs assessment, and, again, working really closely with our local authorities. Our three local authorities have got incredibly mature mechanisms for getting the voice of children and young people heard, so working across those has been incredibly beneficial. We are working with our champions boards, and we are connecting closely with our CAMHS colleagues, as you would imagine. It means that what we have been able to do is to come up with our corporate parenting action plan that sits underneath our parenting promise that is enabling us now to think about what our priorities are from 2022 onwards. Focusing on the pandemic in terms of, as colleagues have described, really sharpening the focus. Some of the things that we are aware of are not new, colleagues have described that as well. The things that we were already aware of, but the pandemic has absolutely highlighted them and escalated a number. One of the other things that we are going to be paying close attention to is a piece of work that I am not sure if the committee is aware of. There is a national children and young people service improvement group that is run through the Scottish Public Health Network, part of Public Health Scotland. It has started through 2021 to undertake a piece of work that will result in a paper entitled ensuring our future, addressing the impact of Covid-19 on children and young people and their families. I commend that piece of work to the committee once it is completed. I am not sure of the publication date and when that will be finished, but I think that that is going to prove incredibly valuable. We are also aiming to focus on a whole-family approach, as colleagues have described. It is impossible to look at children and young people in isolation. Colleagues with more experience than I have described the importance of the impact of parental mental health on children and young people, parental stress and distress, and how we need to make sure that we are supporting families. That brings us back to poverty and how we do that. That is absolutely one of our foundational approaches in terms of supporting whole families and then gradually beginning to unpick that for any bespoke needs assessment that we may need to target particular interventions at time. I am hoping that that is helpful. Yes, sorry, thank you. I do not know if anyone else wants to add that. Just a reminder to our panellists, if you want to come in on anything there, just to use the chat box. I see Jackie Pepper wants to come in. Thank you very much. Just to say that I would agree with Professor Borland and everything that she has said there, what is key is to ensure that an integrated approach is taken and that services are working together. In terms of some of the examples that you asked for, from a person who knows perspective, I would like to highlight the work of our youth services because we have an integrated youth service that works alongside social workers and others, and very much provides that holistic support for young people irrespective of your circumstances and much more in a targeted way. That is low-key, non-stigmatised. You can walk in off the street and you can speak to somebody and receive support there. That has been absolutely invaluable throughout the whole pandemic and is something that we would certainly be wanting to hold on to. It is that kind of integrated holistic support, not just for young people but also for families too. One of the other pieces of work that we are doing is that we are working along with the wellbeing economy alliance, which is a global initiative. We are working along with partners to test out the wellbeing economy alliance design guide, which is about designing or budgeting for wellbeing. The piece of work that we are doing in Perth is engaging with families about what works for them. Professor Borland was very articulate in saying that this is about what works for families. Some of that is actually pretty. It is not new. It is what we know, what is best for families, and I am sure that others will articulate that too. If you speak to families and children, it is very much about what is in and around their community and what supports them in a holistic way in their community. We must make sure that those are easily accessible in their neighbourhoods and have a locality focus, and that they are easily accessible. It is about wrapping around families and providing that holistic family support. Can I come to Heather Conly, then? I echo what my colleagues have said. The whole family approach is really, really important, and it looks great on paper, but how is that embedded in actual services and what does that look like? What are some of the barriers to doing that and having that multi-agency interconnectedness?  In the cornerstones of person-centred care is delivering services with compassion, but if our workforce has no compassion for themselves just now, because they are working under extreme stress and extreme burnout, we will have difficulty in delivering a person-centred service. We are thinking about the whole service and, holistically, we need to think about the workforce that we are delivering and how we can support the workforce to be able to have the effective skills and techniques and support to be able to deliver a person-centred service. Mary Glasgow. Just building on that theme around person-centred, planning our experience and is very much informed by the children, young people and families that we support, is that pre-pandemic and made worse during the pandemic, many of our systems, many of our support services are complicated to understand if you are a family member trying to reach out and engage with them. We use professional language, which is often very heavily weighted towards jargon, that we understand. We can often design processes and systems that, without intent, actually feel quite dignitising or blame and shame inducing. While nobody intends that, we hear really strongly from families that one of the key things that person-centred, that good person-centred services would offer would be more time to talk, to hear from Heather about compassion, more space, more time to really get to know children and young people, to get to know families, to listen to their stories from their perspective, to really have the space and time to understand what it has led to this current difficulty and how might we start where the family is, rather than what the professional or agency can spare to offer. One of the things that we talked about, which was heartening at the beginning of the pandemic, was that we needed to review our systems and make them much more human and much more person-centred, much more getting alongside being with rather than doing to people. I think that that is a theme that we may be losing if we are not careful. We need to hold on to that original intent. If I could just highlight one example that we have worked with alongside our health and social care partnership—in fact, in two health and care social partnerships—designing and developing multi-agency family wellbeing teams, in response to—this was pre-pandemic when we began to test out this model—in response to that concern that many parents, carers, children and young people had that, when they presented at universal services such as GP, which is often the first point of contact with concerns and anxiety about children's wellbeing, about significant worries about anxiety, about eating disorders or self-harming. They were often met with a response from the GP, which was that the routes of their concern could really only be met through CAMHS and through any clinical-based services, and there were long waiting times for that. At Children First, we have prepared and designed services and learned from those services that often what is required are whole-family support services. You have heard a lot about that this morning, where, when we really listen to what is going on, many children are distressed not because they have clinical difficulties—a small number do—or a medical need, but often because social and family relationships are fractured and under pressure, as we have heard. Children often carry that way of worry, anxiety and concern, and it manifests itself in all the ways that we have heard about. They become withdrawn, so each time they stop going to school, they become very anxious. What we designed was a service that offered very quick early help and preventative support to children and families. The GP came directly into our wellbeing team, and we made a commitment to make contact with the parent, carer and family within two weeks. We have offered a whole-family support response, which has led to children not being needed to be assessed by CAMHS. It has led to parents and carers feeling much more confident because they have support, they feel heard, they have got somebody that they can talk through, that is skilled in understanding the impact of poverty, adverse childhood experiences, trauma and take a very recovery-focused and social approach to that. We have seen that that can have a real impact, but one of the challenges that we have is that those test-learn develop initiatives that can produce good evidence are really difficult to take to scale because of a lack of funding. Funding is very short-term, and we really need to fill that gap between universal services and very specialist services, like CAMHS. What we need to fill that gap with is that whole-family support community-based offer that any parent or carer without stigma or shame can reach out, access quickly and get the support they need. Many parents talk to us about feeling that they are funneled through a process in a system in which they are often offered labels and diagnostics for their children, but they are very rarely offered practical or strategic help to overcome some of those difficulties. Many children and families go through that process and have a whole myriad of labels for their children, but they are not left with long-term support to help them manage that and recover from that. I think that person-centred teams are really important when we need to humanise systems, we need to put children and families needs at the centre, we need to build in time and we need to allow really skilled professionals the space and time to build relationships so that they can really focus on long-term recovery and improvement for children and families, rather than short-time dealing with waiting lists and seeing people getting them off. What we know is that it just becomes a revolving door. They just re-present. Again, if we do not actually get to the heart of the matter and really address what is going on, there is a need for investment right across the board that is consistently applied in Scotland for early help and prevention to families' support that supports the whole family to understand what has happened and help to recover from that. I will move on to Christy Louise. I will let everyone know that we have a number of themes to get through. We have got a number of committee members wanting to delve into detail. I know that there is an awful thought just to cover in this session. I will come to Christy Louise and then to Stan. Absolutely, I think that there is so much that we could probably be here all day talking about. I will be very brief. I just wanted to highlight that point again around the need for space and time for practitioners. That is what families tell us that they want as well. Family support is about getting alongside families and building up those relationships. It is worth highlighting the challenges with making sure that it is a person-centred service when there is pressures on funding, short-term funding or insecurity. Looking towards the next year, that can be a real challenge. That could be improved. I echo comments made by Jackie and others around the need for co-creating change with families and keeping in mind the importance of the promise and making sure that the voices of children, young people and families are central to what we are doing. I will be brief. It was just to echo some of what was said that a child in a young person does not function without a family or a support mechanism around them. From an occupational therapy point of view, what can the family manage? Obviously, what we do is offer a practical solution to what would be a challenge for some of the young people. There are lots of talking to the young people, as Mary Glasgow suggested, about some of the wellbeing issues that would routinely be referred through CAMHS. From that occupational therapy focus, it is how we return some of those children, for example, to school. We are able to offer that level of support. What can the family manage? How can we support these young people to get back to school? As an occupational therapist, that is something that we would do. We get them to school every day and put that support in place until the parents and the young person are able to manage that on their own. By working in a graded way and analysing where the challenges are, it gives parents and carers around the young people a mechanism to look at the next challenge. How do we break that down? How do we break that task down to make it more manageable for these young people? Thank you. Now, Standesh, you wanted to ask Mary Glasgow a quick question before I move on. Thank you, convener. It was just a specific question to Mary Glasgow. I couldn't agree more about the filling the gap between the universal specialist care, but GPs like me struggle to know all the organisations that we have for all the different specialist cares and issues that we have. My question is how can we ensure that people in primary care, health visitors and anyone who can refer to you know that organisations that do work like yourself exist so that we can access it? Thank you very much for the question. That is a really good one. The first point is that there aren't enough of those services. While we have two or three whole family wellbeing services across Scotland, they are not enough. We are often contacted by families in other areas who will say, particularly through our parent line service, which is an online phone support and digital service, that we get many calls from very distressed and anxious parents saying, I've been to the GP but the GP doesn't have anywhere to refer me. Do you have services that can support families like ours? While we can offer that type of emotional support over the phone or online, we don't have services in every community across Scotland. First of all, we need to make sure that those prevent to first step, early health family support services exist. We obviously welcome the Government's plan to invest in whole family support, but it needs to be universally applied right across the country. Where should we do exist, organisations like mine work closely with partnerships so that we co-operate them with families, alongside schools and universal services, so that professionals such as GPs and health visitors are very aware of them. The onus is on us to make sure that we co-operate those and that we talk about them, publicise them and make sure that they exist. In one of our services, for example, in a strength reassure, we are linked to every GP practice across that area and we've spent a long time getting to known building relationships with GPs. I guess from an organisation like our perspective, where we take a social approach to our work with families, reassuring that colleagues from the medical profession that, for some families, social support is what is required, that not all those children require clinical interventions. One of the challenges that we have is that we design those services, usually through very short-term funding that we manage to access from trusts and foundations, test-learn and develop new ideas and innovations. We are dependent on making sure that we can evidence that they make a difference and then engage with our HSEP partners to try and get much needed funding to scale and sustain them over time. That is not short-term work, so I know that the question was about making sure that colleagues and other agencies know about services. The truth is that there are far too few of them, so they do not exist, that is why you do not know about them. The first thing that we need to do is to scale up those innovations that have made a real difference. The second thing is to really engage with families, communities and local agencies to make sure that you know where they are and how to access them and that they are built jointly together. I hope that that answers your question. Colleagues, we are going to have to move on. I am sorry that I am not able to really allow colleagues to come back in with supplementaries when we really are prioritising this fantastic evidence from our panellists to give them more time to tell us their views. Can I move on to talking about stigma? Emma Harper, you have a question. If you can direct them as much as possible, can you put an R in the chat box if you have something to add? Thanks, convener. Good morning to everybody. Yes, I do have a couple of questions about stigma. It was one of the things that Professor Hazel Borland mentioned at the beginning in your opening comments. It is nice to see you here this morning, Hazel. A couple of questions about stigma. One of the examples in our papers was a summary from the promise in August 2020, when it talks about the language that we use and how we need to not use stigmatising language in specific examples around not showing up in uniforms, lanyards or branded cars outside people's homes or schools. That is a couple of examples. Professor Borland, if you can talk a little bit about what actions could or should be taken to continue tackling stigma so that families feel confident that they do not experience stigma when they are accessing help. That is lovely to see you, too. I think that we would agree locally that it can feel like we are at the very beginning of the journey in trying to rectify and turn the stigma issue around. One of the things that we need to look at is our use of language. It is one of a portfolio of issues tackling stigma. We are recognising that the narrative that surrounds care and care experienced young people, for example, can be incredibly negative and, at times, then impact on the improved outcomes that we want to achieve for children and young people and how they connect with their support network and their families. We are aiming to use the each and every child toolkit in order to turn that around. We are at the beginning of rolling that out. It has not happened in the way that we would have liked because of the impact of the pandemic and the need to reprioritise some of our universal services at this point, but that each and every child toolkit is going to be instrumental in how we report the difference that we feel that we are going to be able to make. We are focused very closely on the promise and our actions that sit underneath that. We are keen to make Esho and Aaron the best place in Scotland to grow up. That is about working really closely across health inequalities. One of the topics that we have touched on throughout this meeting so far has been poverty. Poverty is incredibly stigmatising for families because it reduces choice and your options. It means that you cannot say yes to things that you might want to say yes to as a child, a young person or a family. It means that your world becomes much narrower and that that can then ultimately create an incredible stigma around you and how you feel about yourself as well as how others perceive you. How we tackle poverty collectively is going to be incredibly important, and while each local authority and each NHS board and health and social care partnership will do what they can locally, we would all agree that there is definitely national focus that is needed in that area. How we also approach care experience and care experience to young people, how we hear their voices, how we understand what their needs are, how we work with those champions boards, how we try to reduce the number of children and young people that need to be taken away from their own place of living to get that care. That is also incredibly stigmatising. It impacts on a children and young person's mental health, which then impacts on their physical health as well. I feel that we are not as far along the reducing stigma journey as we would like to be. For me, that is the impact of the pandemic and some of the activity that we have had to prioritise, but we are firmly focused on it. Probably because we are now seeing the impact of the pandemic on all those things as well, it has made it even more important that we aim to prioritise it. I hope that that has helped Emma. Can I bring in Heather Conley and Kirsty Louise? I want to come in on that, so I will bring in Heather. I will just reiterate, Professor Rowland, that language is so important and the language that they use. When we are thinking about multi-agency whole systems approach, we all need to be using the same language and how we engage children and young people in the services to reduce that stigmatisation. As Professor Rowland has said, if children and young people feel that stigmatisation, that impacts on their basic needs again, about feeling safe and secure. If we lose those basic psychological principles, we will find it really hard to try to engage people again in services. I will go back to an earlier point about things that we do to over-pathologise and over-diagnose people and children and young people and families. Often, it is just normal human responses to things such as poverty and things like that. Being aware of how we interact and engage with people within the services is really important to try to reduce the stigmatisation that people feel that they are. That links into the person-centred support and care in services. If we have services that are much more person-centred, I will let people tell their story and their narrative, really listening to them and validating them. Life is around us and you have got so much difficulties and trying not to over-pathologise somebody into mental health and mental distress, but actually listening and engaging them through that way can be so important to try to reduce that stigma as well. It is a really important point that has been raised, particularly around language. We would like to see a truly trauma-informed approach that is embedded throughout services, which are supporting children and young people, particularly in education settings. Bernardo Scotland, we had teamed up with Public Health Scotland a couple of years ago, just before the pandemic, to work on a video that asked education staff their views about practical examples and tips that they could use for talking generally about wellbeing and mental health within a setting where people feel comfortable and that they are not being put in a tick box or, as Heather Conley had said, pathologised or sectioned off into all you have got this particular issue. Therefore, it is this particular service that we need to see in the whole person. I can highlight one example. If I could of one of our family support services, our nurture service in Inverclyde is a no-wrong-door approach. The type of service that we have is to provide holistic support, which is non-stigmatising and to see the whole person. It provides support from pre-birth right up to the age of 18 and supports parents and families too, but the idea behind that is so important for tackling stigma. It is not about if someone feels stigma around that they cannot afford to feed themselves because they have their gas bills to pay and their uniforms to buy for their children. It is not about saying that that is one particular issue. We are only going to look at you for that particular issue or single that family out. It is about seeing that family and that person as a whole person and not stigmatising them by siloing them off. I am trying to get across the approach that we take in that service is holistic and will receive the help and support in that relational aspect, however they need it and for however they will need it, and what we want to see with that, as well as the ability for that to be scaled up. Unfortunately, as we have similar comments to Mary Glasgow, there will be family support services in certain areas, but unfortunately that is not available to everyone on a universal basis across the country. That is the type of approach that we think would really help in tackling poor mental health and wellbeing. That is great to hear. That whole issue of the No Wrong Door takes an awful lot for somebody to go through a door in the first place. Mary Glasgow, you have a few points on that, because it is such an important issue. One of the things that children, young people and parents talk to us about is the labels that they are given by different agencies. Parents will say, if I go to the GP or the health service I am a patient, if I go to other services, I can be a service user, or sometimes I am just called mum. What they describe is feeling quite dehumanised by that, not seen as an individual in a person. There are really simple things about language. I say that it is simple. I know that it is not simple. We are in the middle of trying to redesign our platform for hosting information and measuring the difference that we make with families, and we are paying really careful regard to the language that we use. We are so used to our systems using language that other people do not understand. What does it mean to be referred and assessed and reviewed? This is not human language. It does not imply that people have agency within their own stories, so we need to start thinking about using much more humanised, kind and compassionate language and really think about access to support and access to services as a right. If you take a rights-based approach and say to people that you are entitled to get support with some of the really complicated and understandable difficulties that are beyond your control, you remove stigma. Much of what we deal with with the children and families that we support is time spent overcoming the shame and guilt that they feel that they need to get help. All of us who are parents will recognise this feeling when your child is not doing well, when you have a child who is anxious, distressed or not coping. The first port of call tends to be what did I do wrong, what did I not do, and parents carry that shame and sometimes inadvertently without intent our systems and our agencies and even our professionals can reinforce that because of the language that we use, because we are under pressure, because we do not take the time to listen and reassure people. The last thing that I want to say is that one of the biggest things that we see that has the significant impact is that when you say to children and young people and even parents and carers, no wonder why you feel like this. There is nothing wrong with you. This is an entirely appropriate and understandable response for some really stressful and difficult circumstances. There is nothing inherently wrong. It is absolutely okay to express emotion, to have distress and anxiety. One of the things that we need to get better at with children and young people from the minute they are born, from the minute we engage with parents and carers, is to help people to name and share the feelings that we have. We know that when you can help children to say out loud what it is that they feel, they automatically feel slightly better and then you can begin to move on from that. Shame, stigma, guilt needs to be removed and I really echo the point about learning and development opportunities for professionals and helping staff. One of the first things that we need to do is think about how do we feel and think about the people that we support. We need to stop other people and get right alongside them and imagine that they need and want the same level of respect, engagement, kindness and compassion as we do. One of the biggest things that we know as a barrier to help is that feeling that you are made to feel that there is something wrong with you or that you have done something wrong. I will move on to a question from Ciaran Mawrhan. I am just going to very briefly because I am aware of the time constraints that you are working to, but it was really just on the point of stigma thinking from a social work perspective and that very complex landscape that we are talking about is that entire continuum of support and protection from very early intervention through to what is the management of complex risk and statutory intervention and the removal of children from their birth families. To recognise that stigma has a place in there too and that just echoing what Mary was saying, that becoming a parent or a carer is one of the most difficult things that you can ever do and just the recognition of that. It is that empathy with parents and empathy with the family, but recognition that that continuum of support right through the system is required and how do we ensure that we have strong trusting relationships throughout that process because it is the relationships with families that are key to that. Carol, can I come to you to talk about health inequalities? Great, lovely. Thank you so much to the panel for coming along. A lot of what has already been discussed talks about things that need to be done and support that needs to be given in terms of inequalities and prevention. There are a couple of things that I wanted to just pick up on. In some of the evidence that we got from young people, they spoke about the lots of support available when they are in crisis, but in that journey and that way towards crisis there is not so much support available. I wondered what the panel thought about that if they had experienced that and if there is some way of looking at that. In terms of time, I will go on and say that I am also interested to hear from the panel. We have talked a lot about poverty and how we look at that and the whole family approach, which is something that I have heard before, just a wee bit more information on that. We talk a lot in government about investment and funding and finances, and I am sure that people have views on what we need to do there, but also what things do we need to do differently that is not just about the financial provision, and I wondered if the members could give a wee bit of feedback on that as well. Is there anyone who would like to pose that to, first of all, to allow a lot in there? I wondered particularly about Kirsty Louise before young people are in crisis, what kind of things do people say they need? Again, that is a really important issue. We hear quite a lot, I think, from young people and the Bernardus Scotland staff that are supporting them. It is about the tears, maybe before you would get to that crisis intervention level, that we need to see support available. What we found from recent engagement in the survey of school-based staff that I talked about, and I have clear feedback that came through that in terms of what is needed, is more investment or better resourcing of the early intervention. When we were talking about the whole family approach, we were talking about holistic family support. For example, Bernardus Scotland has family support workers who are based in schools, so it is that approach where we are taking our wraparound approach to be where children and families are. It is not necessarily about when someone goes to their GP and they are referred and it feels quite clinical or something that is not actually rooted in their own lives, so what we are wanting to get with that is investment and support at that early intervention level so that issues and problems do not escalate. Perhaps at a stage where we need more crisis intervention, we welcome the Scottish Government's plan for the whole family well-being fund over the course of this Parliament, but what we really want to see in Bernardus Scotland is an urgent action plan as to how that funding can get to front-line services and deliver the scaling up of intervention that we want to see. I think that it has been mentioned before by other colleagues. When we are talking about approaches and how best to support families, there is probably a lot of agreement and families themselves tell us what they need, so I do not think that it is an issue that we do not know what works. It is an issue about what action can we take, particularly in light of the impact that the pandemic has had and how we respond to that to make sure that as we continue to go through the pandemic, as we look towards the rest of this decade, we fulfil our promise that was made to children and young people as well. It has to be focused on the actions that are needed to make sure that that infrastructure, scaffolding that the promise talks about, is there so that people that support children and young people are properly supported to do that. I agree that I am conscious of time as well, but I hope that that answers some of what you were getting at. Thank you, Carol. In AHP land, in Scotland, we work under Ready to Act, which is the transformational plan that was set out by the Scottish Government in 2016. Part of that is about looking at children and young people accessing services at the right time, place and opportunities for them. Within that, it is a much more tiered approach to services, so we have universal, targeted and specialist. That is where we can look at that early intervention and prevention before the families and the children and young people reached that crisis point. In thinking about some of the universal services, we are able to offer some parent workshops that parents can tap into. That works across Scotland. We each have different workshops that we might offer, so some of the common difficulties that children and families might experience. We feel that parents can access that quickly. It does not have to be a referral, as Mary Glasgow was talking about. The new language now is a request for assistance. How is that assistance going to look for families? We are also looking at the opportunity to work within schools and education without having that formal paperwork for children and young people supporting staff in those education establishments to provide the interventions with the support of all the allied health professionals. I am talking about occupational therapy today. That is one of the ways that we can begin to put supports in place before the children and young people reach a crisis point. Staff are more aware, parents are more aware, and it is also building that relationship so that they have a relationship with the professionals around them that they are to support before they reach that crisis point. They have a direct access so that they know who they are going to come to talk to for that support and, hopefully, prevent the crisis in supporting the long-term wellbeing of the children and young people. I think about how our services can become a wee bit more psychologically informed on how we support and engage them in this early intervention. Prevention is so, so important. We know that. Otherwise, a downward spiral happens and that makes it sometimes more difficult to engage people and support people at that lower tiered levels. If we need to make sure that we are meeting people's basic needs and basic psychological needs before we can think about any other services that are there, we also need to think about a health-promoting environment so that people do not live in a vacuum and children do not live in a vacuum. Once they have spoken to somebody, they might have had a fantastic, lovely, compassionate conversation, but they are still going back out into that world, which might be hitting them with stigma and discrimination and inequalities. It is that whole-system approach about how we support people. If we are a little bit more psychologically informed about how we engage people and how we can support behaviour change and how the system can change itself, it is a massive system that we are talking about. That itself is really, really complex to support the system to change and adapt to meet the needs of children and young people at an early intervention prevention level. If we can get them at that point, I think that it was Mary that said earlier that often we see a revolving door if we capture people too late in the distress or the difficulties that they are experiencing. I think that all that is important is what everybody has said. Again, I am aware of time, so I will not talk too much. Thank you very much. What a great question about what more can we do around that earlier intervention and avoid the crisis. If I may give two practical examples of that. I am thinking of a piece of work where it was a transformational service redesign that was moving away from providing residential care for young people who could not be held within the family or within their own communities, but redesigning that to create a team of providing intensive family support for teenagers, 12 plus 12 to 18. That was provided in a way that is 24-7, but primarily in evenings and weekends. It is about providing that support when families most need it, when young people most need it. That is a practical example of what more do we need to do and not necessarily to continue to provide things in traditional ways. If we really are listening to families both in what they tell us and how their needs are presenting, we need to design our services in a way that actually best meets their needs and does not just continue to provide it in a traditional way. Secondly, I mentioned the increase in concerns that have come about as a result of the pandemic. A small example would be providing immediate access to family support workers or family and parenting support within the family home through what would be the child protection and duty team. For those families where it was relevant, referring them on to family workers, all that required was two part-time workers working with 30 families who would have otherwise gone through a whole risk assessment and through the child protection procedures. Only one of the 30 of those families has moved on into a referral to the reporter. That gives you a sense of the scale and value of putting one family support worker into that high-end crisis intervention and what that can actually result in. Those are just some examples of what more can be done and thinking about what works with families and where we need to put additional resource in. Thank you. Thank you, Jackie. Can I come to Mary? Thanks very much. I just wanted to make a couple of points about the case about the links between poverty and health inequality that are well made, that we haven't made the shift to prevention, that we should have and that we really need to think seriously about. As far back as the Christy commission, we were identifying then that we needed to shift away from crisis to really take a public health approach to make sure that we address the pillars of inequality, which are poverty. Often, for many of the children that we support, the adverse childhood experiences that their parents and carers experience lead to stresses before they are even born that, without a focus on recovery, just make things worse. We are also seeing particular concern about growing inequality for children and families where there are additional support needs such as mental health and disability, particularly for black children and families of colour, where there needs to be better representation and understanding of their needs and there needs to be better connections to their communities about their specific wants and wishes in relation to the type of support that they have. We know that, in Scotland, we have a growing diverse population, but we are not seeing that diversity always reflected in the way in which we are designing services. I would like to highlight in terms of inequality just a couple of those specific needs, if I might. Thank you very much. Thank you, that is very helpful. I am sorry that I have to move on, but thank you for rolling all your themes into one question. It is very, very helpful with that in mind. I am going to move on to dig deeper into child poverty issues. Evelin, do you want to pick up on some of the things that have been mentioned around that? Evelin Tweed? Yes, thanks. Good morning, panel, and thanks for all your contributions so far. The Office for National Statistics said last week that the gap between the rich and the poor is the largest for more than a decade. We have an energy crisis, good prices are rising. What does that really mean for child poverty and for the health and wellbeing of our children? Can I pose that to Mary Glasgow, please? Thank you very much for that incredibly important and totally concord with that sense that child poverty is just growing beyond anything that we have ever seen before. It was a problem before the pandemic. The pandemic exacerbated it. Quite simply what we are seeing is that the impact on children and families is like nothing that we have ever seen before. I have been a social worker for 30 years. I have never known children and families to be in such dire circumstances. They simply do not have enough money in their pockets to manage a decent standard of living. We need to get money into the hands of children and families quickly. One of the things that we have seen over the pandemic was support from government, direct organisations like mine through an ability to give parents direct parents with cash. We have talked about that revolving door. The shame of poverty, the challenge in our system, the way in which social security is built is so distressing, so difficult to navigate. We see through our money wellbeing services that we provide that very quickly our money advice workers, who are trauma-informed and trauma-responsive, can help families to access huge amounts of benefits that they have not been entitled to but have not been able to claim the cost of systems is just so complex. Literally hundreds of thousands of pounds worth of additional benefits go into the hands of families. That is what makes the biggest difference. Families make really good parents and carers, despite the rhetoric that we often hear in the media, to make really good choices about making sure that children are provided for when they have money. We have to address child poverty in a sustainable way. It is getting worse, and the impact that it has is that it causes terrible distress in parents and carers, and it impacts directly on the experiences and the opportunities that the children and young people who are living in poverty have. They do lives well in school, but it is difficult for children and young people to go to school and concentrate on learning if they have not had breakfast and they are worried about what they are going to do when they go on home. It is difficult for parents and carers to be available with all the warmth and love and support and care to give their children if they are anxious about their ability to pay their utility bill, to buy enough food or to pay their rent. Those are really significant and growing concerns that we are seeing. We need to make some—obviously, we welcome measures that have been taken, but they are simply not enough. We also need to design a system that does not make children and families jump through all sorts of hoops to get access to money. We have been able to directly give payments to families to clear debt, which immediately reduces distress and puts more money in your pocket, to buy things such as new fridges, such as broken fridges and washing machines, to make sure that families have been able to put petrol in their cars to get to medical appointments. Those are really significant things, but one of the challenges that we have as an organisation is that we have five money advice workers based within children's first services. That is not enough. We need to have community-based trauma-responsive, trauma-informed, well-trained money advice workers in every community right across Scotland to make sure that families can get the help that they need and can get the money that they are entitled to in their pockets as quickly as possible. We also need to address the other issues around child poverty, which are complicated. We understand that, but we need to do much better, because the problem is definitely that we are seeing beyond anything that we have experienced before, and it is a real concern, particularly this winter, with the rhetoric around increased utility bills. We know that families are really worried about that. I am just hearing this morning from my teeth that gas bills are going up by 500 per cent. That is shocking. Whatever the Government is doing to mitigate it, it will not be enough to cover an increase like that. Can I come to Heather? I was thinking about a basic need to be met for us to be able to have the flexibility and the space and our brains to be able to engage in other services. If we do not target child poverty and child poverty, then all the money that we are spending on services and interventions and early interventions will not work well, because people will not be able to engage in those services, because they are still too worried about getting food on the table or worrying about how they will get clothes to get their kids to school. We then do not have the ability to feel safe and secure and have a sense of hope that things will get better. Therefore, we are unlikely to engage in other services or with other professionals. We really need to consider that, because there is no point in doing all the other interventions if we have not got the cornerstone of trying to support to meet people's basic needs and the basic psychological needs for them to thrive and flourish. Thank you, convener. I recognise that colleagues have articulated very well the other points that I would have made. In Ayrshire, the most recently published data says that we have nearly 16,500 children living in poverty. Two of our local authority areas are the second and fourth largest authorities with the largest child poverty rates, and it ranges across all three local authorities from just under 25 per cent to just under 28 per cent, so it is a significant issue. The pandemic has impacted in an unprecedented way. Colleagues in public health have described Covid as a disease of deprivation and poverty, because if you were already on that journey and already in that sphere, then unfortunately, Covid has absolutely exacerbated that beyond all belief. Prior to the Covid pandemic, child poverty levels were forecast to increase significantly with relative poverty reaching 38 per cent by 2027-28. We have a very short timeframe to be able to make a difference to that, and the pandemic has really brought that into sharp focus. Our local authorities in Ayrshire and Arran are focused on it in the way that Mary has described in terms of those community-based advisers working closely with third sector colleagues, families and across some of our localities to make sure that families and children and young people are accessing anything that can make their lives better and easier in the way that they should expect. That is not a favour that we are doing, families, children and young people. That is what they should be able to expect in terms of having a standard of living that should be their right, and it is about taking that right's best approach, so it is a significant worry. I am conscious of the time, so I will be brief. Others have articulated the points exceptionally well, and I would agree with everything that has been said by others. I just wanted to highlight a couple of quick examples, because Evelyn's question was about what it really means for children and young people and families. Although it is not shocking to us, although it should be, there are many occasions where the parents and young mums who are within our service will say that they are coming into service and they have maybe not eaten for the last few days, because they just do not have the cash. Increasing incomes and measures to do that are very important, but, as others have mentioned before, that is crucial, and that is what underlies a lot of the other issues in terms of the stress that that causes and the stress that puts in family relationships and the mental health problems that can be caused by that. The other point that I wanted to highlight briefly was a piece of research that Bernard Rose Scotland had done in partnership with the NSPCC, but it is pre-pandemic, and I think that that is what is so concerning, because what we found in a survey of our family support services in 2019 was that, over the decades since 2014, the level of support had decreased, while the level of need had increased, that poverty was a really core issue for families, that the level of destitution had increased, and what we are finding from our services and from the families that we work with at the pandemic has just made that all the more acute. I really just wanted to drive home. It is a core issue that affects the children and families that we work with. Thank you, everyone. Quick question. Thank you, convener. Thanks for your patience. One very quick one. I am very conscious that we had the recent cut to universal credit, and I want to know, has that exacerbated child poverty? Again, I would like to ask Mary Gillespie, please. Thank you very much. Yes, absolutely. It has anything that removes financial support to families who are already struggling. As given one, I am a really clear message that their poverty is not important, and two, has just made life a lot more difficult, so I would totally concur that we see so many of our families queuing up at food banks, waiting to get enough food to eat, coming to us through our parent line service, for example, which again is online and over the phone and accessible to any parent or carer across Scotland. We often receive calls from parents who are saying that they do not have any food in the cupboard and we are able to then get vouchers or actually send out workers with bags of shopping, so absolutely it has made a huge and significant difference. It was not just the material difference that it made and the amount of money that people have in their pockets, it was the message that it sent to children, young people and families about how society views their needs and the increase in shame and guilt that if you are a family that is reliant on benefits or a need of extra support for often very complex reasons that society takes a certain view of you and the way that it was withdrawn was very brutal and very unfair, and it has had a huge impact on the children and families that we support, not only practically and financially, but emotionally too, I think. I think that children, the parents we support are not immune and all of this induces more shame, more guilt, more embarrassment and more reluctance of them asking for help, and we see parents who regularly do not eat in order to feed their children or do not have the money to buy basic things such as children's coats, shoes, particularly in the cold weather, where we are hearing a lot from families about their inability and reluctance to put the heating on because they are absolutely terrified about what is coming in terms of MPs' bills. From our perspective as the health committee, health outcomes suffer as a result of that, so that is very well made. Evelyn, I must move on and come to Sandesh Gohani. Know that you are having problems with connections, so hopefully Sandesh is here, maybe audio only. I hope that I keep working. We could spend the entire time that we have on Covid-19 as a topic. I know that time is short, so at the start of the hearing we heard about the loss of socialising for kids, the loss of the ability to make mistakes and errors as a child that we all have done, and we know that there has been a huge impact on all services. What I would like to know, and I know that it is going to be really hard to answer, but what impact on our young people's development and future development do you think that Covid will have? What should we do to mitigate that and set up services in future? I have three questions. Heather Collin and Jackie Pepper, to start with, and then if anyone else wants to come in. Thank you, Dr Sandesh. The whole social connectedness has been lost for all of us, not just for children and young people, but for all of us throughout this whole pandemic, for the impact that has had on children and young people from school closures, nursery closures, for their ability to learn those skills of how to make friends and deal with the difficulties that social interactions all bring to us and how to manage that has been really tough and really difficult. I have a one-year-old and a four-year-old through the pandemic, so I can see in them how much the impact of having that lack of social contact has had on them, just even from family, not just from friends, but lack of social contact from families. The children and young people in society who have the most health and equality, have the most poverty. That has been impacted harder on them about their lack of ability to engage and support that. We are seeing development, we are seeing the late social skills and how we combat that. Again, what we have all spoken about through the whole of this meeting this morning is understanding how the whole system can approach, engage and interact with our children and young people to support and build those skills. We have a lot of work in the early intervention framework, which has a lot of interventions that are evidence-based and psychologically informed about how to support children in the early years to build on those skills and build confidence, build self-esteem—again, the basic psychological principles that we need to grow into flourish. As services and as communities, we need to think about how we can engage with the people that the Covid-19 impact has impacted on the most in terms of those social skills. We also need to think about the whole system and our whole environment about how we support that and how we become a bit more psychologically informed about how important acceptance is, how important trust is and how important normal relationships are and the impact that we have on them. We are humans and social contact is so important to us. Again, as long as our systems and interventions think about how we can build confidence, build self-esteem and build awareness of the emotional and psychological impacts that all of us have had on us, it would be beneficial. I have heard about the social aspects, but from an occupational therapy point of view, what we have seen is the physical impact on some of the activities that children have not been able to participate in. You have obviously got some of the complex children, who are at risk of physical limitations and more complex neurological conditions, but the children are the basic things of running around the gym hall and what that does for some of the young people. Children are now back at education and that has been on-going for quite a while. However, there have been small bubbles of children. You are only mixing with five or six up to 10, but running around the gym hall is one of the simplest tasks in terms of thinking about your balance and co-ordination. That seems quite simple, but you need your balance to get dressed. You need to be able to stand on one leg to put a sock on. You need to be able to stand on one leg to pull your trousers up. The impact on that lack of physical development, we need to have that physical, that big gross motor movement, which we developed to then refine into some of our finer skills. Children need to be able to hand-write, they need to be able to use cutlery. As a developmental sequence, that is what you have to do. You do all those gross motor activities and that refines into some of the finer tasks. The impact, for some of our young children, we are not seeing yet. We will see that as we go further down the line. From our point of view, we see a lot of those children and we support them with their occupational therapy already. The children that we would not normally come through our door or through our services, we will see more and more of those children coming through. They will come through with difficulties with their movement, their co-ordination, their handwriting, their activities of daily living, how they get dressed, how they access things. There is such a big impact and that is just a small snapshot of the developmental concerns that I think have been highlighted from that lockdown. Lack of activity, lack of meeting, lack of going to school. One of the ways to look at that is, as people have said, is right the way through the developmental life course from rebirth, right up to adolescence and moving into young adulthood. Children and young people have been hugely impacted. We hear of babies born during the pandemic who have only seen people or being out and about with masks or unable to read facial expression, not really knowing that other people are warm and friendly. Babies and toddlers are reluctant to start to go to nursery or to begin to move through some of those social aspects that are so important because they've been so closely cared for by their own parents and carers at home. That type of socialisation and ability to move through development stages, we're going to see impacts of that for a long time to come. We also know that the major issue for all of us, particularly for children and young people, is one of loss. We've lost many normal opportunities to socialise, to be together, to develop and test our skills as humans and we need to think about how we invest in a whole programme of activities, social, emotional and recovery-focused activities, where we spend time with children and young people, with families, reflect on what's happened, identify what the impacts have been and then work with them to think about what would help. From our perspective, particularly for some of the young people that we support, where families do live in poverty, we often have very complex additional challenges such as drug and alcohol use, such as mental health problems that have been exacerbated, such as family relationship problems that are challenging domestic abuse. We need to think about a whole raft of supports that are available and easily accessible to help people to think about repair and recovery, not just from the pandemic but from all of the challenges that they were already experiencing. Certainly, one of the biggest concerns that we have as we move forward is that the ability for the country to be able to continue investment in those important services is about worry. We are really worried and hearing some really worrying things about funding and about support services that were already underfunded, that were already limited, that were already hard to reach, being almost the first things that go, so we continue that cycle of investment in crisis intervention because that feels like the most important thing. What we really need to do is to think about prevention and we need to think about repair and recovery for children and young people. We need to invest in youth work, we need to invest in making sure that every child and young person, regardless of their family circumstances or their economic situation, can access local community groups where they can join sports clubs, where they can go to scouts, where they can go to the brownies, where they can do all the things that help children and young people to develop independence, the skills for adulthood, confidence and all the ways in which we operate as humans when it comes to getting jobs and making the country work. We really need to focus on repair, recovery and our massive investment in social opportunities and activities to make sure that we help those children and young people to feel less isolated and more connected to their peers and their communities. Mary Smith has just articulated it beautifully, I have to say, but in Esha we are particularly focused on the developmental delays in our infants. Just before the pandemic, data that we had from 2019-20 demonstrated that, at the 27-30-month reviews, 17 per cent of those who had a review had a developmental delay in at least one of those domains. Now, there is no doubt for all the reasons that colleagues have described that those developmental delays across those domains will have increased. How we are going to need to be able to support that and make that better, we need to think about our universal services, being able to pick up those developmental delays to our health visitors, our family nurses and then we need to make sure that we have the mechanisms by which to support the improvement of those developmental delays, which in the main is allied health professions. Speech and language therapy for children, occupational therapy for children, physio potentially for children and young people—that is going to be the way that we can influence that, because it is all very well identifying developmental delays, but you then need to be able to put the support in to help those delays be minimised and improved. That probably would be the key point that I would want to make. In addressing the question about isolation and social connectedness, we have all spoken about that. One of the things that was very much a focus from the social work perspective was to ensure that children—those children that were seen to be at risk and highly vulnerable—were seen face-to-face. That was being measured by the Scottish Government and saw us on a week-to-week basis. I think that our practice across Scotland has shown that through the lockdowns and restrictions that social workers in particular have made extreme efforts to see children face-to-face using PPE within the family home, going out for walks, garden visits, all those kinds of things. Relationships have been strengthened as a result of that, but it is those other opportunities that have been less available to children and young people as they move on into independence and thinking about what that means for them. I refer the committee to a number of pieces of research. Stelsis did some work into the impact on children and families. Within that report, it was indicating there that—and some work from who cares as well—although all that work was going on, 77 per cent of care-experienced children and young people that responded to a survey that was done were saying that they felt that they had received less support. That included teachers, lecturers, college lecturers, social workers, doctors, whatever that might be, but that was their experience. We have to hear that very clearly. They described feelings of worry and anxiety and vulnerability and depression and being tired. That whole thing about being ready to move into group activity to take that up is going to take some time. That reflects the comments that were previously made about what that means for the workforce, giving time to the workforce. That is across the whole children's services workforce in its broadest sense, to be able to spend with families and young people. What that means in the longer term is to enable some of those young people who are furthest away from those universal supports and opportunities like Duke of Edinburgh, all those things that are highly motivational and highly successful in ensuring that young people achieve and move on in life. That longer-term impact on the recovery from that is how do we support the workforce and some of those young people for longer to be able to recover and heal from the experiences that they have been receiving? That is a question for me. I have a very short question directed to one of our panellists, and I must move on, or else we are going to disadvantage two of your colleagues. Thank you, convener. Just coming straight back to Jackie, please.  We all have done it. We make little mistakes. We have errors, but that is where we learn. When we become adults, we do not make those errors. Teenagers have lost that opportunity. What do you think that impact is going to be upon that age group? One of the things that we just reflect on what we saw as we moved into spring and summer last year is that young people begin to gather and get involved in what might be described as anti-social behaviour because of use of alcohol, etc. There is a real concern for me locally, in Perth and Cynroth, but nationally as well. What does that mean for young people's interaction and how they engage with each other positively and meaningfully and avoid those very difficult situations? I think that we saw that in some of the cities, but we saw that in our rural area, such as Perth and Cynroth. One of the things that we developed was a detached youth work team to go out and engage with young people on the streets or in parks or wherever they were engaging because they were drinking and getting into difficulties as a result of that, but really trying to turn that around and provide some diversion and engage them in other activities, including physical activity such as football, etc. Those are the kind of things that we really need to think about. Young people who have perhaps been more distanced from some of those very positive experiences, ensuring that they are re-engaged in that and that they do not head off without that experience. I think that that is what you are suggesting. I think that there is a reason in which that can be done, but my point about the workforces is that we are heavily dependent on the workforce to do all of that, and they are pressured. They are dealing with greater demands, and we are experiencing recruitment difficulties in certain areas as well. Thank you. We only have about 15 minutes left, and I have two things that colleagues want to cover. I am going to ask for colleagues not to follow up with a supplementary question, but to roll everything into one, if you can. I come to David Torrance, who wants to ask questions around online content and social media. Thank you, convener, and good morning to all the panel members. The length of time that young people spend on social media and the content that they could access, how has that affected their health and wellbeing? Online bullying has a real impact on young people's mental health. Have we seen an increase during the pandemic? What could the Government and public services do to highlight the dangers of social media to young people? Thank you. It is a really important question. I suppose that there is specific data on whether there has been an increase in online bullying specifically. I do not have specific researcher data on that to hand, but what I would say is that, from the surveys that we have had back from staff in schools who work directly with young children, they have reflected that, as would be expected, there has been an increase in online activity during the pandemic because of that social isolation. Obviously, social media and online communication is a tool, and whilst there are definite issues where we want young people online to be safe, there can be positive aspects to it as well in terms of that ability and the way to have a video call to keep in touch with their friends when they were obviously isolated during lockdown. Bernardo's, as a UK-wide organisation, has some concerns about the forthcoming online safety bill, and we are looking for a further strengthen protections and safeguarding protections for young people in terms of accessing online harmful content and making sure that there is proper robust age verification procedures in place so that young people do not access age inappropriate material. I think that there is not what the Scottish Government can do in terms of raising that awareness around internet safety and making sure that they are speaking to parents. I think that what I would just also reflect in terms of that, especially if we return to school, what our staff and the staff survey that we had reflected back to us was that they felt that young people now were spending more time online than they were pre-pandemic as well. I think that that is something that probably needs more research in terms of that aspect that you brought up as to whether that is leading to other harmful impacts in terms of bullying. I think that it is quite widely documented that social media can obviously be a positive thing in terms of that peer pressure and perhaps other impacts of social media in terms of comparing yourselves to others and social media filters and things like that. There are things there that we want young people to be equipped with the knowledge about what is the differentiation between the real world and online. I hope that that answers some of your questions and I would be happy to follow up again with some of our research and writing afterwards, if that would be helpful. That is always helpful if anyone wants to add anything afterwards until it is no writing. I think that social media has its place and it gives children and young people the connection and that is how they connect. That is how they communicate and it is a fact of life, so I suppose that it is about trying to make it safe for children and young people. We want to make sure that the children and young people receive trusted and safe information and that is where we have a responsibility as organisations. If somebody is asking us a question, we are able to provide up-to-date and relevant information. I think that children, young people and their parents are less likely to go into the vast google searches and try to get information that is not up-to-date in terms of social media and anything that they want to ask. Across Scotland, we have looked at creating bite-size bits of information that parents and young people can access. If you have difficulties in one area, maybe it is how to reduce your anxiety, how to do your buttons, some of the practical tasks, we have created small bite-size videos that parents and young people can access. The hope is that if they can access the information quickly and timely in a place, in a time that suits them, it is whether they are less likely to go on and look for other information. I suppose that it is about trying to make it safe for young people, trying to give them trusted sources and that that is where they would access their information. However, there needs to be a bit more scrutiny on that, in terms of the safety bill and looking at the real safety aspects around that for the children and young people. I think that addressing the problems that young people have quickly so that they are not going and looking and getting information that is not up-to-date or relevant and that can be quite harmful. I think that building on that, I am again to say for many children and young people that social media and the ability to connect online was a lifeline during the pandemic, it was the way they connected to each other, it was the way many of the children or most of the children and young people that we were supporting were able to connect with us. It was a way that we were able to keep eyes on children that we were really worried about during the early days of the pandemic. It has its place and it has been really useful. I think that we have got to measure and balance what we are saying to children and young people about their social media in the context that we expected them to engage with online learning, we expected them to be on screens for many hours of the day for lots of aspects of the pandemic for good reason. One of the things that we have got to do now is to wean them off a bit by giving them really exciting alternatives. Children and young people have nothing else to do, that is why they spend all their time on social media. Often the children that we support who live in poverty do not come from families where parents can pay for expensive activities to get them outside enjoying activities in the outdoors. We need to think about how we support children and young people to make better choices. We need to speak to help parents. We certainly see that in our whole family support work, where family relationships are breaking down, particularly between teenagers, but it is getting younger. Most eight, nine or ten-year-olds have their own mobile phone now, their own iPads. What we spend a lot of our time doing is negotiating between parents and children and young people about how they talk about social media use and on-screen time without becoming an additional reason to break the relationship. We need to help parents to find ways to talk about children and young people. We all, as adults, need to model much better behaviour ourselves on social media. We all spend far too much time on our phones now, because it was all we had during the pandemic. We need to find balanced, positive ways to support children and young people to have better alternatives. There is definitely an increase. We can see that. You might talk about it as almost an addiction for lots of children and young people now. For many, where social skills and their confidence have been impacted, it is an easier and more comfortable way to have some sort of social interaction. Again, we need to think about what alternatives we can build for children and families. In terms of online safety, particularly when it comes to sexual exploitation and what children are seeing, we need to place a much greater responsibility. We need to get social media companies to take that much more seriously. It is literally everybody's job to make sure that children are safe and we do not see social media companies doing enough. We need to take it much more seriously. It is incredibly harmful and we are hearing of very young children accessing information or seeing things that they are not necessarily going looking for but that they come across. We need to find ways to try to address that as a real concern. I am afraid that we must move on from that. We have Paul Cain around public health priorities. Mallys will take us up to 11 o'clock. I might give you an extra couple of minutes if I can, but we will be at the tail end of the long session. Thank you, convener. In some ways, ending the session of health is quite helpful. A lot of what we have spoken about this morning is about interventions and the need to make interventions in the lives of children and young people. That is particularly focused on positive interventions in terms of policy and legislation. I am keen from a public health point of view to understand in terms of tackling issues such as obesity, drugs and alcohol misuse, non-communical diseases and later in life. What do panel members feel will make the most difference in interventions? I suppose that we can wrap up on that. How do we get to a place where those interventions are in stand-alone or in a silo? They are holistic and go across the piece in terms of family support and working cross-seam. Someone had mentioned no wrong door, and that is key to that. Perhaps we can consider those things to take us up to our time. As we have heard this morning, one of the biggest challenges we have and one of the single biggest things will make a difference is addressing poverty. Poverty underpins all the other public health challenges and inequalities that we have talked about today. Our real drive to address poverty is to ensure that we do not forget the links between health inequalities and challenges that cost us later in the long term that are started and underpinned by poverty would be a really important place to start. We have talked a lot about the importance of normalising the need for support when it comes to child reading. Many of us have so many supports that we can call upon, whether it is in our community or within our extended family. That really helps to raise our children, because it is really challenging at times for most families. For many of our families, for many of our communities, we do not have those existing networks. The investment in what we have described as whole-family support is crucial to address public health inequalities. It is crucial to make sure that it is informed by understanding poverty, where it has practical offers to families, where they can access early help and support easily, without stigma, without having to jump through hoops, without having to go through or be bounced around different agencies and different systems, and get access to help to make sure that professionals understand the impact of childhood adversity and trauma on parents and family life. People recognise that parents and carers use drugs or alcohol or have mental distress, and that many of the reasons for that are rooted in their own childhood experiences that they have not had the opportunity to recover from. Really good quality whole-family support is practical, emotional and financial help to strengthen family relationships. I think that the biggest message that we would want to give from children first on behalf of the families that we support is that the families, the carers and parents that we support, love their children, they want their children to do well, they just have many more challenges than the rest of us to overcome, and there are not easily accessible supports to help them overcome them. That we really need to focus and get passionate on the delivery of the promise, that we need to take a rights-based approach through the UNCRC, and that we need to make sure that every child and young person, every parent and carer can ask for help in a non-stigmatised way and get that support in a way that makes sense to them, which is kind and compassionate, child-centred, but family-minded and recognises that children live in families. Families make up communities, communities are the backbone of our society, and we really need to invest massively in that whole family support that we have described. I just wanted to fly my little health psychology flag, because what we have all spoke about today in this session is really thinking about behaviour, and it is the behaviour of people, whether that be the workforce who are trying to engage and deliver person-centric care, whether that be systems trying to change and adapt to meet the requirements and needs of children and young people, and whether that be policy makers who are making the decisions about what best policy and interventions to deliver on certain change and things. That is all behaviour and it is all behaviour change, and I think that if we can pull on a lot of information and knowledge and theories and models from behavioural science and health psychology inform us and for us to be more psychologically informed on how we deliver those services, we are more likely to see more positive outcomes because it pulls on those basic principles of how we listen, how we support people, how we collaborate with people rather than telling them what to do, how we can support them to problem-solve and think of their own solutions to them for the problems that they are experiencing, how we can instill hope, acceptance and trust and security and safety within the systems that are supporting people, and then again, as I said before, people more likely thrive and flourish within that. A little bit of self-promotion, sorry. I wonder if we can maybe round off, just maybe by asking around the past and asking what we think as a result of everything that we've heard today, what we could focus our efforts on in particular? Are you happy for me to pose that question on your behalf? I think that it would be really useful. I mean, obviously, it's a very broad session. If I can just go round everyone and just say in terms of what we can do as a committee to really drill down on something with regard to children and young people's health outcomes, where could we add value? If I maybe just go round everyone individually, we've come to Professor Barlin first of all. I think that that's an excellent question, convener, and I think that my response to that would be anything that we can do to tackle poverty. We've heard from everybody today that it underlies everything, so whatever we can do to tackle poverty in the way that it impacts on children, young people and families, and taking a whole family approach, those probably would be my key messages. Thank you. Can I come to Heather? I think that it's very similar to all my colleagues. I think that tackling poverty is the underpinning of all of our basic needs and then our basic psychological needs for us to be able to develop and thrive. It's so, so important, so yeah. Thank you. Mary? Poverty, first and foremost, underpinning that investment in whole family support, making sure that we bridge the gap between universal services and acute services for children who are emotionally distressed. Most important, I think that the committee can add value by scrutinising the delivery of the promise. The promise is a thing of beauty. It makes a strong commitment to the children and young people of Scotland. It needs to be delivered, it needs investment to be delivered. One of the ways in which the committee can add value is to make sure that we deliver on the promise that was made to children and young people. Where they are loved and safe, they must be within their own families and that the country must do all that can to ensure that parents and carers and families get all the support, all the emotional, financial and practical support that they need in order to fulfil that commitment and that promise. Also, we maintain a focus on repair and recovery from what has been a collectively traumatising event of this pandemic. Those would be my key asks. Thank you. Ellen Cirstie-Louise? I would just echo what others have said, particularly on the issue of poverty. One issue that we've talked about throughout the session is that need for resourcing properly early intervention and investment in family support. That is really key. Having a shift in our focus towards prevention is very well articulated by Mary Glasgow. That need to focus on making sure that the promise is kept. That would be a key focus. Where the committee could really have some good input on making sure that that remains a focus for this parliamentary session. From all those contributions to your very insightful question, I would just echo the approach to strengthening families within the communities. It's about securing children within the families that they live with and the communities that they live in. What really works for families and what works for them in a non-stigmatised way, certainly. Finally, Susanne? Obviously, poverty is the issue, but let's give children and families access to free physical and leisure activities with support in place. Let's give children and young people somewhere to play, to have fun, to thrive for support and to recover from the pandemic. Thank you all this morning for everything that you've told us. As usual, we could go on for a lot longer, but we must break now. We're going to suspend the session until 11.15 because we have got more evidence to take on another issue. If we suspend it until 11.15, thank you all. Our third item today is an evidence session with the Scottish Government on the draft transvaginal mesh removal reimbursement scheme of which the Cabinet Secretary sent to the committee in December 2021 and comes off the back of our scrutiny of the bill. I welcome back to the committee Greg Chalmers, the head of the chief medical officer's policy division, Terry O'Kelly, the senior medical advisor, David Bishop, the mesh team leader and the Elsa Garland solicitor for the Scottish Government. Thank you all for your offer of coming back and taking us through the scheme and some of the issues that we raised in our stage 1 report. I would like to start by asking if you could take us through the crowdfunding issue. Obviously, that was something that came up when we took evidence of some of the women-affected crowd funded for their surgeries. There were some questions that we had about how that might be dealt with if people had gone through the crowdfunding route. I'm not quite sure who I should go to first, but maybe I can come to Terry O'Kelly first if you can just explain how crowdfunding is going to be dealt with. If there's anyone you want to defer to, then please do so. I thank you very much and welcome from Aberdeen. I think that if it's not unreasonable, I think that Greg Chalmers is probably the best. This is sort of a policy issue rather than a clinical issue. Okay, thank you. I feel his thunder. Greg, over to you. Thank you. Good morning. Good morning. Committee members, happy new year. I'm very pleased to come back to speak to you again today about the bill and the reimbursement scheme. It has come directly to crowdfunding. This was one of the issues that you raised in your stage 1 report. We gave consideration to the different circumstances in which individuals will have received money from other people to help to meet the cost of the mesh removal surgery. In relation to that, the conclusion that the Government reached was to distinguish between private arrangements and arrangements that were in essence public. I recall that the committee discussed that with the Cabinet Secretary in relation to arrangements that were essentially private, for example, between family members. It seemed to us, to the Government, most sensible to not get involved in those, to allow those family arrangements to be dealt with privately and for any monies granted to be distributed privately between family members, which families come in all shapes and sizes in different arrangements. That was our view on that. In relation to public and quasi-public arrangements, we think that it is reasonable, and that is addressed in the reimbursement scheme, where monies have been raised publicly. Essentially, through a recorded quasi-public route such as a crowdfunding website, it is reasonable to expect applicants to declare that they have received monies through those sorts of routes. In part because crowdfunding websites will generally have recorded what has happened. Even if individuals, if possible, did not retain the receipts or the documentation at the time, the information is recoverable and can be got from the organiser of the website. In those circumstances, we think that it is reasonable for those monies to be declared. Partly because it is recoverable, and partly because of where private people make voluntary donations to the costs of somebody that they know, but maybe distantly or through social media. I think that the Government would consider that it is reasonable that those individuals did not expect to get the money back. It was a purely charitable donation. That is the balance that we came to on that. As I said, it is recorded in the scheme in paragraphs 17.1 and 17.2. Of course, people might have raised funds or come from various sources as well. Just before I allow my colleagues to come in, how are we going to make sure that the process is not overly burdensome for individuals, some of whom are obviously recovering from surgery? How are you going to facilitate it so that they really do not find it a burdensome task? No, that is a very fair point. I suppose that one thing that we take encouragement from in this area is that the NSS, who will be operating the scheme, has a fair amount of experience in this area now. For example, when individuals have been making applications to the existing Scottish Government mesh fund, there will be occasions when applications were incomplete for one reason or another, possibly for the reason that you give, convener. In those circumstances, NSS has worked with people to make sure that the application is complete to get additional information. We plan and NSS plans to proceed in the same way here. Those applications will be made in good faith, sincerely. If it so happens that there is something else, such as travel receipts, we will make the best endeavours to support people to find or help us to find the information that they need. Can I pass over to my colleague Gillian Mackay, who has questions about the flexibility of the scheme? Gillian Mackay, can the panel provide more detail on the exceptional circumstances provision at paragraph 16, and could it provide an example of the circumstances that may require that provision to be used? Panel members, I do not know if Greg wants to go in first. I suppose that the purpose of paragraph 16 is to give the ministers or NSS that scope for flexibility that it needs in relation to all the different circumstances that will have transpired in people travelling. It is up some way to get their surgery, whether in the UK or internationally. As you would expect, we specify in the RAF scheme that reasonable travel costs are, generally speaking, economy-class travel or standard-class hotel rooms of the type that one would ordinarily use. Of course, one cannot know all the circumstances that have been involved in each situation. For example, if it so happens that, for one reason or another, there was not a standard-class room available in a hotel in the United States in a particular period, or, for one reason or another, it was necessary for somebody in particular to be upgraded in the air transport so that they so happen not to travel what we would all understand as economy-class, then, if the circumstances were reasonable and there was an explanation that made sense, then NSS would have flexibility to pay that bit more. It is really to give NSS a common-sense flexibility to take account of things that had happened with the control of the applicant. Briefly, thank you. Given that many of the women who travelled did not expect to be reimbursed, do we believe that there is sufficient flexibility to address the many different situations that may arise to ensure that anyone who would claim under the scheme will be covered? We certainly hope so. For example, we are conscious that individuals, and why would they, would not have kept receipts for meals, would not have kept receipts for taxis, those smaller but not, but smaller items individually, but which aggregates will add up over a period of a few days or up to a week when people are travelling. We hope that, for those smaller items where people would not have kept receipts, the exceptional circumstances would be wide enough. It is reasonable to expect that, even if people do not get plane tickets these days, but when people make larger expenditures, even if they do not keep receipts, they will have bank statements that they can draw up on for those larger amounts. Given that we know where the surgery is taking place in general, we would hope to be able to get, if it so happens, that people have not kept receipts of the actual surgery cost, which I expect they probably will have. Nonetheless, we would be able to get that information from the surgery provider. In general, we hope that there is sufficient scope for exceptional circumstances. Because it is an administrative scheme, we will have scope if something transpires that we genuinely did not anticipate. We would have scope to remake the scheme to add to it, as we did in the case of the Scottish Government mesh fund. After the mesh fund had been operating for a while, it transpired that some women had had mesh implanted in a private hospital, which, at the outset, we were not aware of. However, because the scheme was made administratively, we were able to amend it very quickly and bring those people within the scope of the existing mesh fund. We would have that option here, too. That is great. Thank you, convener. Can I now move on to questions from Sue Webber about medical issues arising from mesh surgery, Sue? Yes, thanks very much, convener. I am a bit confused, I think, and maybe it might just be first day back or first committee back, but it is in relation to the other cost. I was wondering if someone could explain the rationale behind only allowing treatment for any complications arising directly from the mesh removal surgery to be reimbursed, whereas medical issues arising as a result of mesh removal surgery will not be reimbursed. What is the difference, and why are we reimbursing one and not the other? That is my main question. I am happy to start on that, and then I think I will, if Terry does not mind, hand over to him to describe the more clinical aspects of that. What we are trying to get at here is to make a distinction between issues immediately arising from the surgery. In that regard, we are not actually aware of the issues immediately arising. In essence, if there has been something that has happened during the surgery that needs immediate attention afterwards—to put it in layman's term—something has gone not quite right and needs to be addressed immediately afterwards, and to draw a distinction between that and, in essence, the healthcare that we would offer to patients upon their return to Scotland. We are continuing to care that all individuals can access from the NHS, which we would expect individuals to access through the NHS, as everyone else does. I will let Terry come in to better explain the distinction there. If somebody had an operation, the scheme is specifically addressing reimbursement for mesh removal, and therefore it is entirely appropriate to think that, if there is a complication or an issue, it is related to that procedure—let's say a surgical site infection or some other issue related—resulting in the patient, a woman returning to theatre or having to have additional length of stay or something like that, it is entirely appropriate that that is reimbursed. I think that, for a number of women, there will be on-going problems, and I think that the women themselves have seen correspondence and requests that women are linked to local services and the national MDT so that their future care is taken forward in a coherent and seamless fashion. That will involve perhaps pain management if that involves psychological, psychosexual issues and perhaps the urological surgery. The reimbursement is about the primary procedure to remove the mesh and what surrounds that, and the expenses related to that, rather than additional issues that might have been taken care of beforehand or subsequently. Okay, I think that I have got that. It's a very subtle, isn't it? It's just the way the language is there, Terry, it's quite— I do absolutely agree, and I think that what Greg has—the issue really is about the way the scheme is applied. I think that we are hoping that that will be as flexible as possible and that each individual case will be assessed on its own merits, because the cases will with her, in our doubt. So, Kavina, can I have another question? Sure. Thanks. Is it acceptable that long-term care is not reimbursable under the scheme if the long-term care was required because of that original mesh surgery, the implantation surgery, not the removal? Right. Does the bill specifically address mesh removal, rather than other aspects of careful information? I suppose that I'm just saying that if that patient has got some significant issues from that original surgery, are you suggesting that that would then, hopefully, the treatment would be carried out under the new Scottish mesh? I think that that's absolutely right, or that it will be accessible locally. What we're hoping is the service—now we've got a centre, and that's a line to the other centre of the United Kingdom—that this will act as a hub and spoke, that patients will attend and be referred to and consulted with as need be, but the patients will be able to, hopefully, access as much care as possible locally. The long-term issues—psychological, psychological, et cetera, et cetera—the centre will develop, I can go with time, expertise in specific aspects of that, but those areas of care are accessible and have been accessible through the NHS and throughout Scotland and the rest of the United Kingdom. What we've added to that is that we've attached it to centres for the act of mesh removal, so that there will be issues around that, such as reconstructive surgery, et cetera. Okay, thank you very much. That's great. Thanks, Terry. Thank you, Sue. Now, can I move on to David Torrance? No, apologies, David. I've just realised that Emma Harper has asked for a supplementary on Sue's issues there. Emma, thank you. Thanks, convener. It's just a quick clarification question for Dr O'Kelly. If a person needed anticoagulant therapy, so they needed an extended pre-op assessment, or then even that affected their post-op in a delayed discharge because you have to manage anticoagulants, for instance, that would be part of the mesh removal procedure, so that would be covered. Is that correct? That would be my understanding, yes. It would be very difficult not to support that. Okay, and then the other question that was just kind of on the flip side of that is, if somebody acquired a complication because of mesh removal surgery, like urethral transection or something in the ureter that required an additional surgery, like a urostomy, is that covered because that would be something that happened because of the mesh removal surgery? My understanding is that that would not necessarily be covered unless it was an immediate problem that required urgent or emergency care. I think that the longer term aspects of urinary diversion or other major urological reconstructive surgery, I'm not sure how much of that goes on in the private sector or has gone on in the private sector, but I think that this is care that one would expect. I think that when I gave my evidence previously, this is the care for major centres with all available resources and that's care that we would have anticipated would have been picked up by the NHS and in the future will also be under the austerity NHS. If there was urethral injury or urological injury at the time of mesh removal and that had to be corrected at that time, for sure that should be reimbursed, but that won't, I don't think, necessarily involve the care that you've suggested. It might do, but we are very rare accounts, I think. David Torrance has a couple of questions. Thank you, convener. My question is for Greg. Some of the women who are taking out loans or used credit cards, or even in some areas remorged houses, the costs and cuts through interest payments from the loans, will they be eligible for reimbursement? In general, yes. That's the policy intention. We will be looking to the cumulative, not cumulative, is a big word, but we will be looking to the individual's circumstances and the way in which individuals have raised the money. That might well involve interest repayments and interest payments made in relation to that. As Terry has said already, our general approach here is to maintain as much flexibility as we can in relation to the administration of the scheme, and, certainly, where individuals have entered into credit agreements and other sorts of financial instruments, the cost to the person is what will be considered. In the broad scope of reasonableness, as the minister said in his evidence, we do, of course, need to keep a balancing eye on the use of public funds. I would fully expect that actions that people have taken in those circumstances will have been reasonable. I'm not seeing any other members wanting to ask questions, so I'll thank you all for your time this morning and once again thank you for giving us sight of the scheme and we'll move on to our next item. Our next and fourth item in our agenda is consideration of a negative instrument to abortion Scotland amendment regulations 2021. Those regulations amend the 1991 regulations to enable the notice of termination that is sent to the chief medical officer to be given electronically an extended deadline for given notice. They also reduce the information that must be provided as part of the notification. The Delegated Powers and Law Reform Committee considered that this instrument made no recommendations and no motions to a null have been received in relation to this instrument. I'd like to ask members if they've got any comments in relation to this instrument that they'd like to put on the record. Nope, nobody has any comments, thank you. I propose therefore that the committee does not make any recommendations in relation to this negative instrument. Does any member disagree with that? Nope, they don't, so we agree not to make any recommendations. Apologies. At our next meeting on 18 January, the committee will take evidence from stakeholders as part of our inquiry into the health and wellbeing of children and young people. We'll also take evidence from the cabinet secretary for health and social care on the provisional common framework on public health protection and health security. That concludes the public part of our meeting today. Thank you all.