Felly, wrth gwrs, ddwybod ffrifon yw'r 3 yma'r 2016 ddweud o'r Cymru. Rydym ni'n rymian i'w ddweud yr allu ddweud, ddwybod ddwybod ddwybod yn ddaf yn bwysig i'w cael ffiyngwysgol yn bwysig i'w ddweud, oherwydd i'w ddweud y ddweud o'r ddweud o'r cymdeithasol, oedd yma'r cyflym yn fwy o'r cymdeithasol. First agenda item is a consideration of whether to take items 5 and 6 of our agenda in private. Those items are to discuss our approach to our legacy paper and a witness expenses claim, which we would normally take privately, if members agree. That brings us to our second item of business, which is consideration of PE1463 on effective fly-aroud and adrenal testing diagnosis and treatment on what shall take evidence from the Minister for Public Health. The minister is accompanied today by four officials. We are also joined by Elaine Smith, MSP, who has been in attendance and taken a keen interest in this petition and will allow Elaine a opportunity to join in our discussion. Before we get to that point, I would like to welcome the minister and her officials and invite the minister to make a short statement, after which we will move to those questions. Thank you very much for inviting me to give evidence to the committee on this issue. At the outset, I should make clear that not only do I have an on-going interest in this petition as Minister for Public Health, but I also have, as I previously made public, a personal interest in this petition. In fact, I was substituting at this committee in 2013 when it was discussed. I am aware that there are many people who are affected by thyroid problems and that some of them have been unwell for some time, having experienced difficulties in obtaining diagnosis and appropriate treatment. I am very sympathetic to the challenges that they face. First and foremost, I would like to stress that we take the petition and what the petitioners are saying very seriously. Although I have an understanding of some of the issues that will be raised today, I recognise that the committee may ask questions of a more clinical nature. For that reason, I will require to refer some of your questions to Professor Graham Lees, the chief medical officer's specialty adviser on diabetes and endocrinology, who is also an honorary professor in diabetes and endocrinology at NHS T-side. As the committee is aware, the Scottish Government commissioned a listening exercise carried out by Thyroid UK surrounding the experiences of hypothyroid patients. This online survey was carried out during the summer of 2015 across the whole of the UK. Respondents were invited to complete the survey from a variety of sources, including the Thyroid UK website, forum, Facebook and Twitter pages. Approximately 5,000 respondents to that survey, with just over 4,000 surveys fully completed. The purpose of the listening exercise was to obtain a comprehensive picture of what was happening in respect of patients' experiences of diagnosis and treatment. The survey was aimed at patients diagnosed with hypothyroidism, as well as those who had symptoms of hypothyroidism, but had not yet been diagnosed. A number of questions were asked covering patient experience diagnosis treatment and GP knowledge. The results of the survey are available from Thyroid UK's website, and I would like to take this opportunity to thank the charity for carrying out this useful work in helping us to obtain a better understanding of patients' conditions, diagnosis, treatment and experience. Committee members will be well aware that the role of the Scottish Government is to provide policies, frameworks and resources to NHS boards to allow them to deliver services that meet the needs of their local populations. Within that context, the provision of healthcare services is the responsibility of local boards taking into account national guidance, local service needs and priorities for investment. It should be recognised that progress in clinical science has been and should continue to be based on proper, conducted, scientific-based trials that strive to eliminate any error or unrecognised confounding issues. It is appreciated that progress can sometimes be frustratingly slow, but that is the consequence of trying to get things right and ensure patient safety, which is paramount at all times. Anecdote and clinical observation can be useful to raise scientific questions, but such questions then need to be tested rigorously, as otherwise it can be potentially detrimental and dangerous to patients, as well as wasteful in terms of NHS resources, not just in thyroid disease but also in terms of all other medical conditions. The position statement by the British Thyroid Association published in May 2015 clearly sets out its recommendations on the management of primary hypothyroidism based on the current literature review of published positions of the European Thyroid Association and American Thyroid Association and in line with best principles for medical practice. Those recommendations have been endorsed by the Association of Clinical Biochemistry, the British Thyroid Foundation, the Royal College of Physicians and the South Society for Endocrinology, and therefore reflects current best practice in the management of hypothyroidism, about which Professor Lees will be able to speak more, if needed. The British Thyroid Foundation is a patient support group that, since 1991, has worked with medical professional bodies such as those listed above to provide guidance for all patients and their relatives who have thyroid disease, including those with underactive thyroid, overactive thyroid, thyroid cancer and thyroid eye disease. The British Thyroid Foundation has endorsed the British Thyroid Association guidelines. In addition, the British Thyroid Foundation has written a frequently asked questions sheet for patients and published that on the website. This has also been written for GPs, which is expected to be published later this year in a GP-orientated medical journal. In conclusion, I am aware that the petitioner has met sign representatives and that an outcome of this discussion is that the Sign Council is hoping to determine, in conjunction with the Royal College of Physicians, whether it may be helpful to seek to produce a good practice guide on the topic for general practitioners. That, of course, will ultimately be a decision for the Sign Council and the Scottish Government cannot influence this decision, but I welcome their consideration of this proposal. I was a pretty comprehensive overview of the situation from your point of view. As you said at the outset, the petitioner has been running for a substantial amount of time. Members who have been on this committee have had an in-depth understanding of it as it has gone forward, and I know that some of them are keen to get in and ask questions to follow up the work that they have already done. I am going to go to the deputy convener first, David Torrance, to ask the first set of questions. Good morning, minister, and thank you, convener. Returning to the Thyroid UK survey report, a survey found that 42 per cent of respondents considered their clinician was not open to discussion treatment options, and over 50 per cent considered the GP's knowledge of hypothyroidism was poor. How is the Government going to react to his findings and what recommendations it is going to put in place? As I said in my opening statement, the survey was UK-wide, so we cannot extrapolate the Scottish situation from that. It was not a randomised sample, as it would normally expect to do in a clinical trial. Many of the figures quoted—the people responding to the survey will have been those who have been very involved in it. The figures quoted are likely to be an overestimation of the situation. GPs and endocrinologists generally follow evidence-based diagnostic guidelines, which are agreed in the specialist community. In terms of what the Government is going to do, as I said, the Government cannot intervene directly, but GPs are proposing to develop a good practice guide for general practice. Professor Lees, you are involved in that, so would you like to say something more about that? I am not directly involved with that, but we have been involved with the British Thyroid Association. As the minister mentioned, the British Thyroid Foundation, which is the patient group, has developed a number of frequently asked question responses for patients, which is also useful for GPs. In response to what is happening, there have been a number of ways forward to try to help to increase the awareness of the issues across general practice and specialists. I do not mind, because it is relevant to that point. I might have asked it later, but it is maybe better if you do not mind, convener, to ask it now. It is just on the British Thyroid Foundation that the petitioner tells me that they have recently changed their advice online, I think, as recently as maybe just this week. What they are now saying is probably directly to Professor Lees, if you do not mind, minister, what they are now saying is that, for some people, it would be okay to try T3. I would quite like your opinion on that, because obviously it is okay to try it, but you have to be referred to an endocrinologist by your GP first, because GPs will not prescribe it for you. Secondly, it is okay for T4 now to be slightly over, because that is now acceptable. Finally, whatever medication you would be taking should be one that resolves your symptoms, which brings up the whole issue of desiccated thyroid hormone, which is allowed to be prescribed on a named patient basis, but very few GPs will prescribe it. I would like some comments on that, please. A comment on the British Thyroid Foundation, I am not sure that I have seen the document that you are referring to, but it is probably referring to the British Thyroid Association guidelines. What they suggest is that, which is nothing new, is that, certainly, the blood test is not the whole picture. When you are replacing someone on thyroxin, it is a balance between treating symptoms and treating the blood tests. The blood tests give you a range with which you should be within for safety, but within that you can move around your dose of thyroxin, as long as it is kept within that safe range. That is perhaps more explicit in the document, but that has always been the case. In terms of the use of T3, or Lyotyrhonyn, there is scope within the British Thyroid Association document that was published in May for the use of Lyotyrhonyn in exceptional circumstances. That is also stated in the European and American guidelines. In exceptional circumstances, it is felt that it is going to benefit the patient. As you say, it may need a referral to an endocrinologist for that. I might just come back briefly, convener. I wonder if you could also comment on the range, because it is something that the committee has been looking at. It is different in different countries and, far too often, we have heard evidence that GPs just rely on the blood tests and they do not look at the patient's symptoms particularly. There are a lot of patients on many other medications treating symptoms that, if their thyroid was treated correctly, they would not have to be on all of those other medications, including drugs for depression, for example, drugs for fibromyalgia, painkillers, et cetera. If there was better treatment for thyroid patients, treatment that was more centred to them, such as the way that it is with diabetic patients, there could be moves forward for patients and for the NHS, the scope there for the NHS to be saving money. Why is it that diabetic care, which is a fellow endocrine neighbour of hypothyroidism, is treated on a person-centred basis, whereas those with underactive thyroid are simply put on level thyroxine? That is the basis, one medicine for them. The evidence would suggest that the patients on thyroxine are treated very much at an individual level and that the guidelines and most GPs would try and adapt the levels according to symptoms as long as it is within a safe range according to the blood tests. For people who are not so involved in this, anybody on the level thyroxine gets a blood test every year, a TSH test. If there are abnormalities in that test, they are tested for T4. If there are still abnormalities, it may be tested for T3, which is my understanding of it. Routinely, patients on the level thyroxine get an annual blood test to see if there have been any changes and the dosage may be increased or, indeed, reduced as the blood test shows. It is worth noting that there is a wide range of what is acceptable TSH so that there is scope for moving doses, perhaps to small amounts, to maintain patients within that wide range of TSH, which is thought to be safe. Thank you, convener. The minister mentioned in an opening statement that there would be new guidelines published later in the year for GPs. Can you expand a bit on those guidelines and how quick will sign implement them? I need a third part of that. Can you just repeat some of that? Save it again, please. There is some noise at the background, so I am threading to you. How quick will sign implement those new guidelines for the GPs? There just needs to be an increased general awareness of those guidelines. I think that comes down to educating GPs, advertising the guidelines. Every GP has to do a certain amount of professional development every year. There are opportunities there to educate GPs. They have a huge number of different areas to cover, but thyroid disease is one that can be put into that. It is something that most GPs will definitely come across in their practice, but on the other side of that, there are websites from the British Thyroid Foundation and others that people who take levothyroxin should be aware of so that they know, just like Diabetes UK, that there are tests for people who have diabetes and what they should be getting from their GP. I think that awareness of patients is important as well. I accept what the minister says about the figures in the report that they are UK based, so it is not clear about what is the true picture in Scotland. I think that, perhaps, the minister might consider doing a report of a role in Scotland to try and determine the actual figure, but also in terms of timeframe in making doctors aware, I think that that is important. I do not seem to get a feel for the real timescale in this. What are the timescales that you are participating in in which you intend to circulate this information for GPs so that they are equipped with all the information that they need and the support that they would need to carry out? It is not just a one-off thing. The guidelines have been available since May, and it is a matter of continuing, like any advertising campaign, which is what it comes down to in terms of increasing awareness. You have to keep at it and keep educating GPs the philosophy of treating patients within a range of TSH, and perhaps changing their doses is not new. It is just re-emphasised in those guidelines. Stepping around the issue, you are still not giving me a clear guide on how you are focusing on this, how you are homing in on this, and how we are going to assess the success of the advertising campaign that is going to be taking place. Surely you will be looking for effects and figures of how successful the campaign is going to be and what timescales you are looking to achieve those in. I am wondering more clarity on how quickly you hope to deliver it on the ground. There are already signed guidelines for GPs. What we are talking about is perhaps revised sign guidelines for GPs, but it should also be said that one of the petitioners has been involved in seeing whether the current sign guidelines and any future sign guidelines should be altered. In fact, as a result of discussions, it was discovered that current sign guidelines are pretty good and that, if they were left to the petitioner, she would probably have come up with more or less what is out there now. As I said, the petitioner has been involved in discussions about sign guidelines, which is my understanding. I do not know if anyone else wants to come in on that. The Royal College of Physicians through the sign council will be issuing new ones in the near future. I accept what you say. I am sure that you are going to try and determine to make sure that it is fit for purpose. I am pressing continuously and I will stop at this stage because this is my third attempt. I am clearly looking for some sort of programme that you have in terms of timeframes and when you hope to achieve that. Without having a timeframe, it is going to be open-ended and that surely is unhelpful. I think that what I said in my original statement is that it is not up to the Scottish Government, it is up to the sign council and we cannot really determine their time frame. I think that perhaps I add to that in that the guidelines are out there. They are in the process of being distributed at the moment and you have talked about measuring the success of that. I would welcome your thoughts as to how you measure the success of that. Shall I respond to that? I am happy to do that in a bit to try and help. I have already indicated that, in terms of figures, we do not have Scottish figures. We really need to in terms of how many patients there are and how many patients are benefiting from the service and how well it is being delivered in terms of the GPs and practices, how much information is actually available to them and whether it is being successful or not in the delivery. At the end of the day, it has to be measured. Everything needs to be measurable. If it is not measurable then we cannot judge its success or failure. We do not know whether we need to change things or not or do we leave that status quo. I understand that the guidelines are... I think that Gonzales makes a very good point, which I do not think that you have clarified at all here. We are relying on this thyroid UK survey. I am just enhancing the question, if you do not mind. If I make a point, you can respond. I am not stopping you from responding. I just want to add to what my colleague has said, because I want clarity around this as well.  There is evidence that people have been refused treatment for T3. You are accepting the survey. You are accepting that there are issues within the survey. The question that is being asked, or I would like to add to the question that is being asked, is that, given that we do not have a full picture in Scotland, you are depending on a survey that you consider yourself not to be complete. Why are we not trying to complete that picture? You are working on the basis of a survey that does not give you the answers, but you are not doing anything from where I can see to achieve those answers. Why not? First of all, to answer, we know exactly how many patients there are on thyroxin in Scotland. We know how many there are on live thyroxin as well. Do you know how many are being denied or refused treatments that they are asking for? No, we do not know from the thyroid UK survey either, because it is... That is the point. We do not know from that survey, but you are not telling us how you are going to try and find out. Can I say that there are about 6,500 patients in Scotland on T3? That is 1 per cent of people who are on thyroid medication. However, there is no supporting evidence to support the routine use of thyroid extracts, the T3 monotherapy or the compound thyroid hormone. You are giving the wrong impression that a patient can just ask for T3 and routinely be put on it. That is not the same... With all due respect, minister, I am not giving any impression. I am asking... If all of the work that we are discussing here, if all of the understanding that we have on this situation is primarily based on a report that you yourself consider to be incomplete, why are you not trying to complete that understanding of the situation? We did not say that it was incomplete. We undertook to undertake a listening exercise and we commissioned the British Thyroid Foundation of Thyroid UK to undertake it, and they did it across the whole of the UK. We know from that survey what patients think about their treatment and, as a result of that, the specialists have taken forward the sign guidelines. I will let you come in again. I know that you have lots of questions, but other members of the committee will come back to you. I will not miss giving you the opportunity to ask questions, but some of the colleagues have been waiting for a period of time now. I will come to you. The minister just mentioned that there are 6,500 patients on T3. We know that there have been supply issues with regard to T3 in recent months. We also know that Mercury Pharma is the only licensed manufacturer of T3 in the UK. I suggest that there are issues with regard to Mercury Pharma having a monopoly on supply. In light of the supply issues, is the Government aware of any action that has been taken to evaluate the improvements to Mercury Pharma's manufacturing process of T3 tablets? Is there likely to be another UK manufacturer of T3 coming forward in the near future, which would clearly assist in the supply? The other point would be that, if there are 6,500 patients on T3, is that limited because of the supply issues? Could there be more on T3 if there was more available? There were previous supply issues of T3, and action has been taken to evaluate the improvements to Mercury Pharma's manufacturing process of the T3 tablets. However, as you will know, regulation of supply is reserved to the UK Government, and enforcement of the regulations on supply is a matter for the Medicines and Healthcare Products Regulatory Authority, MHA, RAA. We are not aware of any issues with regard to the supply of the T3 tablets at the moment, but I do not know whether the two pharmacists would like to come in. We know the number of prescriptions that are dispensed for T3, and that is 6,500. Scottish officials are in regular contact with the colleagues in the Department of Health who will work with the manufacturers. There have been no supply issues at all in 2015. There have been in contact with the manufacturers to make sure that they improve their processes to ensure continuity of supply for patients so that we do not have the problems that we had a couple of years back. Work has been undertaken to try to resolve some of those issues. In terms of the company being the only company that produces the product, that is a commercial decision that a company would make. Maybe because there is a comparison to the £2.5 million that there are for T4 prescriptions, you can see that it is a small proportion. It is a decision that a company would make, not the UK Government to produce the medication, but there have been no supply issues in 2015, and active steps have been taken to make sure that the manufacturing process has improved to ensure continuity of supply for patients. Part of my question was that you are aware of any other manufacturers who may be looking at it, but you may not be able to answer that. We are aware from our colleagues, and I think that it is probably a commercial one as to whether a company would decide to manufacture it or not. With regard to natural desiccated thyroid, this might be a bit of a naive question, but I was wondering if it would not be a simple solution to the current issue, which leaves the personal liability of the prescriber or the GP. The onus is on them, if there is any comeback. Would it not be a solution just to approve it and allow it to be used without any comeback on the GP, which might be a reason why very few people have been prescribed natural desiccated thyroid? I think that people are even buying it off the internet, because of that specific issue. There are some physicians who prescribe liol, peroxin, as it does have a licence, but there is no robust scientific evidence, clinical evidence for its benefit, and significant theoretical concerns have been raised about its long-term safety. There is plenty of evidence out there in the wide world that it is working on. I think that the Professor would say that it is anecdotal, but I will hand over to you, Professor. I am sure that the patients would certainly vouch for the fact that it is working. Put a few of those issues together to try to get clarity. I think that everyone would agree that there are patients on peroxin who do not feel well. That is recognised by everyone in the professions, and that is highlighted in the Thyroid UK survey. The issue really is not so much how many or whatever it is, it is what we can do about it. As you were saying, it comes down to anecdote versus clinical evidence. As was said in the original statement, in that 11 out of 12 trials show no benefit of lyothuronin in patients who are feeling unwell on peroxin. The one trial has been done with desiccated thyroid showed no benefit in a randomised control trial. Having said that, there are anecdotal reports. The position that we try to take as a professional group is to listen to those anecdotal reports but to try to take them forward in a scientific way, which is what has happened with those randomised controlled trials. At the moment, they do not support in a controlled clinical environment the use of these other agents, and that is the position that we are at at the moment. However, that does not stop us doing more clinical trials, perhaps trying to look at specific patient groups in that area who may benefit from those drugs. However, at the moment, we do not have that evidence. All the guidelines that I mentioned earlier are evidence-based guidelines, because that is the way clinical practice works at the moment. The other thing, convener, is that the guidance does advise that patients who remain symptomatic should be referred on by their GP to an endocrinologist for further investigation. Of course, some people who live with hypothyroidism or thyroid problems will say that that is not happening. However, the committee did hold an evidence session with sign in November 2014, and the committee agreed to invite sign to consider developing further guidance and guidelines as a result of that. Thank you, convener. Good morning, minister. Just a couple of questions about the work of Thyroid UK in the survey that was produced. We note from the preface, and you also made reference, minister, that the Scottish Government commissioned this research. I ask how much did this research cost? I do not have a figure for that. We could certainly get it to you. In terms of the commissioning of this research, was there no guidance given to the Thyroid UK regarding the extrapolation of Scottish patient experience in the survey? As both yourself and Professor Lees have said, you cannot extrapolate from this report the experience of patients in Scotland. However, the Scottish Government commissioned this report without asking specifically to get the details of Scottish patients' experience. The committee has been asked in the petition to deal with the experience of Scottish patients. Although, and hopefully, the minister will provide the committee with details of the cost of this commissioned piece of work from Thyroid UK, clearly there is an issue here in terms of who commissioned this work and why the work did not focus in on the experience of Scottish patients in relation to their treatment in the diagnosis regime that currently exists in Scotland. I am hopeful that Thyroid UK will be able to take this to the UK Government and make good case for better treatment regimes in the UK and England and Wales. Clearly, this committee is concentrating on the experience of patients in Scotland. It would have been extremely useful and whoever drew up the commissioning document to say to Thyroid UK, can you break this down and give us Scottish figures in relation to the areas that you have identified? Clearly, that never happened. Hopefully, minister, you can come back to this with the cost, but maybe you can come back to this as to why specifically you did not ask in this commissioned piece of work what the experience of Scottish patients in terms of the treatment and diagnosis in relation to the petition that we are dealing with. Well, maybe we could go back a step because I think some people were under the impression that there would be a short-life working group set up, but I think my predecessor advised the committee in a letter on 5 February 2014 that there was no evidence base to support the changes that were being sought by the petition at that time. Instead, we asked for a listening exercise to be done by Thyroid UK and that I resulted in the survey that they undertook. As I have said previously, that was not through their website, Facebook and Twitter. It was not a survey in the sense that you would have a specific group of people that you would ask. That is not what the exercise was meant to do in the first place, but we can certainly send you details of the cost. The committee has just said why not in terms of the situation that we are looking at. In relation to the decisions that have been made since the petition was received by the committee in 2012, we heard earlier the frustration of the petitioner in relation to some of the responses that you gave yourself, minister, and we will examine that further as a committee. However, the decision to commission a piece of work by the Scottish Government to identify the issues, and you talked about a listening group, how do you establish a listening group if you then take examples for the rest of the UK when we are trying to deal with Scottish examples in relation to patient experience? We do know across the UK that there may be different experiences in different health boards and guidance that is issued. You have mentioned the sign guidance that will be issued, and you cannot instruct sign how to give that guidance. However, the Scottish Government has a role to play in that. We have asked, as a committee, the Scottish Government to examine the patient experience and the medication that is being provided to patients and the benefits of that medication. However, you have spent money asking an organisation to conduct a survey that, quite frankly, to paraphrase yourself, you are basically saying that it is not worth the money that was spent on the report, because it does not give us anything conclusive in trying to take forward the issues that have been raised in the petition. I am not aware what the parameters were of the listening exercise that was undertaken. As I have said, I will undertake to write to the committee how much it cost and what the parameters of the listening exercise were. However, I doubt that the experience of patients across the UK might be all that different in terms of that. Indeed, given the state of the health service south of the border, it might be worse. I have, like one or two colleagues, been following this petition since it was launched in 2012. It was the aim of the petitioner that endocrinologists are able to accurately diagnose thyroid and adrenal disorders and provide the most appropriate treatment. That is where we began. Professor Lees, although your words are very carefully couched, essentially the solutions that patients are looking for seem to me to be branding nothing more than quackery. However, thousands of women are clearly not benefiting or are unwell from the routinely prescribed treatment of T4 in Scotland. Although you say that the evidence is only anecdotal, I would love a definition of anecdotal, because anecdotal can be a little woman at the bus stop who said that she read it in the Daily Express, who found it in Hello Magazine, or anecdotal can be the first-hand experience of thousands of women who have been prescribed and who have said that the allergic reactions that they had or the symptoms that they previously had had been alleviated and they were now well. I do not want to call it a professional conceit, but it almost seems like there is a predetermined establishment position, which was meant to be part of a listening exercise, which it now seems was the listening exercise, which I understand involved multiple patient groups with diseases, not just the one that we are looking at, is now used. I think that the minister said at one point that I was a little astonished in respect of the survey. Those who responded were very involved in it, so that might explain why it was waited as it was. What was the point of the survey if it was not involving people who were very involved in it? Naturally, I would expect that to be the outcome. It seems to me that, after three and a half years, there is an establishment. I have heard that in relation to other things, and nobody wants people to be prescribed things that are unsafe. However, the anecdotal charge—you talked about clinical trials—was it conducted? How many people were involved in them? When were they conducted? What is the real substance in the face of, I do not think, trivial evidence to us as politicians, but the real life experience of many women that seems to me to direct that there ought to be a process by which we try to do more by way of prescribing alternatives? You give me the impression that you think that there is a conspiracy theory behind all of this, but in reality, if you speak to any clinician, 99 per cent of them will come from. 99 per cent? That is, let me at least say, 99 per cent of the Parliament. Where did 99 per cent come from? If you get six and a half thousand people being prescribed, then doctors are clearly making decisions to give women this medication. How can you come up with a figure of 99 per cent of people believing that the survey that you have got is the accurate position? I am sorry, I do not think that you are listening. I asked you where 99 per cent came from. Where did the 99 per cent come from? Were the figures bandied about all morning about the number of people who were being prescribed? You just pluck a figure out of the air to justify your position. Was 99 per cent perhaps an anecdotal percentage? What I was saying was that the majority of clinicians, as I said, are actually… That could be 51 per cent now. So not 99, could be closer to 51. I am asking you where your figure of 99 per cent came from. Of what? You said that 99 per cent of clinicians agree. Where is that 99 per cent established? What did I say? I did not say 99 per cent. You did? I said no, I did not. We are not going to agree on the figure, so could we just get the… What I was trying to see is that the majority of clinicians, and what I was seeing is perhaps 99 per cent, because there may be the odd one that is not, and then I was interrupted. I mean that is just typical. No, I am asking you where does your 99 per cent come from? Every time I try to make the statement, I get interrupted. No, I am asking you specifically… Can I finish my statement? No. I am asking you, you are actually responding to my question, and I am asking you where your 99 per cent figure comes from. What? You have said that 99 per cent of clinicians believe. Where is that 99 per cent verified? No, I never said 99 per cent of clinicians believe. I said what? Can I please finish the sentence this time, for the third time? I said that the majority of clinicians are compassionate, is what I was trying to say. No, that is because I kept getting interrupted. No, he did not. I think that it was a good well after he made your point that Jackson asked you to clarify what you were actually trying to say. Well, I hope that this is on tape. It is, it is all recorded, so we will be fine. What I was saying was the majority of clinicians, and then I was about to say, because there may be the odd one that is not, but 99 per cent of clinicians, and that is when I got interrupted, and I was going to go on to say that we will be very compassionate about the problems that patients are facing. So that is what I was trying to say, and that is what I am trying to get across. So the fact that there are comments about conspiracy theories and quackery, I do not think is fair in that the majority of clinicians will be upset when they have patients in front of them that have ongoing symptoms despite being on thyroxin. But there are a number of different possible reasons for that, and I can go into them if you want, but there are a number of different reasons. The other thing that we need to be thinking about is that these clinicians do not want to be doing any harm with any treatments that they may prescribe or recommend as well. The other comment that I would like to get across in terms of the issues about anecdote is that that is exactly why we do, that is why we listen to anecdote, because they often raise good clinical questions, which then, as I said before, need to be tested in a clinical trial to make sure that it is actually going to do benefits. And an example I can give you for that is if you look at a completely different disease area in painful neuropathy, we do trials giving drugs for pain, and to do that you will give half the patients the active drug and half the patients a placebo drug, because that is how you know which one is benefiting and they are blinded to know which one is getting. And in those kind of trials up to 50 per cent of patients will get pain relief with placebo. And that is why we need to do these clinical trials to see whether drugs really do benefit or whether there are other aspects of the care that they are giving that help patients. And that is why I come back to the compassion that clinicians have wanted to show and in the majority of cases do show their patients. So those are the points that I was trying to get across. I am sorry, have I got mixed up in all that? I just want to pursue that point. Specifically then you referred to the clinical trials. Where were they conducted? When were they conducted? How many women were involved? I cannot tell you exact numbers. There are thousands of patients involved in the trials. Is this an anecdotal response? No, it's just my answer. You don't know is the answer. Perhaps thereafter you could write to the committee giving us full details then of the clinical trials. I don't want to know what you think. I want to know what you know. When were they conducted? How many were involved? I said I didn't know the exact numbers involved. Well, they were conducted between 1999 and 2008, I think it was the last one. And thousands of patients involved. One trial showed a benefit, but the other 11 in randomised controlled trials did not show a benefit. There have been four meta-analyses where were they conducted across western world and America and the UK. And four meta-analyses combining those trials didn't show a benefit. Right, but you can forward that information to us. I can do that. Can I just answer the question about the listening exercise? We've got to remember that hundreds of thousands of people live with thyroid problems, probably on thyroxine, and live perfectly well and healthy lives. But what we said in relation to the listening exercise was that those most motivated to reply and answer the questions that thyroid UK posed are likely to be those most unwell and most unhappy with the service that they're getting from their clinicians at the moment. And what we're trying to establish is the best way to take those concerns forward for those patients who are still feeling unwell suffering from thyroid problems, but may be suffering from other problems as well. And Elaine Smith is right that most clinicians look at the whole person and the type of drugs that that person may need may not necessarily be related to their thyroid problem. And I accept that totally. So, hopefully in the guidelines that, you know, these kind of issues will be highlighted for GPs and through the various thyroid organisations, help patients in the type of appointments and discussions that they have with their GPs and if they're passed on to secondary care to the endocrinologists. Thanks, convener. I don't know where to start. If the minister thought I said that most clinicians looked at the whole person, then that was a mistake if I did say that on the record, because that's not what I'm saying. What I think I said was that GPs tend to look at blood test results and not the whole person. The point that Professor Anthony Toft has made is don't look at the blood results, look at the patient, listen to their symptoms, work out from there what you should be doing. So that's one issue. The issue about the other drugs that they're on are often, they're on them because of their thyroid problems and that if they were on the right medication for their thyroid, then they may not have to be on antidepressants, pain meds etc. So that's one point. My second point would be that, first of all, the obviously petitioner was rather upset. I think maybe the minister, I don't know if you were perhaps wrongly briefed because the petitioner didn't, as far as I understand, come to any agreement about guidelines. In fact, she's not aware that there are actual guidelines for thyroid conditions and she was interested, I think I would be interested, I don't know if the committee would be interested in getting a copy of those actual guidelines that are in existence at the moment. I think that that would be interesting for everybody to see them, so that's the first thing. I suppose that it then brings us to the issue that, as the minister confident, that the current treatment for hypothyroidism can be considered safe when it's admitted that 10 per cent of patients who remain unwell on level thyroxine, that's what it's admitted. Personally, I would say that it's a lot higher minister because the professor talked about people on T4 never coming back and saying they're unwell, but actually I know lots of them who do and they don't know, they don't think it's related to their thyroid because they're told, here's this little pill, take it for the rest of your life, you'll be absolutely fine and we'll test you once a year to see how your bloods are. It's not routine to test T4, it's not routine to test T3, it's certainly not routine to test T3, so I wonder what you could say to A the ones, the 10 per cent, which is a modest figure, who are not doing well, what are we going to do for them? What could we say to the people who are not being diagnosed because they might be slightly outwith the ranges and actually if they were in America they would be getting diagnosed? What do we say to all of the people in this country who we don't even know how many there are, who are buying desiccated thyroid hormone off the internet, and why is it that desiccated thyroid hormone was fine until pharmacy invented T4? I think that these are questions that really have to be answered about how patients are going to be treated in the future. I don't think that I as a politician should be saying what the medical profession should do, that's up to the medical profession, but I think that I ought to be clear that there is guidance for patients and for GPs and endocrinologists at the moment. There are no sign guidelines, but there is guidance for them at the moment and what is being developed is, as Professor Lee said, whether there should be sign guidelines, so there is a difference between guidance and guidelines, but I would like Professor Lee's answer to your other questions. There were a lot of questions in there, but I hope that a lot of the answers may be within the British Thyroid Association guidelines, which are very similar to the European and American ones. I'm afraid not because I don't know how you feel about this. It's anecdotal, but the problem is, as you put it, that for lots and lots of menly women—obviously, some men—it's something that you said earlier that they could go back if they're unwell, but the problem is that they go back if they're unwell, and it sounds like—now, I've been through all this myself, so that's why it's anecdotal—it sounds like depression. Here's some anti-depressants. Oh, it's probably your weight, so let's see if you can go on a diet or your fibromyalgia is actually something that we can give you cocoa them all for. So it goes on, but it never ever comes back to the fact that it's your thyroid. For me, it went on for two years, and the two years, I had brain scans, I had blood tests, I was tested for Lyme disease, I was tested for lots and lots of things, I was tested for putting heart monitors, it must have cost a fortune, because instead of sending me to an endo, I was sent to a neurologist. I didn't have an endo at that point. I was eventually told a DME, and I wouldn't accept it, so I demanded that my GP—and even though I was very, very ill, I'm quite assertive—so I demanded that my GP send me to Dr Anthony Tofford. Within one session with him, the blood test for the T3, I wasn't converting, I was put on T3, six weeks later, I was much, much better, and it's taken me, you know, even till now, to actually get the doses right of the T3. So this is what's happening to a lot of people. I know women on T4 who tell me about all those other symptoms, and they think, oh, I'm all right on my thyroxine, my T4, but actually they're not, because all of those other symptoms are down to the fact that they're not on the right doses, or they should be on T3, or actually desiccated thyroid hormone, which was the treatment previously for so many people who were considered safe when it was the actual treatment. So I think these are the things. I think what women really—and maybe what the petitioner is looking for—is that patients are listened to. GPs use, as I said earlier, the name to patient basis to prescribe what is best for the patient, to let patients try out what they want to try out and not have to buy it off the internet, which is very, very dangerous. So I just wondered how you feel about that, because you talk about trials, but there are so many people out there that you won't reach because they're not in the group that you're going to be looking at. I think what your personal case that you described, there is actually provision for what you went through, and so there's provision within the guidelines to address your issues now, and there may not have been in previous guidelines, but the modern ones do actually, you know, you would, in an ideal setting, go down the line that you eventually did go down. So the guidelines would address your particular situation. The point, convener. I understand that there's about 20 per cent of people, and that's a bit anecdotal, but I don't have those figures in front of me, but there is a high percentage of people who have been diagnosed with ME who actually have an existing underactive thyroid condition. I would like to know whether or not you would consider that those people should all be tested for not converting their T4 to their T3. If that was the case, if they weren't converting T4 to T3, the TSH would go up. The TSH isn't going to be all-in-end all. I think that, as the minister said earlier, that GPs can test the T3 and the T4, which they don't routinely, if a patient is presenting with these symptoms. My TSH is not at a level just now that anybody other than the endocrinologist who's been dealing with me for years would let it be, but I'm doing well on the T3 that's now been upped and the T4 that's now been taken down. What's happening with me is that it's not my TSH, the blood test that's being looked at, it's me that's being looked at and it's how I'm dealing with it. I'm going to get any further pursuing that line of questioning in the line, but I think that we've given the situation a good hearing this morning. I would suggest to the committee that, because we've had such an amount of information and a lot of questions that I've arisen out of that, that we need to write to the minister to get some clarification around those points. We can come back to a meeting. If we can get information back from you that's been raised this morning so that we can discuss it at a future meeting, we're beginning to run out of time in terms of the meetings that we have, but I think that, based on the questions that arose from the evidence that we got this morning, there is still a bit of distance to go with this petition and I think that we have to pursue this quite diligently as we move forward. We are pressed for time and I think that the clerks and your officials can discuss the timescale by which we need to get answers back, but we do have to get them reasonably quickly. I don't think that we'll have time to invite you back, minister. I don't think that that's going to be possible in this session of Parliament, but it may be that our legacy paper will suggest that we have to keep an eye on this petition given the number of questions that keep arising and the failure to arrive at a conclusion. I know that you came along this morning to try and be as helpful as possible, but I just think that we ended up with more questions than answers. The best of intentions that you had to give us the information just led to more questions being posed by the committee. I won't comment personally on the style of the evidence session this morning, but I think that there might be a degree of dissatisfaction with that as well. Getting the answers in a written forum might help us to get some progress on this petition because I don't think that we got exactly what we were looking for this morning and that leaves us disappointed. We have to continue to pursue that, Elaine, if you've got a suggestion. Obviously, there was some misunderstanding, which sometimes it's better to get things in writing, between guidelines and guidance from endocrinologists, etc. I wonder whether, or not, given that the petitioner has been pursuing this for nearly four years now, if she might be afforded an opportunity to come back and give some evidence on the information that you received? It would be difficult to suggest that to a future committee, and obviously we'll have to wait and see. That option is always on the table, but certainly further consideration of the petition is something that she's merited. I think that we can guarantee that, but it wouldn't be for me to tell a future committee who they should and should not invite to give evidence. It's just not the appropriate thing for us to do, but I certainly think that the committee as a whole can continue this petition and suggest in its legacy paper that future work requires still to be done in relation to that, but we can, as I said, get the written answers to the questions that arose this morning so that we can have a further consideration of this in this session. I think that that would help us to direct the legacy paper towards the future committee, so that that can continue to be looked at. I want to take some questions as soon as possible and we can after we get them. Our third item of business this morning is evidence from a number of health boards on PE 1568 on the funding, access and promotion of the NHS CIC. I welcome to the meeting Katrina Renfrew of NHS Greater Glasgow and Clyde, Dr Hugo Van Worden of NHS Highland, Dr Harpreet Coley of NHS Lanarkshire and Professor Alex McMahon of NHS Lothian. The members have the usual briefing and background materials on this petition, which will allow us to ask questions, but before going to our witnesses, I would like to point out that the paragraph 4 of our briefing note should refer to inpatient integration cover beds rather than homeopathic beds. With that, we will move straight to questions. Does anyone want to kick off questions? The one that has been raised with me around this new facility at Gartnavel. If health boards have decided not to put funding into the support of CICs and there are people with chronic pain who are already being treated within your health board areas, where will they then be treated? There are a number of different strands around the centre of integrative care. There is a national chronic pain service being developed, which will be available to all health boards, and that is a new service. Then there is the homeopathic service, which is also part of the centre of integrated care at the moment. Then there is a range of other services, including mindfulness, CBT and some allergy treatments, so there are a range of different services. I think that chronic pain is the one that boards will expect to get from the centre when the new contract is in place with the Scottish Government. Specifically, what is it that health boards have decided they do not want to fund? I think that that is probably better for the three health boards to answer, because there are shades of difference in that. If I can start off in relation to NHS Lanarkshire, our board took a decision in December 2014 to stop referrals of patients to the centre for integrative care, which includes interventions, including homeopathy, but a range of other interventions as well. What was the rationale? Is it just funding better use of the money, or is there a clinical reason underpinning that? Absolutely not. It is not due to the issues of cost. As the papers that we have made aware to the committee make clear, the decision by the board was taken on the totality of the evidence in relation to homeopathy, but also other interventions provided by the centre for integrative care. It was based on the evidence and not the cost. In terms of NHS Lothian, NHS Lothian still refers patients to the centre for integrative care, so that was the decision that we took as part of our process of consulting on homeopathy. That still continues on. We have a service-level agreement with NHS Greater Glasgow and Clyde on that. There is a process for people being referred that exists within NHS Lothian, so it is a case-by-case basis. NHS Highland took a decision in 2010. A board paper was taken, which took the position that homeopathy would not be continued to be funded by NHS Highland. We have a clinical advisory group that looks at all referrals, so there is the opportunity for individuals to make a case to be referred anywhere. Those cases are referred. Over the last five years, we have made about two referrals a year to the centre for integrative care, but those referrals have not been for homeopathy. There have been a few four or five requests per year that have not been supported by that committee. There has not been a recent change in relation to NHS Highland's position. The position goes back to a board paper in October 2010. Just for clarification, Dr Crowley, could you tell me that you made the statement that the Lanarkshire Health Board did not make any referrals to the CIC? Could you clarify whether that is any new referrals? I am sure that we have heard in evidence before at this committee that Lanarkshire Health Board would continue to allow the treatment of patients who had previously been referred prior to the decision being made by the board. Is that the situation? I can confirm that. That is true. As with other service changes, if there are patients who are already receiving a service, we continue that, and that is the case. On that basis, Dr Crowley, could you tell us what evidence the board heard that was conclusive to make the board take a decision to stop any future referrals to the CIC? As part of the process, we undertook a review of the literature, the world literature, on interventions provided by the Centre for Integrative Care. That included homeopathy, but a range of other interventions as well. On the basis of discussions that we had with the Centre for Integrative Care, we were on the review group that we had. We looked at the evidence from other reports. We undertook a survey of GPs. We undertook a survey of a selected sample of patients attending outpatients at the two outpatient clinics in Lanarkshire. We made available literature about our process of consultation to those attending the CIC. We took on board comments from the Centre for Integrative Care, from the clinicians and patients who attended the CIC as well. Beyond that, the board decided to do a wider consultation, in which just under 6,000 individuals responded. The board considered the totality of the evidence in that, including the evidence of the effectiveness of not just homeopathy but the other interventions that were offered by the Centre for Integrative Care. The board came to a decision, not an easy decision, but a decision that we should stop new referrals to the Centre for Integrative Care from Lanarkshire. Dr Cooley, on the number of groups and organisations that you went to as a health board to seek advice, information and reports, could you tell the committee what the response from the patients in relation to the surveys that were carried out by the health board? We are supposed to talk about the health boards, and the health service talks about a patient-centred approach to care and treatment. It would be interesting to find out what the patients themselves thought about the services that they were receiving and the potential decision by the board to withdraw the services, not only in terms of referral to the CIC, but to withdraw services in Lanarkshire health board completely in relation to homeopathic treatments. As the board paper, which you have access to, makes clear the minutes of the meeting, we made it clear that we were open and transparent about the feedback that we had from patients, not just patients but from the public. It is undoubtedly true that homeopathy and the other interventions that are provided by the Centre for Integrative Care are popular. They are acceptable to patients and the public, but that does not mean that they are effective. Otherwise, there would be no need to have organisations such as Scottish Medicines Consortium. I ask the question, because you said that the treatments are not effective. Who makes the determination whether or not the treatment is effective? Is that the patient or the clinician? If you look at how the effectiveness of interventions is measured, you need to have high-quality studies, you need to have unbiased studies, you need to look at the literature that exists not just within Scotland, the UK but worldwide. That is one part of the evidence that the board took on board. It also looked at the feedback from patients. As I have said, we made it absolutely clear that patients and the public find homeopathy popular and acceptable, but that does not mean that it is effective. If I can continue, I would point out that, if that was the case, there would not be a need to have organisations such as the Scottish Medicines Consortium producing guidelines or NICE, because those organisations assess the effectiveness of interventions. It is important to take on board the views of patients and the public, but if we are looking at effectiveness, we need to do that. I think that if you had been in for the previous session that we just had, Dr Coley, then I think that you would have heard the committee unanimously agreeing that some of the guidance that is out there and the sign guidance does not deal with the issues that patients are dealing with. What we are trying to, as a committee, look at in terms of this petition, is to look at the benefits that are given to patients in terms of their treatment, in terms of their care, and in relation to how they feel that makes them participate in as an active life as possible. I would like to move over, convener, to the situation in terms of the Centre for Integrative Care in relation to the continued viability of the centre. If what we are hearing today is with the exception of Lothian, is that health boards are withdrawing referrals or not making referrals to the centre, how financially viable is Greater Glasgow and Clyde health board in terms of maintaining the level of services for patients who may desire those services despite the fact that the local health board is not making a referral? There are two different elements to that. One is the routine business, if you like, that we call cross-boundary flow, where other health boards fund us for the services that their patients use. We need to look at the loss of income and we need to look at how we reduce costs to reflect that loss of income, but I think that the view that we have given the committee is that the centre and the services that it provides are still viable because the majority of them are used by NHS Greater Glasgow and Clyde residents. There is a piece around the centre that is about cross-boundary flow. We have also indicated our intention to review the centre in terms of the services that it provides, their costs. In part of our financial planning for 1617, we have about 40 or 45 different service reviews that we will be running over the next few months in order to set our budgets for 1617. There are two different processes at play, but we have been clear that the viability of the centre is not threatened by the loss of cross-boundary flow income. It means that we need to reduce costs because we cannot afford the service to run exactly as it is at the moment. We are doing a wider service review of the service in terms of financial planning for next year. How many other health boards have signed up to make referrals and will be providing funding to the CIC? There are only two or three boards that send no referrals at all. As colleagues have said, other boards have cost-per-case arrangements where their residents can flow through on an assessed basis. Our population is nearly a third of the Scottish health service, and we are using about half the capacity of the centre for integrated care. In our view, the viability, while NHS Greater Glasgow and Clyde continues to commission it, is there. It may be a smaller service because there are less patients coming in from elsewhere, but we have confirmed to the committee our view that, despite that loss of income, we will be able to continue to run the service, subject our own review of the service as part of our own work around what services we provide. If you are providing the core funding to have the facility there, if other health boards are only using it or buying into it on a case-by-case basis, and others have decided not to refer at all, that makes it very difficult for you to plan future funding and maintain the funding that is required to ensure that the service is there, should anyone or anyone from any other health board wish to access the services that are provided? We work with other health boards on three-year arrangements to give some stability to the flow of finance and referrals, and we have arrangements, cross-boundary flow arrangements, with all of the boards that use our services. It is not an unusual arrangement where some boards buy one aspect of a service and others don't, and there are different volumes from different boards. There is nothing unique about the centre in that regard in terms of the cross-boundary flow arrangements that we run. Can I ask, just by way of introduction, a clarification question, the new national centre for chronic pain, which will be located there. The cabinet secretary confirmed this to Parliament in 2014. Where is that currently in terms of its development within the facility at Gartnavel? The detailed planning is being done literally as we speak. There has been a series of discussions this week. There has been engagement with the public and patients, so that work is going ahead. The fact is that, with regard to homeopathic medicine, there is no national position of the Scottish Government in relation to whether it is a good thing or a bad thing or whether it is provided or not. It has been left to every individual health board to take a view as to whether or not it is something that they wish to be to support. Some health boards have never, in fact—we are focusing on a doctor colleague who is one that did and now has chosen not to—but some health boards never have. I am interested in the inherent contradiction in all of that, because, if I can ask you again, Ms Renfrew, clearly then Greater Glasgow and Clyde health board believe that it has merits. In essence, Dr Coley's position was that they had taken peer group studies of the effectiveness rather than desirability of homeopathic medicine across the wider world. I will come back to him in relation to the judgment of his own patients. It concluded that it was not effective. It seems to be an essential contradiction between the views of different health boards, because if Glasgow is committing to continue to provide the service at the CIC, Glasgow must have concluded that it is effective, otherwise it would not. As Dr Coley said, any health board doing a review like this looks at a whole range of factors, public opinion, patient opinion and evidence review, and the board will weight those factors in making a decision. Different boards weight those factors on a whole range of services in different ways, so that they will find a different pattern of health services in greater Glasgow than in other areas. There is not a single scientific correct answer when you take on board patient opinions and public opinions and so on. The evidence base, as Harpeets described it, is clear, and that was one factor that Lanarkshire considered when they made their decision. We will review the services at the centre again. What we have said is that it is financially viable as it stands, because the majority of its work comes from NHS Greater Glasgow and Clyde, but we need to look at the decisions and the reviews that have been done on other health boards and revisit whether our position is the correct one, and we will be doing that. I am not quite sure whether that leaves me in relation to the commitment that I understood that you were giving it to the centre. Is it the view of Greater Glasgow and Clyde at the moment since they financed this treatment that it is effective? We last looked at the service in detail, I suspect, about 10 years ago, and we concluded then that we would stop providing homeopathy and the board reviewed that decision as part of a process where there was a great deal of public anxiety and anger and patient anxiety and anger and took the view that we would continue to provide it. On the strict definition of effectiveness, I think the evidence in the way Dr Coley has described it supports Lanarkshire's position, but there are a number of other factors that were considered in reaching that decision, which is now several years out of date, and we will look at the work that other health boards have done in revisiting our own conclusions. I was making the point that the centre is financially viable. That does not mean that it is not subject to review along with almost everything else that we do as we go into 16-17 and need to set a balanced budget. No, I appreciate that. Given the pressures that there are on NHS resources, I suppose that I would be slightly concerned if we were investing in services that you did not ultimately conclude were effective, if I can put it that way, so I find the conundrum a difficult one. If I asked Dr Coley, you talked about all the international evidence and then you talked about your own, you said that you had contacted or you had taken advice from those patients that you had referred. How many of them said that the treatment they had had had been ineffective? Most of the patients that we contacted said that they thought that the treatment was effective. That is their opinion, yes. In coming to the conclusion that you did, it was in spite of the evidence from the patients that you had referred and was largely drawn from the various other peer groups that you read. As I said earlier, the board took on board a whole variety of evidence, including the literature on effectiveness. What individual patients say is important in terms of acceptability, in terms of whether they think that that is something that they want, it does not show that it is effective. But the majority of them said that it was. They felt that they had benefit from it. The board took that on board, that is noted in the paper that we presented to the board, but critically the board looked at the totality of the evidence around it, not just homeopathy but for other interventions provided for the Centre for Integrative Care. I understand the argument that goes on around homeopathy. I guess just when I am presented in a committee like this, if you will forgive me with professionals who are taking those decisions. I do find that a slightly ironic position that the patient base that was referred from whom you can take direct evidence of the effectiveness of the treatment that they received said that it was, but you have discontinued it notwithstanding that because there is a totality of evidence from elsewhere that says that it is not. Precisely the reason why there are organisations such as SMC, such as Signs, such as NICE to assess the effectiveness. Importantly, yes, it is important that feedback from patients from public form part of that. It does not answer the question about effectiveness. I suppose that I would conclude that it was not important at all what the patients said, but that is me. It was set aside at the end of the day. It was set aside. Their views were set aside in favour of this broader evidence. Is it just that you needed to save money and this seemed like an obvious way to do it? No, it was not about cost, it was about evidence. As a doctor, as a director of public health, I can emphatically state that this was not about cost, it was about the evidence. This was not an easy decision for board members to make because here we have two elements of the quality strategy, if you like, in dissonance. The evidence that we have about the effectiveness of interventions and patient centredness, the board members and the discussion reflected the difficulties that that poses. I ask what the consequence of not referring patients to the centre of integrated care has been, because clearly thereby they must have been put down some alternative treatment. I suppose that that must have had its own consequence for the various service provisions that those patients will now be taking advantage of in terms of their initial appointment, but possibly more importantly, since I know that that can very often be met within a timescale, the subsequent treatment that they receive. Have all of the patients who would otherwise previously have been referred, are they being, what is the prognosis for them? We made clear in the consultation document that if the decision was not to refer new patients to the centre for integrated care that they would have access to other services and we have ensured that that they have access to psychological services, to the chronic pain management services, to self-management programmes within Lanarkshire and we have monitored those since we stopped new referrals to the centre for integrated care. What has your monitoring told you? I understand that they have access. We all have access in the sense that, if that is the provision of the health board, it is easy to say that you have access. In practical terms, what has the monitoring suggested in terms of the impact it has had on the timeous nature of the treatment that people receive? Our monitoring has shown that patients who may have been referred to the centre for integrated care previously have been referred to those other services and that there is no additional pressure on those services. All those patients will be being treated without having created any additional delay to their treatment or the treatment of others? They have been offered alternatives. I am getting a bit of deja vu with the thyroid meeting. First of all, on what Jackson was pursuing, there was more than 80 per cent of the public consultation that wanted the services to remain. I suppose that the first question that I would like to ask Dr Coley, because I am interested in Lanarkshire and I am particularly interested because the clinic in Coatbridge stopped, was about democracy and the patient's charter. Do you think that it is right just to ignore that number of people? That was a consultation. It was not a vote on treatments provided by the Centre for Integrative Care. The board, when it made its decision, took on board that has a duty of best value, including investing public funds on interventions that are based on sound science and evidence. It was not a vote. The board had to make a difficult decision based, as I said, on the totality of the evidence. It was mindful of its duty of best value. You do a consultation and then basically what happened was that the people who responded were ignored because it was not a vote, it was just a consultation. It seems to me that what people responded that you just ignored it. Can I move on then to the other thing that Jackson was pursuing? No, we did not ignore it. It was brought to the attention of board members and it is noted in the minutes of the meeting. That is why it was such a difficult decision to make, because you are weighing up the evidence from a whole range of different sources. That is why it was so difficult. That is why, personally, it should have been referred to the Scottish ministers. MSPs who were representing people should have been involved more in the decisions that were taken. However, the other issue is about the conventional services now, where the patients are having to go. I have seen a plea from a Lannardshire patient who was given to me—it was said in the response letter to that patient from Heather Knox—that, regrettably, there is continued increasing demand for chronic pain services in Lannardshire, which is outstripping the current available capacity. Does that mean that, because more people are now forced to go to other services, the delays are now becoming commonplace? Is it acceptable for people to have delays for their repeat treatment? In terms of chronic pain management services, you are right. We have challenges just as we have challenges in a whole range of other services. We have improved that service, but there is more work to do around that. I can let you know of a range of things that we have undertaken to improve the access to that service. In relation to psychological services, which is the other main service, Lannardshire is the best-performing board in terms of patients waiting for treatment. They have access to a wide range of services, including self-management services. You are right. We have challenges in providing the whole range of services, but that is true not just of those services where patients who have been referred to the Centre for Integrative Care have been referred to, but other services as well. Dr Collie, are you aware of how many patients the chronic services are having to cope with since the withdrawals in April 2015 and how many extra staff, if you have put on, have other staff to deal with that? How many extra staff do you have in terms of clinicians and nurses? Firstly, in terms of patients, to get the precise number of patients would need a review of and a survey of patients, which is not possible, but we have taken on board the comments from the service itself in terms of the pressure on those. We have employed additional staff in terms of a nurse specialist. We have created additional capacity in terms of medical input. We have revised and reviewed and remodelled the service model. It is a community-based model rather than a hospital-based service, and we are piloting with three GP practices a community service. Have you looked at the extra costs before you took the decision to not refer? Did you look at the extra costs that there would be on the other services? You said that it was not possible to review, but I wonder why it is not possible. Initial patients will be given the guaranteed waiting time, so they will be dealt with. That will include the patients that I am moving over from CIC services. Is that why repeat patients are not being considered? When I talked about cost, I said that the decision was not based on cost. We did consider the impact that it would have on other services, and that is exactly what we have been monitoring. It does not sound like a meeting of MSPs with Lanarkshire health board. We have got witnesses here from other health boards, and I am interested in how they arrived at the conclusions. They arrived out because they appear to be different, but I want to understand before going on to the other colleagues' questions. Did you carry out similar consultations? Did you have the same access to the extraneous considerations? Can you suggest why you might have arrived at a different conclusion? Other than that, there is something in the air, in the water and in Lanarkshire that arrived at a different conclusion. What made you arrive at the decision that you did so that we can get an understanding of why we seem to have this differential? In our consultation in 2012, we did open it to the public, staff and other stakeholders. Almost 4,000 people responded to our consultation. 75 per cent of them said that we should not provide homeopathic services in NHS Lothian. As Dr Coley has said, when the evidence was presented to the board, it was a totality of evidence. It was not just those people who responded to the consultation. It was the worldwide literature that was looked at in relation to that, in terms of the boards making that decision. In terms of the decision about continuing with the SLE and the Greater Glasgow Implied about CIC, that was in relation to specific therapies, not the totality of homeopathic remedies. The majority of the patients that we send are receiving mistletoe therapy in particular, which is more for end-of-life care. That is a specific service that the CIC. However, we would not deny the opportunity for any patient to be referred to. That still stands from that point of view, so we do not uphold every referral that those are looked at clinically individually. That is where the slight difference is, but in terms of the process, it is very similar to that that Lancer undertook. As I say, the issue was discussed at the board in 2010. Since then, NHS Highland has a clinical advisory group. Any patient who wants treatment outside Highland, any referral outside Highland for a specific treatment goes through that group, so there is an application process. Each case is considered on its merits. I am aware that there were a couple of cases in particular that had extensive focus in 2013, in which NHS Highland referred to the Scottish health technologies assessment group in relation to two specific forms of therapy for bihomeopathy. We have a process for consideration of each individual case. The original decision on whether to continue with referring, that you conduct a similar type of consultation to the other health boards? Can you give us an indication of the level of support from those who were receiving support or would have potentially received support from a CIC, whether they wanted that to continue? Was it similar to Lancer and Lothian? I have only been in NHS Highland for a year, so I am not part of the history as it were. My understanding from the chief executive is that there was support from the GP community for the decision to be made and consultation within wider groups. I do not think that there was a formal patient consultation in the same way, because the decision was made to have a committee that would consider each individual request. It is a slightly different approach, if that makes sense. I do not want to think that I am targeting you because you have been very clear in your responses. I also respect the board's decision that they took on a lot of other issues other than just this. I am not looking for Katrina Renfrew to get business from your authority either, but the question that I am posing when to ask you is that whilst people attending the integrated care centre in Glasgow and the patients were happy with the services they received there, the new patients that you are not sending to them, are they equally pleased with the services that you are providing in your own authority? Has that survey been carried out to see the satisfaction level of patients there? Also, in terms of the cost implication, is it actually value for money for your authority in terms of keeping patients in-house? I do not know if you have the information to hand, but if you do, I will be helpful. As with all those services, we monitor that. In terms of specifically those patients who may have been referred to the centre for integrative care, short of following up individuals in a whole range of services, it would be impossible to track those down. However, as I say, we monitor the services across all the care that we provide, but, specifically for that, it would be impossible to try and identify those. To make a fuller assessment of the failure or success of any service or change of any service would determine whether the patient was actually benefiting from the steps that your authority has taken. If you do not have that in the absence of that, it is difficult to assess whether what the board did decide was prudent or not for the patient in the first instance, and then in terms of resource in the second instance. It would be interesting if we could get some follow-up information for that in due course. The aspect of all of this is, which is very important, is the satisfaction level of patients who are receiving the service. Without evidence in terms of facts and figures, it is very difficult to then judge whether the decisions that were made were in fact correct and accurate at the time. Also, it becomes difficult in terms of assessing the CIC's position in terms of how they will continue to be a viable proposition in west of Scotland. Do you think that you are in a position to go back and get us that information? If so, what sort of timeframes are we looking at? In relation to patients who may have been referred, that is a very difficult study to undertake. I think that considering the issues of identification, of trying to follow those up, that is almost impossible to do in the context of NHS Lanarkshire. It might be a research project that could be undertaken over a long period of time. That would be quite significant in terms of the resource issues that that would require. In terms of trying to assess whether the decisions that were made were wise ones and whether the patients who actually received the service benefited from it or not and whether they were actually value for money or not, it can only be done if we have figures to substantiate the end result of the delivery of the service. We monitor the services, particularly in relation to where those patients who may have been referred are being referred. That is to chronic pain management services and to psychological services. We monitor those services, not specifically for those who might have potentially gone to the CIC, but more generally. It is important that we have been monitoring complaints in relation to the decision taken. We have had three complaints in relation to the decision taken by the board in relation to stopping new referrals to the centre for integrative care. I think that I have made my point. Sorry to come back to Dr Coley, but Dr Coley, in response to Jackson Carlaw and Elaine Smith, you said that you made an implication that it was not down to financial decision about withdrawing the referral to CIC from future patients in Lanarkshire, but you did make reference to best value. I often ask the authorities and others who cite best value as a justification for doing something. What is your definition of best value? As I said earlier, in relation to best value, it is investing those public funds on interventions that are based on sound science and evidence and clearly in relation to not just homeopathy but for other interventions provided by the centre for integrative care, that evidence was lacking. It may be that, in the future, that evidence may increase and we made that clear during the board discussions. We base it on sound science. Ultimately, the decision that was made was based on sound science. Rather than the patient's experience in relation to the treatment that they were receiving, that is where we get into the debate about what I mentioned earlier in relation to the patient's experience of the health service versus what clinicians and decision makers think is in the best interests of the patient. We are trying to get to the situation in which you have made the comment about that you have based decisions on sound science—the sound science—as you see it, not as the patients. You also made, in response to my colleague Hanzalaam Malik, in relation to whether or not you can measure the effectiveness of alternative services that are being offered by Lanarkshire health board to those patients who felt that they may have been referred to the CIC. You said that you measured the services in general but you cannot measure the services specifically to an individual patient in terms of their course of treatment. You said that that would involve a large research project that would need to be conducted to do that. If your clinicians are making a decision to refer on to other services rather than the CIC, why can you not measure how those patients' journey of experience and the effectiveness of the treatment that they are being offered instead of being referred to the CIC? I see a practical difficulty in identifying patients who may have been referred to the Centre for Integrative Care if we had not taken that decision because the decision by the board has already been made. So trying to identify those from GPs would be an almost impossible task to undertake because the policy has changed. You said that you had received three complaints from patients in Lanarkshire health board that would have disappointed the decision that the health board took not to allow them to be referred to the CIC. The difficulty for many patients is that many patients accept the clinical judgments of the medical professionals because they do not know what other options there may have been open to them to take. Effectively, Lanarkshire health board has closed down the route for many patients to receive alternative treatments at the CIC. In fact, it closed that down and told that in the sound science of the professionals that they can only receive the treatments that they feel as appropriate in their medical professional opinion rather than a patient-centred approach to treatment. We talk about the patient being at the centre of the treatment that they feel they require to make them better and make them live a better life, but the reality is at the present moment and this is a wider issue for the other health boards to try and understand where the patient fits into this process because if we did only take decisions based on the medical opinions of clinicians and GPs, the reality is that many patients, as we heard and as Elaine Smith made reference to the deja vu of the earlier discussion today, clearly patients' views and opinions and wishes are being denied them because the health boards seem to be closing down an option that was previously available and had been previously available for a number of decades. I have to say that this is not based on clinical judgments. It is based on the totality of the evidence that we have when we undertook our review of all the evidence. We did a survey of GPs. There are some GPs who favour homeopathy. We made that clear in the board report. This was based on the totality of the evidence. As I said earlier, there are really difficult issues where we have different elements of the quality strategy that run contrary. The board needed to look at the totality of the evidence, including the feedback from patients and the public. It was a difficult decision to make, but it did that by weighing up all the evidence that it had. I should have declared a personal interest in this, because 22 years ago my daughter was referred for an operation when she was two years old for an adenoids to have an adenoids dealt with and her tonsils removed because she continued to present with streaming codes and the blocked up sinus. The response from the medical profession at that time was, we will remove the adenoids and tonsils and that will resolve the problem. My wife at the time was attending a homeopathic clinic in Glasgow. The homeopathic individual there indicated that maybe you should keep your daughter off dairy products and see how you get on up to that point. My daughter had been in constant receipt of antibiotics to deal with the problems that she was having. When my daughter went for pre-op, the doctor that saw her said that she can't carry the operation because she's been on antibiotics in the past six weeks, so we can go ahead. After the visit and taking my daughter off dairy products, the following visit to the pre-op, the doctor said that this is a different child that you are presenting to me because this child is clear of all the problems that we have identified and we were going to operate on. The reality is, and I'm basing it on my experience of what happened to my daughter when she was two years of age. She would have had her adenoids removed, her tonsils removed, and today she's still got her adenoids and still has her tonsils and she knows how to manage the problems that she had because she stays clear of dairy products. That's a practical example that I have of someone that an operation that would have cost the NHS money and time to treat was treated fairly straightforward and fairly simply by someone out with the professional medical profession saying, keep your daughter off dairy products and see how you get on. That, as I said, is an example of why we need alternative options for many patients in society today. To close down that alternative option, it closes down a whole raft of alternative treatments that would actually save the NHS money, time and patients, particularly hardship and frustration about being dealt with. The only comment that I would make is that I respect your experience and your views. Over time, I think that evidence changes and, in fact, we do much fewer tonsillectomies now as evidence base on tonsillectomy has grown. The only other point that I would make is that there are alternatives to patients who are not being referred to the centre for integrative care, and we have provided and outlined those alternatives. Elaine, you wanted to make one short supplementary. I'll come to you. Thank you. It's just a short supplementary. Before I do, Dr Coley said that the NHS board had made the decision. Of course, we do know that, if NHS Lanarkshire has made the wrong decision, the ministers in the past have overturned the board decision, so we know that that can be done. I was just picking up on what Dr Coley said. In the times that have stretched the budgets, what I would like to know is why did NHS Lanarkshire not do a cost assessment of the impact of switching those patients to conventional services? Why did it not do a cost assessment of that? We were quite clear that this was not about the cost of the service. It was about the effectiveness of the service. We identified costs of around £200,000, as we made clear in the board paper, but that was the best estimate of the centre for integrative care. That forms part of the service level agreement that we have with Greater Glasgow and Clyde. It could be more cost effective to keep the services. The patients want the services, but the board decided not to keep them. A fundamental point about cost effectiveness is that the service or the intervention needs to be effective in the first place. That is why our focus was quite clear. In the board position, we were interested in looking at, among other things, the effectiveness of the interventions offered by the centre for integrative care. We looked for cost effectiveness studies around not just homeopathy but other interventions. As we found, few and far between, we were undertaken by Healthcare Improvement Scotland, which looked to evidence on homeopathy and clinical and cost effectiveness. Notably, the decision on the evidence has been backed up by an Australian review undertaken just under a year ago in March 2016, which concluded that there is no good quality evidence to support the claim that homeopathy is effective in treating health conditions. John Finch-Raeff. John Finch-Raeff, can you tell us who commissioned the Australian study? The Australian study was commissioned by a healthcare organisation in Australia. They looked at the evidence throughout the world. Pardon? Is this a private healthcare organisation? No, it is a Government organisation. I can provide the details of that. What should the committee wish? I think that there is a much wider issue than about homeopathy of the balance between evidence and patient opinion. It is an incredibly complex area. If you take the tonsillectomy example that has been raised, when we changed our policies on tonsillectomies and stopped doing them, to people of my age, no child got to five with their tonsils intact. The policy was that if you looked at somebody the wrong way, your tonsils were removed, so your daughter was extraordinarily lucky to live in a different era. We changed that policy quite rightly on new evidence and stopped doing tonsillectomies. We had parents objecting and petitioning health boards and saying, I want my child's tonsils out because they are off school again. The clinical evidence was that that was not the right thing to do. I think that it is a very difficult area of debate, but there are many things that patients want that the health service does not provide. We are very focused on homeopathy today. I know that that is the subject of the petition, but there is a whole raft of alternative treatments that the NHS does not provide because they are not evidence-based. We try to cling as NHS boards to evidence as a basis of making decisions. If we do not, we have enormous difficulties in engaging with patients about what it is that we deliver for them. Occasionally, we have been sucked into the idea that this is about delivery of homeopathic services, but it is not. I do not need applause from the guy, either. It is about delivery of integrated care. Given that you are the health board—the Great Glasgow and Clyde—that provides the facility that we are discussing, how widely do you promote it in order to make sure that people are aware that the services are available and that they might then put pressure on their GP to be referred? I do not see part of our role, to be honest, as marketing services. The GPs in our area know the range of services that we have available, and they will make decisions with patients about which services they refer to. We have enough demand for healthcare in the NHS Greater Glasgow and Clyde without actively seeking referrals, but we do make sure that GPs are well aware of the range of services that there are. As I have said, we need to review the centre as part of our review of all the services that we provide, and that will be happening over the next few weeks and months. Can we clarify, then, that the review of the future of the centre for integrated care is in the light of the reduced cross-border flows, or is it not, just before the convener winds up the session? It is a review that we are commissioning on the basis of our overall planning for next year across all our services. As I have said, we have about 44 or 45 different reviews to look at how we can set a balanced budget and meet the needs of our patients in 16-17, so no, it is not provoked solely by the cross boundary flow issue, but that is part of the financial issue that we have. It is explicitly part of the reason that we need to do the review, because we do have less income, but we would be doing it in any event. I thank all our witnesses for coming and answering the questions that are put to us. Some questions have arisen on the basis of the questions that we have asked, and we need to give the petitioner the opportunity to hear the evidence that we have had this morning and respond. We will continue, if colleagues agree with this petition, to look again at the responses that we receive from the petitioner and anywhere else that we get correspondence from, because there are a lot of people following this petition in particular, and we will have a contribution to make to the discussion that we have had. However, I do appreciate that he did come in front of us this morning and answered the questions that we put to you, and we thank you for that. I will also spend the meeting for a couple of minutes again until we change over. Business this morning is consideration of 15 continued petitions, the first of which is petition PE1105 by Marjorie McCance on the market of Scotland hospice. As you know, Gil Patterson has taken an interest in this, and I will give Gil the opportunity to comment, but just to point out to members that at our last meeting we asked for an update on when a meeting would take place between the Scottish Government representatives of the health board and the hospice. I understand that that meeting has now taken place and all parties appear to be content with the progress that is being made, even if a solution itself has not yet been found. It is in that context that we are discussing the petition again this morning. Gil, is there anything in particular that you wanted to raise with us so that we could add that to your consideration? I do not mind. I would not mind convener just to highlight some points, because I thank you very much for the opportunity again to come here. I think that the accountancy review has got to be done sooner rather than later, and because if there is an inbuilt disadvantage, I actually think that there is, and I will maybe come on to that just in a moment or two again. However, my big concerns in this regard are with the joint boards. If the joint boards, what will their notional way of deciding what is the appropriate funding? If you remember that, all the different hospices are then in a different place, and if there is an inbuilt disadvantage, I think that it would be very difficult for St. Margaret's to come up with a cohesive argument to an individual joint board. I think that that has got to be sorted very, very soon. I come on to the difficulty with an accountancy firm. There has definitely been difficulties. I know that looking at what you have been presented, it would seem that we are on the way to getting somewhere, but we have not decided yet on an accountancy firm. I did suggest the last time, and maybe the committee would endorse it, that we use our weight of opinion to the Government that, if they want to look outside Scotland to find an accountancy firm, they will find it, but that might be difficult in itself. Perhaps we should suggest that maybe a chair that takes this on board will have a high court retired high court judge who can appoint an accountancy firm who may have had some contact or contract with the Government or with the health board. I am not speaking on behalf of the committee. I have not been briefed on that in this regard, but to move it on so that it does not get stuck, that might be a solution to it. Some of the difficulties that I have just went through some of the information that I previously had because it is a simple straightforward thing. I have a paper here from the 10th of the 7th 2015, and it shows, if I could just quote, if you do not mind, if you can indulge me. Those are all hospices within Greater Glasgow and Clyde, so we have got the accord. The funding per bed is £159,891. The art gown, which is £153,883. I do not have anything on Marie Curie, but I have got the Prince and Princesses of Wales Trust, £140,471. We have got St Vincent's, and that comes in at £131,377. Then we go to St Margaret's, which is £53,328. The reason I say that is that it is the formula that is crucial here, and nobody that I have contacted including the health board can tell me what the formula is. The only way that we can get to the bottom of that is a proper review by an accountancy firm. I have posed the question, and you can clearly say that it is clearly not in beds because the numbers—again, if I gave you the numbers, I should have made them—but it is 8, 8, 14, 8, so those are all the other ones that I quoted, and it is 26 at St Margaret's, so it is certainly not on beds. We need to understand what the formula is. Before I move on, I would like to highlight about the appointment, and that is what St Margaret's said. The appointment of a firm accountants was discussed in light of the fact that many of those accountancy firms approached St Margaret's of Scotland Hospice felt unable to participate in an accountants' review due to the conflict by having carried out work in the past for either the Scottish Government or the NHS. I do not want that to be a blocker. I do feel that if we cannot find someone that what I am suggesting might get around that. It is good that there is a willingness to share, but it should be able to be published if the information with regard to each of the hospices is there. It is public money, so it should be published, and then that will let the committee see the figures for themselves and make a judgment. I certainly would like that, because we are so close, and I know that it is coming to the end of this term and that there can be a pressure on the committee itself to close. Before it closes, we should see that the outcome of the review is published. After that happens, I will be content. I will not come back. After that review takes place and the information is published, I will not be coming back to ask you to keep it open. The committee is under no pressure at all to close any petitions, because we are coming to the end of the session. Petitions can carry over, so that is not in our consideration. I think that the members have got what usefully this committee is contributing to the outcome that might be achieved. That is what we have to consider. Is there something else that we can do that will allow a solution to be brought in this specific case? We have also got to take on board that we do not adjudicate in individual cases. It is not our remit to do that. What we are trying to do is identify whether there might be problems that can be brought to the attention of the Scottish Government or any other authority for which the Parliament has any jurisdiction in order to improve administration, resolve wider issues or correct policy. It is not about whether the issue that St Margaret's brought to us could be continued or not continued. It is whether this committee can usefully contribute to providing the outcome that will be achieved in whatever way the decision is made. That will be a matter between the Government, the health board and the hospice. I am just looking to the committee to see if there is anything—we have heard Gil make a couple of suggestions about us suggesting a chair or some independent way of assessing this. I am not sure that we have got the capacity to do that. We could suggest to the Government that they have a look at that, but it would not be for us to make that decision. We could do that and then not do anything else with the petition. Our final say on it would be that there has to be some independent involvement, because we are in a situation that has moved on from 2006, when the petition started, that we now have the Government's committee to review the hospice funding and its strategic framework on pallidive and end-of-life care. Things have moved on. It is just that that individual dispute over the financing of the beds at St Margaret's has not been resolved, but the overall policy and the structure in which it is all taking place is clearly different from what it was when the petition was originally started. I am actually looking at committee members to see whether they think there is something useful that we can do to contribute to resolving this. From my perspective, I think that the fact that the petition has been kept open has been what has brought us to where we are. I fear that if it had closed when the Government had recommended that the petition had been closed, I really fear that we would not be where we are at the present time. I think that it would be extremely useful if the committee, just for that simple straightforward reason, the power of this committee and the regard that is held in by the Parliament has been the thing that has got us to where we are. That is what I really believe. I appreciate that you can make that consideration. It has just been brought to my attention that the question of seeking an independent arbiter or chair to try and draw the thing together has already been put to the Scottish Government by this committee. I am not necessarily sure that we have got a conclusive answer to that, but that is a situation that was already put and it did not meet any positive response. Again, we are now at a position where what we have tried before was not taken forward, but you seem to believe that, just by keeping the petition open, it is making a difference. Do the members of the committee believe that that is the case? I can certainly see the merit in Gil Paterson's request for continuing to monitor the situation prior to closing the petition with a view to keeping a watching brief and waiting for the outcome of the review of the technical accounting issue that is in dispute. I think that the committee has come to the end of its influence on the issue, but it might be worth waiting to see what the outcome of the review is and then looking at closing the petition. I want to pay tribute to Gil Paterson and the previous constituency member, Des McNulty, both of whom pursued and led on the issue with support, I hope, of other MSPs. There undoubtedly was a very deeply ingrained suspicion that there was a prejudice in the health board, which then led to a kind of mutual animosity between the parties, which meant that, albeit in theory, there was a working agreement previously in place, nothing ever materialised from it and time continued to pass. One of the things that the committee sought to do was to get the cabinet secretary to take a more direct involvement. That was one of the things that she was reluctant—she, in the sense of both the cabinet secretaries who held the position—was reluctant to take that direct role and very much sought to have the various parties continue to negotiate to a point. I feel that Shona Robison has actually more directly intervened and the Scottish Government has been more directly involved. I understand Gil Paterson's point about that historical suspicion and the fact that, at certain points, during the progress of the petition, the fact that the committee continued to take an interest in it was politically resonant. It seems to me that we are at a point where I am not quite sure what I would be inviting the committee now to do, rather than simply to keep the petition open on the basis that that might still be a productive thing to do. It is clearly open for a future petition to be lodged in the event all of this goes pear-shaped. In many ways, it seems to me that the sort of Danocles that was hanging over no longer does and that the direct involvement of the Scottish Government that we sought is now there and that, in fact, the efforts of Mr Paterson and others in relation to the future of St Margaret's have been achieved. I am not a sheer leader for either proposition, but I find it difficult to see what I would be asking the committee now to do and that is the key. That is exactly my point, Jackson. As much as I want to see this resolved and I want to see it resolved, I could probably declare an interest as the convener of the cross-party group and palliative care that wants to see the advancement of the hospice movement as much as anything, but we, as a committee, are not involved in an individual dispute between any given health board and a particular hospice, although we can seek to ensure that any issues that come out of that are addressed by the Government. Having looked at all of the correspondence and all of the actions that have been taken so far, what I am suggesting to the committee is that there is nothing useful that we, as a committee, are actually doing at the present time, which is taking this forward. Anything that is taking it forward is now in the hands of those parties who are concerned. Even the suggestion that you made this morning is something that the committee has already looked at and tried to get on the table. There is not, to my mind, anything else that this committee can usefully do, which is going to make the situation better at the current time. As Jackson said, if things do go wrong, there is a failure to agree. The petitioners are at liberty to come back again and raise that issue, but given that the Scottish Government has now got a strategy or a framework in which the whole totality of funding is being considered, I think that things have moved on. Although there might be an individual dispute between one hospice and the health board, I genuinely believe that the committee can do that at the end of the road. I bring the committee's attention to the letter from Shona Robison on 19 January, and her final sentence, in which she says, I hope to be in a position to update the Public Petitions Committee more fully soon. Clearly, there is still an update to come. If there is still an update to come, then we should keep the petition open until that is received, unless I am told otherwise. The information that I have is that the action points on which the petition was raised have been taken forward. Therefore, any response that would come back is just a continuation of the discussion on the action points. Again, we are not actually taking those action points forward now, but they have already been enacted. I can see that convener. We have closed petitions. I am trying to be fair to every petitioner. I am not just one. There must be other people out there who say that, in similar circumstances, the committee closed the petition because it had useful arrived at the end of what it could do. They accepted that. They might have been disappointed by it, but they accepted it. However, they might look on us and say, why are they continually keeping one open in exactly the same circumstances when they are not actually asking for anything more to be done? If anything else, we should be consistent. Occasionally, we are going to leave people disappointed, but we do not necessarily help ourselves if we are inconsistent in leaving some people disappointed and not others. I think we have done our law. We have gone out of our way in this particular petition. I recall supporting it on at least two occasions when I thought that would probably be the last time it was in front of us. It seems to be just getting dragged on, but not actually achieving anything other than what we have already achieved. I would concur with what you are suggesting now that I think it has passed itself. I bite it. To the other members of the view, the angus is suggesting that we continue. I think that everyone else is saying that we think it has come to the end of the road. I do not want to deviate. I am trying to get a consensus. I am trying to get an agreement, but if we cannot get an agreement, we have to make a decision. I can sense that I am a minority convener. Reluctantly, I would be able to close the petition, but very reluctantly. I am the same as the Angus MacDonald in this one. I have seen this petition virtually all through the process. I think that there is a point at which we have to say, as a committee, that we need to stop. However, at that time, we can no longer take it any further forward, but we have to also bear in mind that the Scottish Government has committed to doing things with the hospice and the health board. I am not asking for the petition to remain open. What I am asking is to close the petition. We remind the petitioner that, if, within the specified period, they are not liberated to come back and present a new petition. However, we also write to the Scottish Government and advise them that we have closed the petition. However, there were certain things that the Scottish Government committed to undertaking in conjunction with the health board and the hospice to take forward. We hope that the board that is being established by the Government takes on board the issues and recognises the issues that have been raised by St Margaret's of Scotland hospice in relation to the allocation of resources to hospices in Scotland. As you said, convener, there are a number of hospices that I may find themselves in a similar situation, but that would be my support for closing it that we actually take on board those other issues and we get assurances, but at the same time close the petition. Close petitions are in those terms before Jackson. If we do close the petition and, given the sentence to which Angus MacDonald has referred, it might be that we close the petition but ask the cabinet secretary if, instead of writing to the public petitions committee more fully on the progress that is taking place if she was to write to the constituency member and the regional members in the west of Scotland who I think were directly interested in the progress of the petition so that that progress at least can be kept alive by the political representatives within the region if not by the petitions committee itself. I thank you for the effort that you have put in on behalf of the petition to your credit that you have stuck so doggedly with it that we are still here so far on making this decision. There may still be issues that the committee will have to look at at a future date but they have to be new issues and I think that is the point that we are trying to make. There is nothing that we, as a committee, are actually actively doing at the present time that is going to resolve it and we have closed the petition on that basis but the reason why we are still being discussed at this late into this session is because of your determination so thanks very much for doing that. I am disappointed, you obviously know, I would be disappointed but it would be remiss of me to go away from here and not say to the committee particularly to John Wilson and Jackson Carlaw but to all the members here that you have supported me, you have supported the petition, you have seen what is wrong and that something needs to happen so it would be wrong for me to walk out here and not lay on record my thanks although I am disappointed. I really appreciate the time that this has been considered in the due diligence that you have brought to it and thank you for that. The next petition is PE1480 by Amanda Coppell on behalf of the Frank Coppell Alzheimer's Awareness campaign on Alzheimer's and dementia awareness and PE1533 by Jeff Adamson on behalf of Scotland Against the Care Tax on abolition of non-residential social care charges for older and disabled people. Members have a note by the clerks and the submissions on this and Amanda Coppell has written to the clerks to say that she would welcome clarification as to who will be responsible for administering the £6 million fund announced for local authorities to provide free personal care to those aged less than 65 years and that the objective of her petition remains the same. I will invite contributions from members. Again this is one that we could get an answer to and get back if we get a speedy response from the Government. We could ask them to get back for clarification on that and then we'll look at that answer hopefully before the end of the session. The next petition is PE1548 by Beth Morrison on national guidance on restraint and seclusion in schools. Again members have notes and submissions from the petitioner. Members have any comments on it? Again maybe just go back to the Government just to ask for the assurance that the views of the petitioner and other stakeholders are taken into account. Members agree that we do that just to get clarification. Where it's open to political parties to decide if they wish to make any specific commitment in relation to the suggestions that are being made in the forthcoming election too. So it's not just an issue now for the Government, it's an issue for the political process I think too. So we'll write to the Government and ask them to clarify that. The next petition is PE1549 by Alan Clark Young on concessionary travel passes for war veterans. Again members have a note. We've tested this one to destruction. I think that I'm quite happy to propose this. I wish to support this particular petition just on the grounds that I think this particular petition is an important one because we recognise the physical and mental contribution armed forces personnel make to this country. And I think it was a good petition and I'm not sure how far we can take this now because one of the suggestions that I would possibly make is that the Government needs to possibly explore the possibility of actually getting the transport providers to provide the service without actually getting a remuneration from the Government. Now this may well be a part of the condition of the licence that they get in terms of providing the service. Now I know it's not the job of this committee to suggest that. However, I'm very interested to see or hear from the transport minister himself to see if he would be inclined to possibly explore that possibility. I think that the negotiations that I was referring to are actually financial transactions, unless what you're really suggesting is that the Scottish Government should be writing to private and indeed public, given that I live in the city of Edinburgh with Lothian, and asking that they do it voluntarily free of charge, which I think would have implications for other service users. It seems to me that the Government will have considered that. To be honest, I take your point. I do support the premise of this petition. I think that there is merit in what was suggested. The reality is that we've asked the Government for its position. We have checked out alternatives and made suggestions to the Government on those suggestions. We haven't moved the situation forward. I don't know much, what much more we can do. I don't think that we've specifically asked the Government to look at this angle. I think that it's worthy of another shot to see if the Government would take up that opportunity. If they say no, that's fine. However, the fact still remains is that that's an unexplored avenue. I think we should do it. I think that this is a group of our population that, if anybody deserves it, they do. Therefore, I think that another plea for the Government to explore that possible avenue is not a bad one to pursue. I'm sure that we could make it last another meeting. I have to say that my experience of asking bus companies to continue running what they view as unprofitable routes has been fraught with failure throughout my tenure as both a constituency and regional MSP. I can think of particular bus routes that are wanted by the elderly. I can think of claims made in Edinburgh about the inability of pensioners to access seafield crematorium. There's a valid point there. We've been unable to achieve it. We may not have a specific Kero referral back from the Government on this, but all my information is that these bus companies will say, we run commercial routes unless you subsidise it. It's the purpose of the Public Petitions Committee to try and change Government policy. We're not going to change Government policy. We've been told that it's not going to change. We've given them suggestions. What you're asking Hanzala is for us to ask private companies. I don't think the committee can do that. No, chair. I'm not asking for that at all. What I'm asking for is we ask the Government to ask the transport providers to consider it. I don't think that's been considered. I think that off-peak buses, when we see many of them that are half-empty travelling up and down our streets, there's no harm in asking the companies to consider it, which has not been done. If that could be done, I'd be grateful. All I'm asking for is just a suggestion to the Government to see if it could actually explore that possibility. To the other members of any of you, I think that you're in a minority of one Hanzala. Because I think it's important. I don't want to take it to your vote, as I said. I always try to get a consensus. One of the things that we tend to underestimate is the sacrifice that our armed forces make around the world. We're demanding more and more. I don't think that anyone says that. No, no, no. We've had that discussion. I think that everyone accepts the premise of the petition. I think that the problem that we've got here is that we've asked the Government to support a scheme, a concessionary travel scheme. They've said no, essentially, and we've given them what other options we've investigated ourselves, what other options are available. If the only option that's available is to ask the private companies, what you're effectively doing is asking the Government to provide funding for private companies to operate the scheme, which is the concessionary travel scheme, and they've said no to that. Whatever way you look at it, the current concessionary travel scheme is the Government providing money to private companies to run buses. And if you were just widening the scope of this to veterans, which I support, then it's the same concessionary travel scheme, and the Government has said they're not widening it. So you're asking the same question. You're just asking it a different way, but you're asking the same question. No, chair. I'm actually asking it. I'm asking something totally different. What I'm asking is that the Government actually wants to ask the transport providers to provide the service free of charge. I'm not asking the Government to make a payment. Concessionary travel scheme, what sounds like? At the moment, yes. There's wider issues about the concessionary travel scheme, convener, than just about whether or not someone travels free, because there's the issue of the cards, there's the issue of the administration behind that. There's a number of factors in the Scottish Government, and if it's a Scottish Government scheme, then there'll be additional costs. The Scottish Government made it quite clear that they don't, at the present moment, support the additionality of veterans going on to the concessionary travel scheme. As I said, it's not just about going to bus operators and saying, will you allow veterans to travel free? There would need to be some administration behind that that would have to be carried out and verified by the Scottish Government, which they have said they're not going to do. Having dealt with, as Kenny MacAskill said, with some of the bus operators, they're certainly not going to chip up and say, we're going to let these individuals travel free charge as long as they purchase a card, because if they were that magnanimous, then surely we'd be saying anybody over the age of 75 or anybody in other conditions should be travelling free as well. Every bus operator that travels under the bus concessionary scheme or transport concessionary scheme gets a contribution towards every passenger that travels. I doubt very much that they would allow one group of individuals to travel free charge while the Scottish Government isn't having to pay for everybody else to travel. I'm in agreement with your own position on this. We have asked the Government, the Government has said no. It's clearly open to individual members of this committee to make representations to their own political parties with regard to any commitment that might be forthcoming in the manifesto that can be put to the electorate in the forthcoming election by way of a commitment of this nature. What the committee can do, I think, has now been exhausted because we've asked the Government and they've said no. I think that that's the point, Anzala. If you want to take it to a vote, David, do you want to make a contribution? I'll give Anzala one final word on a bill. I support the petition that the Government, as Jackson says, says no. The petition isn't going anywhere else. I take on word what very experienced members are saying. However, I do feel quite strongly about this issue. I think perhaps the Government might want to speak to the armed forces themselves to see if their charities want to engage with the Government in terms of taking this petition forward. I think there's still an opportunity. This is our last meeting in this session. I don't see what the damage will be if we just simply write for this last opportunity to see if the Government is prepared to even speak to the armed forces to see if they're willing to come on board and engage with them to take this forward. If the armed forces are not willing to do so and the Government is not willing to do so, I'll accept that. I have to say, I think that that would be just a futile gesture and I don't think that the committee's into doing that kind of thing. Again, we were sometimes relieved that the petitioner was disappointed. I'm sure that the petitioner will be disappointed that he didn't get the outcome that he looked at. I genuinely suggest that we write to the petitioner to say that perhaps they might engage with the armed forces to see if they can… I think that we do that type of thing. We make the petitioner aware of the conclusion. The conclusion is that we've tried our best. The Government has made its position clear and we can't get the solution that the petitioner is looking for. On that basis, we have to close the petition. That's my suggestion to the committee. Could I also just add one small paragraph to say that if the wish to engage with the armed forces themselves to see if they're willing to engage with the Government to take this case forward, if they wish to do so, it might be an avenue for them to pursue it from a different angle. Can I suggest then that you write to them on that basis, hands on, and encourage them to do it? Okay, I'll do that. Okay, we'll close the petition on that. You went down fighting. I think that the armed forces would be proud of you. Our next petition is PE 1551 by Scott Paterson on mandatory reporting of child abuse. Again, members have notes from the clerk and the submissions that have been received. I'll open it up to members to make contributions. I think on this. There might be a bit of distance to go on this one, but I'll be prepared for Angus. David, do you want to comment? Thank you, convener. As soon as the UK Government still launches consultation on this, I feel that we should keep this open to see what responses come back from it. Members from Northern, I think. Just to say, I think that it will have to form part of our legacy. Because, given that September 2016, before the UK Government expects the report, then it would be, there's no point in further consideration until the next session of parliament. Yeah, that'