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I want to build on the point about the Scottish complex mesh surgical service being the opportunity to evolve the model. Given that there is such a small volume of defects in the national population base, combined with Scotland’s relatively small geography and population base, the idea of a concentration of skills to deal with and rectify complex defects could provide a way to build the service to include some of the examples that Dr Spencer Netto has called for as key takeaways. Building that national centre would not be to say that everyone has to get a surgical mesh repair for a hernia in a national centre in Glasgow—for example, if they live in Lerwick. However, if there are complex or high-risk cases, that might be the most appropriate solution. Do you agree that we should look at that?

I thank the witnesses for their contributions so far, which have been very interesting. I have some questions around mesh removal procedures and protocols. We have had a number of written submissions from members of the public—patients—who have experienced adverse outcomes and complications. Martin O’Neill commented that his life is improving now that he has had the mesh removed. He said:

“I’m still mesh afflicted due to the device being left so long in my body that pain and damage is permanent. BUT I have hope. It’s out! There is at least a possibility of me doing something with life rather than taking pills that don’t allow basic functioning, coupled with pain that still doesn’t stop sleepless nights and an overwhelming sense of wanting to die than live in that horror of pain that mesh causes.”

In other cases, individuals were told by surgeons that the mesh was too enmeshed in their body to be removed without causing serious consequences such as the loss of their rectum or testicles. Individuals have resorted to private surgery to get the mesh removed, with some even travelling abroad to do so.

In another written submission, Carole Coutts described difficulties in getting her mesh removed on the NHS in Scotland. She said:

“My GP ... discussed my case with other GPs. She said none of them knew much about mesh.?She tried referring me to the Scottish Complex Mesh Surgical Service”—

which is a service for women who are considering specialist surgical mesh removal—

“and I also emailed them”

as a patient.

“They refused my referral as they only accept gynaecological referrals.”

In 2018, your predecessor as chief medical officer wrote to the health board medical doctors in Scotland on the use of mesh in sites other than the vagina. In that letter, she said:

“The management of patients with mesh-related complications must follow agreed pathways which should involve a multi-disciplinary team of clinicians with appropriate skills and experience.”

In the light of all that, can you talk us through the “agreed pathways” for non-gynaecological “mesh-related complications” that your predecessor referred to in 2018? Do you believe that those pathways are operating as they should?

Okay. Thank you very much. I want to follow up on an instance that was mentioned earlier. It is in one of the submissions from a patient. The national complex mesh removal surgical service in Scotland accepts only gynaecological referrals. Why cannot patients who wish to have other types of surgical mesh removed utilise that service? Why is it restricted in that way?

I think that the substantive issues in the petition have been addressed by the actions resulting from it. If there are subsequent areas of inquiry, there is no impediment to the lodging of a new petition that is focused on those issues, which will be addressed by the committee in due course. If people feel that that would be a tidier approach, I am happy with that. I have no strong feelings either way.

Thank you for that contribution. The point about there being such a small number of cases in the national scale of things requires us to reflect on how best to address it. The pathways perhaps need consideration of how we might establish learning curves so that defects can be addressed by a network of people who are robustly capable of doing it rather than it being a lottery.

Could the NHS consider establishing a protocol for investigating such cases so that it could understand, for example, why someone has gone for a private surgical solution, what the outcome was and what could have happened differently? Is there a way of addressing the concerns that are expressed in the patients’ submissions that we have received, such as by conducting a deeper analysis of what has gone wrong in their journey to identify whether there are opportunities for improvement?

The discussion has been really worth our while, in that it has focused on what the effects need to be. We need a check and balance on health boards and providers to ensure that, where necessary, there is correction, through inquiry into people’s experiences by giving them a proper formal voice and through the ability to put obligations on providers. In that sense, the petitioners’ requests are significant and require further advocacy by the committee.

The testimony that we have heard has been compelling. The democratic deficit in decision making on health boards, and the tension between the tendency for the medical profession to want to centralise in national centres and build capacity, and the rights of rural patients to access services, have been borne out in discussions that we have had on a number of petitions.

I will ask the petitioners about defining the rights of patients regardless of where they are. Perhaps the advocacy body that has been proposed would be the best way of defining the right of a patient to access services safely, whether in gynaecology or any other context. Examples such as William Sinclair described in relation to Caithness could be identified through data, study and inquiry as unsafe provision. That would mean that the health board would have an obligation to address the situation. The advocacy body could place on the health board an obligation to deal with it.

An alternative to that might be to say that, in instances in which it is appropriate to travel to Glasgow for an operation—in neurosurgery, for example—the patient has the right to have their travel costs covered and the right to accommodation for a companion for the duration of their period of surgery and recovery.

Those are mechanisms by which the rights of patients could be defined and advocated for, so maybe they are the ones by which those rights could be delivered. A national body in which stakeholders from different geographies can come together and define the standards that all citizens should be entitled to in different contexts, and one that can take evidence from clinicians and patients is, perhaps, what we are all driving toward. Would petitioners agree that that is where we need to arrive?

In closing the petition, we could perhaps advise the petitioner to maintain a correspondence with his local members of the Scottish Parliament in order to ensure that he receives a satisfactory outcome from his discussions with Transport Scotland. If there are any concerns, they can be taken up accordingly, rather than it being done through the petitions process.

The committee has heard concerns that HIAL management places too much faith in “Air Traffic Management 2030 Strategy: Scoping Study”, which was produced by the consultant Helios, and the results of which relied significantly on emerging new technology. How do you respond to those concerns?

Thank you for that overview. Systematic reviews comparing mesh and non-mesh repairs have found that post-operative complications, including the chronic pain that you define, are generally lower for mesh repairs. Why does the Shouldice hospital’s written submission indicate an alternative view of the evidence? Can you explain why its written submission varies from the systematic reviews?