Seòmar agus comataidhean

The Scottish Government continues to advocate for the use of HIIAs as part of our health in all policies approach to policy teams across Government and public bodies, and among wider stakeholders, supporting colleagues to embed the assessments in practice and to ensure that the potential impacts of policies and programmes on health inequalities and the wider determinants of health are fully considered.

The HIIA guidance was last updated in 2016, and Public Health Scotland will be updating it later this year. We are also working closely with the Glasgow Centre for Population Health and Voluntary Health Scotland on developing a new tool to measure the impact that major housing and transport projects can have on improving health and wellbeing and reducing health inequalities across the Glasgow city region.

Ultimately, we would like to see the use of HIIAs within a health in all policies approach. There is a great deal of learning to be taken from countries such as Wales, which made the use of HIIAs a statutory requirement for public bodies when the Public Health (Wales) Act 2017 was passed by the Welsh Senedd. I am interested in taking that approach in Scotland.

Many health and social care professionals—and certainly those in the regulated professions—already embed reflective practice in their development. I take on board your point about ensuring that it becomes part of the trauma-informed package, because I know that that goes out to a much wider staff pool than simply the regulated health professionals. It would be well worth my going back to check that it is there.

However, reflective practice is about not just an individual’s practice but changing the system to make it more person centred, flexible and holistic in the way that it is designed, built, delivered and implemented. If we focus only on individual practice, we will not achieve our goal and we will also run the risk of having an extremely weary workforce who feel that it is their fault that things are not working when it absolutely is not. We did not build these systems deliberately—they evolved over time to meet needs—but most people will acknowledge that some of our most vulnerable citizens have to navigate a really complex and bureaucratic system on a day-to-day basis simply to get help that they have a right to. That is not good enough, and we need to reflect on that and build things better.

That is an important point. I have talked about how the Government well recognises and understands the impact of adverse childhood experiences on somebody’s entire life course. It is important that our public services are trauma informed, and it is disappointing that there are times when we feel that people who are presenting looking for support from public services are further traumatised by what they meet there. We really have to work hard to get that right.

In November 2021, the Deputy First Minister told the Finance and Public Administration Committee:

“we need our public services to wrap around ... people and to be person centred, holistic and responsive to their needs, instead of expecting people to fit around what public services offer and to navigate complicated systems from positions of vulnerability and need.”—[Official Report, Finance and Public Administration Committee, 30 November 2021; c 2.]

We are backing that up with actions, one of which is to increase the availability of training in trauma-informed practice. We are also trying to simplify—although the task is almost impossible—the way in which some of our services are delivered. Again, Michael Kellet might wish to say more on that.

As members will know, with regard to our children and young people, we talk regularly about GIRFEC, or getting it right for every child. For our adult population, we now need to think about GIRFEA—getting it right for every adult—or GIRFE, which is about getting it right for everyone, every time. We have not quite decided on an acronym, or at least I have not settled on it yet, but I am campaigning for it to be GIRFE.

We need to think about the people who present to services. An important example involves the work that Angela Constance is doing on drug addiction. One of the challenges in that area is that it is quite hard for people to get into treatment and very easy for them to fall out of it. We need to make it easier for people to present and to get treatment quickly when they do so, and we need to make it hard for them to come out of treatment. We need to be trauma informed and to understand where the individual is on their journey to recovery, and we need to catch them and hold on to them until we can get them better.

There needs to be a reduction in stigma in those services, and there needs to be dignity in everything that we do. That is a classic example of how we can transform those services. It takes a lot of work, but we are absolutely on it, and we are working on that aspect. That is just one little microcosm.

I have responsibility for a lot of chronic illnesses, and the last thing I want is for individuals to feel like they are a collection of conditions. I am really keen to ensure that people are able to access holistic person-centred care and that they do not have to present for several weeks running at different clinics for blood letting and other things. I want them to be able to present at one place and get holistic person-centred care. That will make their lives easier and make them more productive economically, and it will save money for the NHS. Why would we not do it? It is a bit trickier to achieve in reality than it is in our imagination, but we are definitely recognising the benefits not only for us, but absolutely for individuals who are trying to access public services.

Yes, I can. I will take action and come back to you on that.

Link workers can be a really important and powerful tool for the holistic care that I talked about, given their understanding of the social determinants of ill health and their work on maximising income and ensuring that people do not fall through the net.

We also have to reflect on the systems that lead to that sense of people falling through the net as they move from secondary to primary care. I think that everybody will acknowledge that, at every interface in the health service—and there are many—there is a risk of communication failing and of folk being lost to follow up. As we build the social care system, we are looking very carefully at that and at how we can improve communication between health and social care. There is a recognition that such communication, even within health, is challenging at times, but we think that there are digital solutions that will make it simpler to transfer information from one area of the health service to another and potentially to areas outwith the health service—to social care and so on, and perhaps, with the individual’s permission, to third sector organisations. That said, we are definitely still a little distance away from such solutions.

Something else that might arise from those solutions is people being in charge of their own information, which would be an empowering experience. I have no doubt that, if he were here, my colleague Kevin Stewart would be talking eloquently about the many people whom he meets who are retraumatised by having to tell their story time and again. They cannot understand why, their story having been told once to somebody in the system, it does not follow them the whole way through. We are very aware of the issues, and we are working hard to improve matters and resolve them.

One of the ways in which we will build those systems better in the future is by putting lived experience at their heart. If lived experience is at the heart of policy development, we will be much more likely to get the policy right. That also holds us to account with regard to policy implementation, as we are more likely to find what is sometimes a gulf but is often a gap between what we have intended and what is actually happening on the ground. I think that the best way of ensuring that we achieve our policy aims is to be held to account on the basis of lived experience.

Does Michael Kellet have any more to say about that?

Data collection is a challenge right across the board, is it not? However, it is important to show how effective these policies are.

Community link workers are at the forefront of our efforts to tackle the consequences, and the determinants, of health inequalities. They work directly with individuals to help them to navigate and engage with wider services. We know that they are invaluable in supporting people with issues such as debt, benefits advice, social isolation and housing. They are important in connecting individuals to community resources—for example, in helping to ensure that individual folk find out about food banks and are able to take the first step to get that support, or in helping people into mental health provision—and they also provide people with on-going emotional support.

That is all quite hard to capture. We can say that we have employed X community health workers and that we have achieved the national aim but, as Tess White pointed out, that does not necessarily mean that we have national coverage. Therefore, we need to keep going back and looking at the data and the outcomes. We need to look at the differences around qualitative data rather than quantitative data and see whether we can capture the impact that community link workers are having.

I must admit that those people were a very impressive bunch, and I absolutely got the impression that there is a passionate army of social justice warriors out there, doing their best for Scotland. The presentations that they gave were really powerful. I met them shortly before the event, and I know that they are doing impressive work. They are really getting alongside people and helping them to flourish.

I guess that you and I will absolutely agree that the austerity politics that came in in 2010 has been severely detrimental to our local authority colleagues and to Scotland as a whole. Policy decisions have been made to cut the Government budget and, in turn, the Scottish Government budget. Some of those cuts have had to be passed on, but actually, when I look at the numbers, I see that local authority services have been largely protected from a lot of the cuts in comparison with local authorities in England, some of which have found themselves in a really precarious situation.

All of us—well, not all of us, but certainly you and I, deputy convener—will agree that austerity politics has been really harmful. I go back to David Walsh’s testimony to the committee, in which he said that we are paying the cost of the tragic consequences of decisions that were made some time ago. We went into the pandemic in 2020 on the back of 10 years of austerity politics, and there is absolutely no doubt that we would have fared better in the pandemic had we not been in that situation when it hit.

I am not sure that I have much to contribute on the vaping debate. It is clear that, for people who are choosing vaping as a means of smoking cessation, it is less harmful than smoking; there is absolutely no doubt about that. However, there are some concerns around the contribution to health inequalities and the attractiveness to children and young people, and there are real concerns around the role of vaping in the future, which we need to consider carefully.

The Scottish Government has a commitment to a tobacco-free generation, in contrast with the Government down south, which is committed to a smoke-free generation and is actually very pro-vaping. At the moment, I am quite open-minded, but sceptical and cynical about the role of the tobacco industry and how those cessation needs are portrayed. That is the Scottish Government view on vaping.

I move,

That the Health, Social Care and Sport Committee recommends that the Health (Tobacco, Nicotine etc. and Care) (Scotland) Act 2016 (Supplementary Provision) Regulations 2022 be approved.

Motion agreed to.

You are absolutely right. Those choices are not easy for any Government, and we see issues around health inequality affecting many countries around the world. However, the UK is fundamentally one of the most unequal countries in Europe. It stands out when we compare it to our neighbours—it is not a great record to have the second-highest gender pay gap or to have such high levels of in-work poverty. The policy choices that any Government makes will make a fundamental difference to the level of inequality that is experienced.

To pick up on your point around mitigation, the situation at the moment is that we are a devolved Government. The amount of money that we have is largely dictated by the Barnett formula—Scotland gets a population-based percentage of what it chooses to spend—so the choices that the UK Government makes on spending account for the bulk of our budget, which restricts how much money we have.

We have some levers over raising money in income tax but we do not have all the tax levers. We have no power over national insurance and, as some economists would say, it is pointless to have any power over income tax if you do not also have power over national insurance—the two almost always require to be balanced.

The other thing is that that money is for our devolved responsibilities. About 70 per cent of Scottish revenue spending is by the Scottish Government on devolved issues, and every time that we make a choice to mitigate a reserved issue, there is less money in the pot to spend on devolved issues. That is why the situation cannot go on forever—that pot is not limitless. We have devolved responsibilities on which we need to spend money, and we have limited means of raising extra money, should we choose to do something different from the UK. It is a difficult situation for any Government to be in.

Another issue, which came up time and again during the pandemic, is the inability to borrow. Most Governments around the world are struggling to balance their budgets now, but most Governments have the opportunity to borrow. The Scottish Government has to bring its budget in bang on the money every time.