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Thank you for inviting me here to discuss the regulations, which make supplementary provision to the legislation that created the no-smoking perimeters around hospital buildings. Today, I seek your agreement to giving designated officers of local authorities the power to issue fixed-penalty notices in respect of two new offences relating to the ban on smoking outside hospital buildings.

There are three new offences relating to the ban. Without this Scottish statutory instrument, local authority officers such as environmental health officers would be able to issue fixed-penalty notices only in respect of one of those three offences. The regulations will enable local authority officers to issue fixed-penalty notices in respect of the other two offences, too.

As the committee previously noted, the prohibition on smoking outside hospital buildings requires effective enforcement to ensure compliance, especially during the introduction of the 15m boundary. It was the intention that local authority officers would lead on the enforcement of the ban, much as they led on the enforcement of the indoor smoking ban. However, as drafted, the provisions for enforcement of the ban do not fully reflect that intention. That issue was identified only after the Prohibition of Smoking Outside Hospital Buildings (Scotland) Regulations 2022 were made earlier this year.

The ban on smoking outside hospital buildings will come into force on 5 September 2022. On that date, section 20 of the Health (Tobacco, Nicotine etc and Care) (Scotland) Act 2016 will amend the Smoking, Health and Social Care (Scotland) Act 2005. The 2022 regulations will also come into force.

The 2005 act, once amended, will contain three new offences relating to the new ban: knowingly permitting people to smoke in a no-smoking area; smoking within a no-smoking area; and failing to conspicuously display no-smoking notices at the entrances to hospital buildings. The 2005 act will also give the police and local authority officers such as EHOs powers to issue fixed-penalty notices in respect of those offences. However, only the police will have the power to issue fixed-penalty notices in respect of all three offences. EHOs will have the power to issue fixed-penalty notices only in respect of the first offence: allowing people to smoke in a no-smoking area.

As the intention is for EHOs to lead on enforcement, it is critical that EHOs also be able to issue fixed-penalty notices in respect of the other two offences, particularly the offence of smoking in a no-smoking area. Giving EHOs that power will ensure effective enforcement of the perimeter ban.

I am sure that we all agree that hospitals should be places of health promotion where healthy ways of living are demonstrated. They should be environments in which people are protected from harm and supported in making positive lifestyle choices. The sight of people congregating near doorways to smoke outside our hospitals is incongruous to that. The no-smoking perimeter will reduce the risk of exposure to second-hand smoke near entrances and windows. It will prevent smoke from drifting into hospital buildings and protect people who use hospitals, particularly the vulnerable.

The regulations that we are discussing will help to deliver the effective enforcement of the ban that committee members called for during passage of the Prohibition of Smoking Outside Hospital Buildings (Scotland) Regulations 2022 earlier this year. They provide local authority officers with the same enforcement powers as are granted to Police Scotland, which has indicated that it would be operationally difficult for the police to be solely responsible for enforcement.

This is a team effort. We have been working with health boards, local authorities, Police Scotland and others to bring the ban to fruition. Without the additional powers, we limit the effectiveness of the restrictions even before they come into force. I urge the committee to pass the regulations and help us to stop smoking near Scotland’s hospitals.

I think that there is systemic racism in every aspect of society—to be frank, it would be foolish to deny that. Over the past couple of years, the Black Lives Matter movement has shone a light on systemic inequalities. In addition, the experience of the pandemic highlighted that members of black and minority ethnic communities were more likely to work in jobs that meant that they were exposed to the virus, more likely to live in housing that meant that the virus spread through their families, and more likely to live in poverty. Those are all systemic issues to which we cannot close our eyes—we have to acknowledge them.

That does not mean that those issues are easy to tackle. Every society has to focus on ways of tackling the systemic inequalities that have built up over centuries and sometimes—in the case of women—millennia. There is not one society in the world that does not have a challenge with inequality for women. We have to acknowledge how difficult it is to tackle those things, acknowledge that they are there, and have our eyes and minds open to ways to improve the situation.

You are absolutely right. When people experience systemic racism, they feel that society is not built for them, so it is very hard for them to access public services. An acknowledgement of that issue and an endeavour to improve the situation are really important.

I go back to the work that we are doing with the Gypsy Traveller community, which I met recently. That is one example of how community health workers from within the community were able to make a significant difference to the health of their community. That issue is worth exploring.

It is important that we have good data to guide us, and it is always difficult to find data for people who are outside the system. We can do better, and we have been doing better. The vaccination programme was among the first in which we collected ethnicity data at the time of administration. That has been really helpful in focusing our efforts on outreach programmes. We ensured that we put in special programmes to reach minority ethnic communities that were less likely to take up our offer of the vaccine. Extra efforts were successfully made with the Polish, black and Pakistani communities.

It is much more difficult to capture people who are not participating at all. The Gypsy Traveller community talked to me about how difficult it is for members of that community to register with a GP because they are not in one location. They move around all the time so, by definition, that makes it almost impossible for them even to get into the healthcare system. It is very difficult to capture data on people who are completely excluded from the healthcare system.

Finally, there is an issue relating to research and studying. For example, women have suffered from this being a man’s world. The fact that much of the medical research of the past century has focused on men, who are much more likely than women are to participate in clinical trials, for understandable reasons around pregnancy and childbearing, means that our medical understanding of men—largely white men in the developed world—is far greater than our medical understanding of women, men from ethnic minorities and, in particular, women from ethnic minorities. There are real gaps in our understanding, and we can see them played out in real life.

The impact of ethnicity on maternity and birth outcomes has been the subject of academic studies in England, one or two of which have reported recently. Although those are English studies, I am absolutely sure that there will be lessons for us to learn from them, because there is solid evidence of black and minority ethnic women suffering severe health inequalities as they pass through maternity services. We need to look at that, understand it, learn from it and implement changes in Scotland.

I would need to ask NHS Greater Glasgow and Clyde that question, and I will do that.

You are absolutely right about tiny things making a big difference. As a woman, I absolutely recognise that I live in a man’s world—I have daily reminders of that—and I think that it is exactly the same for black and minority ethnic people. Small reminders that this world is not their world will have a profound effect on them—to be frank, such reminders will have a far greater effect than whether they got a plaster on their cut. You are right to say that small things make a big difference. It is important that we take care of those small things. Frankly, it is incredible that we have not done so thus far.

I am sure that NHS Greater Glasgow and Clyde makes sure that health information is available in multiple languages, and I know that it has access to translators. The NHS Greater Glasgow and Clyde area has the greatest ethnic diversity in the whole of Scotland. Ensuring that resources are available in different languages might not go far enough. There might have to be other alternatives, whereby information on a website, for example, can be easily translated.

We need to go a little further than just ensuring that information is available in different languages. We need to make sure that our work is culturally sensitive to whomever we care for. I hear that time and again from people from minority communities. I am sure that almost all members of the committee will have heard it reported recently that members of the LGBTQ+ community feel—and there is evidence to support this—that alcohol services are not meeting their needs.

What I am saying is that we need to go further than going through a tick-box exercise of ensuring that information is available in different languages. Although we absolutely need to ensure that information is available in different languages, we need to go further and have person-centred services that get alongside people and which are sensitive to the culture that they are from. We must ensure that we deliver care that is sensitive to their cultural needs and which does not make them feel as though they are outside the community.

When she announced the payment, Kate Forbes made it very clear that she was balancing the tension between getting it to the right people and focusing on the people who need it most, and the speed required to get it out the door and into people’s hands.

The Scottish Government is frustrated, because as a result of the pandemic it has discovered that there are not always easy mechanisms in place to get money into people’s hands. I am sure that the Government will reflect on that. The mechanisms will improve with the growth of the social security system, but it is not always easy for us to identify the individuals who need the most help and get the money to them. Kate Forbes was very frank about the compromise to be made in getting the money to the people who needed it most and fast while knowing that some people who got it would not need it.

I think that it is easy to lose the focus on health inequalities, but I genuinely believe that my local authority colleagues are as troubled as I am about this. There is also amazing work going on in the third sector, which does a power of creative work in difficult circumstances—and, to be frank, insecure financial circumstances. It does amazing things.

I think that it is easy to lose focus, to take your eye off the evidence and to feel overwhelmed by the situation that we face. When we are faced with such desperate need—we hear about it on the news day in, day out from many people the length and breadth of Scotland—and there is an understanding that it is only going to get worse, it is easy to lose the focus on health inequalities. Part of my job is to make sure that we keep an eye on the golden thread of health inequalities that runs through everything.

We must remember what causes health inequalities. They are fundamentally caused by inequalities in wealth, power and status. I and all our partners who are trying to tackle health inequalities need to remember that in everything that we do. We must not disempower our communities or individuals. Every policy that we bring together should empower them and help to tackle inequalities. That is why, fundamentally, putting money into people’s pockets is a far more powerful tool than giving them a box of food. It is a much more empowering experience.

Convener, I have an opening statement, if you would like to hear it.

Thank you for inviting me and giving me the opportunity to return to this important topic.

I am pleased to say that we have made significant progress in our action on transvaginal mesh. We have established a national service for the management of mesh complications, and women have options with regard to their treatment, which can be undertaken in Scotland or elsewhere in the United Kingdom and with an independent provider if desired.

Most recently, the Transvaginal Mesh Removal (Cost Reimbursement) (Scotland) Act 2022 was introduced, and the associated scheme opened on 6 June—just this Monday. The contract with Spire Healthcare has been concluded, and arrangements are being made for the first patients to attend for surgery. Meanwhile, discussions with Dr Veronikis are progressing.

I am mindful of the concerns that have been raised by campaigners over the years about the use of mesh in other sites, such as in hernia repair. That is what I will focus on. I am sorry to hear of any instance of complications and the adverse effect that they have had on individual patients and their wider families.

As members know, the Scottish Health Technologies Group has looked into the use of mesh in hernia repair and published two reports on the subject, one of which was published shortly after my previous committee appearance. Those reports, which are based on current published evidence, support the continued use of mesh in a variety of abdominal wall and groin herniae. That is, of course, subject to all the tenets of realistic medicine: ensuring shared decision making and informed consent with knowledge of the benefits, risks, alternative measures and the possibility of doing nothing.

We have discussed the findings of those reports with professional bodies, including the royal colleges and the British Hernia Society, and we will continue to work with them on that important issue. Work is also going on to establish the medical device information system—MDIS—which will provide important surveillance and outcome information.

Since I last appeared before the committee, the chief medical officer has—in December 2021—written to board chief executives and medical directors to draw their attention to the SHTG report. In the letter, the CMO asked health boards to consider the availability of non-mesh surgery, how best to address skill gaps, if they exist, and the development of broader clinical networks for the management of complex cases. The actions resulting from that will be discussed at a meeting of the Scottish Association of Medical Directors in August.

I know that the committee has received a report from Shouldice hospital in Canada. Although the results reported are notable, it is important to remember that Shouldice hospital is a specialist centre dedicated to natural tissue repair and that it operates in a healthcare system that is very different from the national health service in Scotland. For that reason, the report should not be considered in isolation; rather, it needs to be considered in the context of the wider available evidence.

As I have said before in front of the committee, there are, of course, still some gynaecology procedures for which the use of mesh has not been halted. In those circumstances, there is a high vigilance protocol in place across NHS Scotland. It is important to remember that some of those procedures are complex and long established with few, if any, viable alternatives. Therefore, to suspend the use of mesh would leave a cohort of people with limited or no treatment options.

I reassure committee members, as well as the campaigners who lodged the petition, that the Government is absolutely committed to ensuring that everyone with mesh complications gets the care and treatment that they need.

I look forward to answering any questions that members have on the matter.

It is probably worth going to Mr O’Kelly on that question. As I understand it, Shouldice has a very specialised unit and patients there are somewhat pre-selected. It is therefore not a population that would be reflective of the general population who seek surgery in Scotland. That aside, its results are impressive and we are very interested in the work that is being done over in Canada. However, as I understand it, if we were to compare the population who use the unit in Canada with that seeking hernia repair in Scotland, there might be significant differences, for example in terms of obesity or ambulation.

I will hand over to Mr O’Kelly, who will be able to give you a better explanation.

It might set the context and answer some of the questions that you are keen to put to me.