���˿���

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.

You are absolutely right to consider those differences. You and I, and every MSP around this table, know very well that you cannot have a one-size-fits-all approach in Scotland. We might be a small country, but there are lots of different areas with very unique factors, which is one thing that differentiates Scotland from the rest of the UK.

A number of years ago, the Joseph Rowntree Foundation looked at the level of poverty in each of the countries in the UK, and one of the things that protected people in Scotland was the quality of our housing stock and the availability of social housing. The Scottish Government has had a huge programme of investment in social housing, and we have built more social housing.

The quality of rural housing stock and the difficulty of bringing the insulation up to an appropriate grade to mitigate fuel poverty is a challenge. That is vital in relation to reaching our net zero ambition and tackling fuel poverty. We have kind of done the low-hanging fruit. Upgrading insulation is easy in large-scale modern housing in an urban setting, but it is a much tougher job in a rural setting with more dispersed housing, different types of housing and different qualities of housing stock. We will have to get into that challenge.

That illustrates the need to work together. If we are going to achieve either or both of the ambitions of tackling fuel poverty and aiming for net zero, we have to get in about the challenging issue of improving the housing stock in rural areas. I do not need to tell you about the impact of the cost of fuel in rural areas. Although there is cheaper electricity in the south than we have in the far north, the cost of fuel for cars is challenging for my community at the moment. The lack of public transport options and the need to run a car is a challenge in rural communities, however well off you are.

I had a heartbreaking communication from a constituent who is a pensioner. He lives 20 miles from his local shop, had no fuel in his car and had only £11 in his bank account. He could not heat his house because he could not afford to fill his oil tank, which was his form of heating. You will all be aware that in many parts of rural Scotland, filling your oil tank so that you can get heat and hot water is a huge outlay, but that constituent could not afford the outlay. He was in a cold house and had to gather wood for his wood fire—this is in 2022—in order to heat his house, and he was unable to access his nearest shop to buy food. That is a disgrace, and it is absolutely about policy choices.

Reducing the VAT or making it zero on heating fuel or reducing the VAT on car fuel would relieve that situation. We can help with welfare policies, and my office directed him to all the funding that is available through the Scottish Government, but it is difficult to tackle those particularly grisly issues, and it will only get worse, which is heartbreaking.

People in my constituency—and I am sure in Emma Harper’s constituency—feel that those stories are hidden, because urban deprivation is so challenging for Scotland.

I am certainly more than happy to ask the Deputy First Minister to bring forward a plan of what is happening over the next year—or perhaps an outline of the type of cross-portfolio working that he does.

An area outside of public health in which we see a laser focus on tackling health inequalities is the child poverty plan. That is a national mission for the Government, and was prioritised even in the resource spending review, which was a challenging set of figures for the Government to receive, work through, share with our partners and local authorities and put into the public domain. Within that, you can see that tackling child poverty is still a priority.

Our action against child poverty is firmly rooted in evidence, with a robust evaluation strategy. Cumulative impact assessment and wide-ranging analytical materials underpin the approach that was outlined in our second delivery plan for tackling child poverty, “Best Start, Bright Futures”. That plan has a sharp focus on six priority family types, who are at the greatest risk of poverty, including those from a minority ethnic background, those with a disabled household member and those with a lone parent.

We are taking that evidence-based and balanced approach to tackling poverty, focusing on increasing household incomes through social security and employment and reducing household costs. Our action will focus on drivers of poverty, balanced with a focus on the next generation, supporting children to thrive and ensuring that we support the wider wellbeing of families. We have talked about the Scottish child payment, which we have already doubled in value. We will further increase it to £25 and extend it to children under 16. In my last portfolio, we had a massive social infrastructure investment in early learning and childcare, for which we doubled the entitlement.

That is where we get the biggest bang for our buck, as a Government.

We all know and cannot deny that the impact of poverty on a child can be lifelong. Tackling child poverty will absolutely deliver benefits in tackling health inequalities. It will be decades before we see those benefits, but it is absolutely the right thing to do.

Michael Kellet might want to come in.

Yes, I am supportive of the concept of proportionate universalism. I agree with Professor Sir Michael Marmot’s position that action to reduce health inequalities must be proportionate, with more intensive action lower down the social gradient. However, action also has to be universal to raise and flatten the whole gradient.

We already deliver a number of services in that way. For example, we are currently refreshing our tobacco action plan and considering other initiatives, such as the role of minimum and maximum pricing in tobacco, as well as initiatives such as the New Zealand phased approach to a smoking ban, which could be developed. Such action is universal and would have an impact right across the population. Every citizen in Scotland would benefit from those policies.

However, we also target services. We provide £9.1 million a year to health boards to fund smoking cessation services that are targeted at the most deprived areas, because that is where smoking rates are significantly higher. As Carol Mochan regularly points out in the chamber, there is a huge difference in the numbers of people who smoke depending on socioeconomic background. It is something like 6 per cent to 7 per cent for people on the highest income and up near 30 per cent for those on the lowest income.

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.