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No, thank you.

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.

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

No. I have to commend NHS National Services Scotland, which is pursuing the conclusion of that contract. It is very close to finalising that. I know that it is frustrating but, if we stop and reflect on the differences in the medical and legal systems in the two countries, we see that it is understandable that there has been a deal of to-ing and fro-ing. However, I am confident that everything is being done to conclude that contract, and I hope to be able to update Parliament on it soon.

Mr O’Kelly will want to come in on this but, as I understand it, there is real interest in improving the expertise within Scotland in natural tissue repair and they are looking at centres that use those techniques in Europe—just because of the ease and practicalities of links with Europe versus links with North America.

I will let Mr O’Kelly tell you a little bit more about that.

Absolutely. The review is now well under way. It was established following the serious concerns that were raised by some of the women about whether their case records accurately reflected the treatment that they had received. It is expected to conclude later this year.

In Scotland, we have a system that is based on realistic medicine—I am sure that Professor Sir Gregor Smith will want to come in on this. We want all patients, at all times, to be well informed and to be part of the decision-making process. We use the acronym BRAN to remind everybody who is involved to consider the benefits, risks and alternatives, whether the intervention is needed now, and what will happen if we do nothing. That type of conversation is vitally important when people are considering surgery.

There is no risk-free option when someone has a hernia, and it is important that people are well able to ask questions about, and understand, the proposed treatment—not just the risks in general, but how those risks apply to them—in order to make a fully informed decision on how they want to proceed.

I will let Gregor Smith say more on that.

I understand why you ask that question. I know from debates that have taken place in my constituency that there is a real tension between accessing healthcare as close to home as possible and being able to access national expertise when that is required. I get many more expressions of concern from constituents who have to travel within the constituency to access care than I do from people who want to travel to benefit from specialist expertise.

In NHS Scotland, the way we tend to work is that it should be possible for people to access routine care as close to home as possible. There are lots of good reasons for that. From the point of view of not just the medical model of health but the biopsychosocial model of health, with routine procedures it is important that people are treated close to home, have support around them and are able to recover well within their family and their community.

However, with particularly challenging or complex procedures, we need to build in expertise. We will have to work in a networked way across Scotland to deliver that. We have said that there are challenges with volume. If people are to train in natural tissue repair, they will have to see enough people to maintain that training. We will certainly consider what is the best model for Scotland but, at the moment, I am not minded to reconstruct the unit in Canada here in Scotland.

I will hand over to Mr O’Kelly, who is keen to come in.

Certainly. The Shouldice hospital deals with more routine operations and at quite high volume. In order to give people options in highly skilled and trained surgeons who are using those techniques, that is something that we need to explore on a national basis, although we can also build up local expertise.

I agree that there needs to be a national multidisciplinary team to look at those particularly complex cases. Clinicians from all over the country need to be able to access that expertise. It is difficult to understand how challenging it can be to communicate across boundaries in the NHS. That is a theme that comes up time and again. We are very keen to bust those boundaries to ensure that clinicians can access the expertise that they require for their patients, wherever they live in the country.

We are also mindful of developing systems that mean that patients, wherever they live, can access the right level of expertise. People in Lerwick are probably more comfortable with travelling than people on the mainland because they travel all the time. Patient choice needs to be part of it. We need to make shared decisions with patients about what is the best option for them.