Health and Sport Committee

Meeting date: Tuesday, December 15, 2020

Official Report 682KB pdf

---

Scrutiny of NHS Boards (NHS Borders)

The next item is an evidence session with NHS Borders as part of the committee’s on-going scrutiny of health boards and special health boards. I welcome, from NHS Borders, Karen Hamilton, who is the chair; Ralph Roberts, who is the chief executive; Nicky Berry, who is the director of nursing, midwifery, allied health professionals and operations; and Andrew Bone, who is the director of finance.

We move straight to questions. Will the chair give an indication of the overall financial position of NHS Borders?

We are having some difficulties with Karen Hamilton’s sound. Will Ralph Roberts give an indication of the costs to date of the additional measures that have been required to manage the Covid pandemic in the Borders? Where have those additional costs been incurred?

We cannot hear Ralph Roberts. We are having little luck with NHS Borders this morning. In that case, I am bound to go to Andrew Bone, the director of finance.

I will answer your questions, if that is all right. In the year to date, we have incurred about £6 million of direct costs in response to Covid. That expenditure has been across a number of areas. Money has been spent on a combination of public health and infection control measures, including social distancing measures in hospitals. There was spending on a reconfiguration of our bed base in the Borders general hospital and on a number of actions in the community to manage resilience in care homes, for example.

The biggest element probably relates to our acute bed base. We have provided additional beds specifically for Covid patients, and there has been a change in our staffing model as a result. Across the health board, in order to deal with staff who were shielding or otherwise in the initial phase, we increased sickness absence provisions during that period.

That is broadly what the expenditure has been on. I also highlight the costs of expanding the testing service. As we have entered into another phase, the costs of the remobilisation of services, our winter planning and our flu planning are starting to come through, too.

You have described the additional costs that have arisen as a result of this year’s circumstances. Clearly, even before then, both NHS Borders and the health and social care partnership were under financial pressure and seeking to manage that through brokerage. As the board’s director of finance, is it your view that you will be able to continue to manage with the level of brokerage that was agreed before Covid-19?

Yes. We have worked closely with the Scottish Government throughout this period. Prior to the onset of Covid, we had a financial plan that sought a reducing level of brokerage over the next three years, but with an on-going requirement as we started to implement some of our turnaround plans.

At the moment, our expectation is that the level of brokerage that we described in our financial plan will still be required. The additional support from and constant dialogue that we are having with Scottish Government colleagues in the finance team give us a measure of comfort that we should be able to live within that level of brokerage; we might yet see some slight movement downwards.

Thank you very much—that is helpful. I will just check to see whether Ralph Roberts is connected now. Ralph Roberts, can you confirm that you are in communication with us?

Hello, convener. I can hear you. I apologise for the problem earlier.

That is quite all right—we know the perils of online meetings all too well. Can I also confirm that Karen Hamilton, the chair of NHS Borders, is connected now? No. Well, one out of two is progress. We will, I hope, be able to hear from the chair in due course. Emma Harper has the next set of questions.

Good morning, everybody. I am interested in winter planning and Covid numbers. We have heard about a recent outbreak of Covid cases in the Borders. Are you able to manage the demand and pressures from the second wave or additional little outbreaks of Covid-19 infections, through all your processes, as we head into the winter?

I might bring in Nicky Berry, the director of nursing, in a moment. To start with, it is worth emphasising that this winter is a winter like no other; we are managing a number of contributory factors. We are dealing with the normal issues that we would have in any winter and then Covid is placing additional pressure on us.

Alongside the Covid patients who are coming through our services, we have to manage the vaccination programmes, test and protect, the testing of our staff, and the work that we are doing to support care homes and social care, in terms of the quality of service that they are providing.

We also need to be aware of potential issues associated with Brexit, and we need to recognise that because of the pressures across the whole system—particularly some of the pressures within social care—the flow of patients through our system is likely to be slower this winter than it might have been in a normal winter. Those factors all add up to a significant set of coincidental risks that we need to manage as a whole.

You are right to reflect that, over the past week, we have had a significant number of Covid cases in Borders general hospital. In our Covid planning, we have a system in place: we have a series of Covid wards that we can open as additional Covid patients are identified. We currently have our first two Covid wards open and we are right at the transition point of needing to move into our third Covid ward. The issue around managing that is about ensuring that we have enough staff across the hospital to manage everything. It is also important to be aware that our third Covid ward is the ward that, up until now, has been our green clean pathway for routine elective patients. Therefore, if the numbers continue to increase and we need to move into our third Covid ward, we will need to step down our routine elective activity, which will obviously have an impact on the non-Covid harm that we have in the system. I hope that that gives you a useful overview.

10:45  

That is very helpful. I will bring in Nicky Berry.

I am afraid that we are not hearing Nicky Berry; we might come back to her. Because of the issues that we are having in connecting to NHS Borders, we might need to supplement some of today’s evidence with additional input from the chair and Nicky Berry. We will see what can be done and we will invite written comments if necessary.

I am sure that we can get written responses if the sound is a challenge.

I have seen amazing work by health service staff, who should all be thanked. We are managing outbreaks. Teams are adapting. Everybody hit the ground running in late February or March and people have been running ever since. What role does the health board have in managing minor outbreaks and in supporting staff?

That is an important point and one that the board is aware of. It is important for us all to understand that the pressure that staff are now under as we go into winter is greater than it has been throughout the pandemic. We are dealing with that with staff who have been in this situation for nine months. That gives us significant concern. Although we can see that vaccination will bring benefits, we know that we will be in this situation for at least three more months, if not longer. We are conscious of that.

We must recognise that staff have responded incredibly well. As leaders of the organisation, we are proud of them and thankful for that response. We must also acknowledge that staff will react in different ways, depending on their circumstances. We must allow staff the space and the time to depressurise when that is right for them.

We have focused on staff wellbeing throughout the pandemic. Work in that regard has been led by our employee director and we have taken care to involve staff in that. We have put additional psychological support in place and we have made breakout spaces available for staff.

When we came out of the first wave of the virus, we ran the collecting your voices programme, which was a bottom-up approach to getting staff feedback on how things have felt for them and what we should do next. That has taught us some important lessons that we can take into the next stage. Some of those lessons were about the impact of moving staff from one team to another and the additional support that is needed when people are working in teams or departments that they are not used to. We are aware of that as we go through the next phase. We will continue to focus on supporting our staff.

We must continue to monitor that.

I have read about localised outbreaks in Greenlaw, Jedburgh and some other areas. What role does the board have in managing those specific wee outbreaks? Is it about engaging outwardly, or public education?

I will bring in Ralph Roberts and ask him also to explain the current position with the outbreak at Borders general hospital.

I suppose that we have a number of roles, one of which is the one that you have just mentioned, which is to make sure that the public get good information about what is going on, to help them to make the right choices about their behaviour and how they comply with the controls that are in place, and to make them aware of the risks around what they are doing every day.

We are also involved in the work that our public health team does in conjunction with other partners, particularly the local authority, in managing individual outbreaks. Who that team engages with will depend to some extent on the nature of the outbreak. If it is in a commercial premises, the individuals involved might be different from those involved if it is an outbreak in social care or a care home or hospital.

We have a trusted and practised health protection response to outbreaks that includes our public health team leading problem assessment groups, which is where the information about an outbreak is first collected. If the outbreak is significant, it will move to an incident management team, which our public health team would lead. That would involve staff from our infection control team and the council. If the outbreak is linked to social care, social care managers will be involved along with council emergency planning officers and senior council staff.

We use that well-run process on a more-than-daily basis, depending on the scale of the outbreak. It requires an awful lot of input. The team will look every day at the control measures that are in place to try to understand the reasons for transmission. That links into the information that is coming in from the test and protect service about what the numbers are, who they are, and who their contacts are. The team collects all that information and then tries to make sure that the appropriate controls are in place.

Linked to that, there is a wider question about the significant impact and lessons that we have learned and the relationships that we have continued to build on throughout all this in working with partners. That might be something that we come back to later.

Specifically on Borders general hospital, we became aware about 10 days ago that some positive cases had been identified on one of our wards. We applied the same health protection approach to that by having incident management teams daily testing other patients in adjacent beds and bays, testing all the staff on the wards, and trying to put in place additional mechanisms so that we can manage the outbreak as effectively as possible.

Nicky Berry, do you want to add anything?

There is no sound, so perhaps not at the moment. We will move to George Adam.

The NHS Borders submission lists a number of positive changes that have been made because of the pandemic and says that you mean to retain those, which is great. I have a simple question, however. Why did it take a world-wide pandemic to improve services?

That is a bit of a loaded question. There are a number of things to say. We continually improve service, but through change methodology we all understand that part of the process of managing change is people’s willingness to change or their understanding of the need for change.

As we look back over the Covid response, particularly at the initial phase, our staff have said to us quite a lot that, in managing change and making decisions, they found it helpful to know that we had a very clear common purpose, which was to address the outcome of the pandemic.

That allowed us to be more specific in our prioritisation of decisions and increased the pace at which people accepted that decisions needed to be made, as well as their willingness to go along with those decisions, even though they might previously have said that they would not do so or they would have had more conversation about the pros and cons and balances of any decision. Therefore, there is a lesson for all of us about the importance of prioritisation and being clear about our purpose. We were able to put some things, such as virtual appointments, in place because staff and patients recognised that they were an absolute necessity and to patients’ benefit, so they were willing to accept changes to the way in which services were provided in a way they would not otherwise have been. It is about recognising the cultural and human dimension to change, which was fundamentally affected by us being in a pandemic.

A number of the changes, such as our wish to use more virtual technology but also things that we had been talking about—such as the way we manage our bed base and whether patients are cared for in the acute sector or supported in the community—were also accelerated. A number of those were part of the longer-term transformation programme that flowed out of our financial issues and a strategy to shift care into the community. The pandemic accelerated the need to do that, so we were able to move forward faster than we had until now.

Thank you for that, Mr Roberts. I would have thought that you would have had a clear common purpose pre-Covid as well, but never mind.

Specifically, what has the leadership team done during this period to empower staff and improve collaboration between health and social care partners? We have been talking for years about how we should all make it a lot easier and break down barriers, but it has always been an issue.

I will comment first on the common purpose. It is important that we all recognise that the delivery of health and care is a complex set of issues and, at all times, we have a significant level of competing demands. During the Covid pandemic, particularly at the beginning, there was a clear single purpose, which was to make sure that we had as much capacity available as possible in order to address the potential increase in Covid patients. That meant that we stepped down other services, and our whole focus was on how to create enough capacity to deliver against the potential level of Covid patients. That was what I meant by a common purpose. That is not to say that we do not have a clear set of corporate objectives or priorities, but having a clear set of priorities and having a single thing to deal with is a different context.

In relation to what we did, some of which was fed back to us by our staff, we instigated the normal pandemic response, which would reflect the response to any major incident—

Mr Roberts has dropped off the call. I will check whether Karen Hamilton is now on the call.

No, we do not have the chair or the chief executive but, happily, we have Andrew Bone.

11:00  

I will try to finish Ralph Roberts’s answer for him. I hope that I will hit the key points. He was describing our response to the pandemic—or, indeed, to any emergency. We stepped up our pandemic committee and our gold, bronze and silver command structure. That meant that routine meetings were held frequently—daily in the initial phase, and then stepped down to every other day. We are currently running our pandemic committee meetings weekly, but we will continue to review that. That meant that there was a constant connection between the direct operational management of each element of our service and the pandemic committee. That represented a significant burden for managerial time—we would not operate in that way in a normal phase—but it meant that we were constantly communicating and bringing together the organisations’ various tiers of management.

In addition, we have weekly calls with our partners, and also informal calls outwith that pattern through our relationship with our council colleagues. With the changes to the chief nurse’s responsibilities, Nicky Berry in particular works closely with our social care colleagues. We have a close working relationship with care homes, and our social care colleagues in general, at the moment, as we have done over the past nine months or so. We are in constant communication with them almost daily, and certainly weekly, on planning for community services and responding to issues arising in those environments.

In the first instance, our approach was about establishing the structural aspects of our response. However, the same common purposes that Ralph Roberts described in relation to the health system have brought us together with our health and social care colleagues to form a wider system.

Good morning, everyone. I will add to what Andrew Bone has said. We had previously planned for clinical leadership of a pandemic event, but facing Covid-19 has obviously been new to all of us. Our approach has been very much clinically led and clinically driven. Our clinicians have been involved in planning our response across the three clinical boards. The initial planning phase had to be rapid. We had to scale up our intensive treatment unit immediately, by quadrupling its capacity, and we opened nine Covid wards and a Covid hub. We ensured that all our board’s clinical directors in the acute division, our mental health clinicians and our general practitioners in primary and community services were linked. Our board’s area is not huge. We have the Borders general hospital and four community hospitals, and our mental health service has three in-patient wards.

Initially, Ralph Roberts, our general managers, our associate nurse directors and I held meetings with staff. We held daily comms meetings to discuss what was happening with the pandemic and how we were faring. We shared our plans with the senior medical teams. Our aim was to ensure that communication was key, because everything was changing, sometimes hourly, to—[Inaudible.]—just had to respond to that—[Inaudible.]—partnership with our health and social care colleagues.

As Andrew Bone mentioned, we now have weekly meetings between health and—[Inaudible.]—but in the midst of the pandemic those meetings were daily.

Those are all my questions. Thank you very much, convener.

I am interested in the suggestion in your submission that cancer referrals and treatment have remained a priority throughout the pandemic. You also indicate that your out-patient activity has suffered and that out-patient appointments are at only 40 per cent of pre-Covid performance levels. Furthermore, you anticipate that the situation will worsen as primary care capacity increases, which is not being matched by capacity in secondary care.

The remobilisation of mental health services is also detailed in your plan. It shows that child and adolescent mental health services are running at 60 per cent capacity and community mental health teams are at 75 per cent capacity. I think that you would agree that that is worrying, considering the increase in mental health issues during the pandemic.

Is the board able to follow its remobilisation plan as expected? If not, what are the challenges to doing that? Why were those not predicted?

That is an important area for us to be sighted on. We all need to understand that the impact of the pandemic on our services is long term and will take considerable time to address. We also need to recognise that the harm from that is about the potential impact not just on patients who have Covid and the impact on them in the short term, and, potentially, in the long term, but on our other patients.

If there had been no pandemic at the end of March, we would have hit our waiting times targets. We would also have only had a small number of patients waiting longer than 12 weeks either for their first out-patient appointment or for their treatment time to come and receive a procedure under the treatment time guarantee.

As you have pointed out, because we are not able to remobilise all our services up to 100 per cent of previous activity levels, there has been a significant increase in the number of routine patients who are waiting.

We are pleased that we have been able to sustain all our emergency and cancer work throughout the pandemic, and that has been very important. However, we should not underestimate the impact that the situation will have on patients who have been waiting for more routine procedures. Their numbers are continuing to grow, particularly those who are waiting longer than 12 weeks. In addition, a significant number are now waiting longer than 26 weeks. The numbers will continue to grow until at least March next year, depending on when we can get back to a position in which we are running services normally.

Nicky Berry might want to come in and give a bit more context to the position on capacity. However, it is important that people understand that the process of seeing patients has changed—it takes longer to see individual patients because of the requirements for personal protective equipment and so on. We have also had to move staff out of a number of our services to support the essential Covid response, not only to increase the hospital capacity but to support test and protect and the vaccination programme, for example.

Unfortunately, the reality is that there will be lower levels of routine activity until we are through the pandemic response. It will then take a considerable period for us to address the significant backlog. That will take months if not longer to address, and we should not shy away from that reality.

I call Nicky Berry.

We seem to have lost Nicky, so I will go back to Brian Whittle.

I think that we all appreciate the pressure that Covid has put on many services. However, on the board’s suggestion that cancer referrals and treatment remain a priority, the performance does not match that. Therefore, an issue is managing expectations.

Will you comment on the suggestion that improved capacity in primary care is not being matched by improved capacity in secondary care to deal with the backlog?

I will comment on the cancer aspect. As I have said, we have been able to sustain our performance throughout the pandemic. It is important that we recognise that, and I am grateful to staff for their focus on that. We have delivered against our cancer targets this year to a level similar to what we have delivered in the past.

On routine activity, right at the beginning of the pandemic, obviously, we stopped doing such procedures in hospital, as everywhere else did. Therefore, we had a number of patients on our waiting list who, at that point, will have waited for less than 12 weeks, but then moved along the curve, if you like, and ended up waiting longer than 12 weeks, because we were not doing any activity.

Of course, during the initial part of the pandemic, primary care also focused its attention on Covid. Therefore, patients who might otherwise have gone to primary care services and then been referred to secondary care were not going to their general practitioner and therefore the number of referrals coming in from primary care services into the hospital also dropped. Therefore, although more people were waiting longer because we were not able to operate routinely, the number of patients being referred initially went down. Obviously, as we began to remobilise services, primary care started seeing patients again and the referral rate has begun to move back to the normal expected rate.

It is again important to emphasise that, throughout, primary care continued to provide services and was available to anyone who needed to be seen urgently, albeit that that was being done in a different way.

As primary care referrals have begun to move back up to the normal level where we would expect them to be, obviously, if we are taking only 40, 50 or 60 per cent of our normal level of patients, there is a disconnect between the number of patients being referred in and the number of patients who we are able to treat at the other end of the waiting list. That then creates a disconnect between the number of patients being added to the waiting list and the number of patients who we are able to take off the list.

We are still having some technical difficulties, so I suspend the meeting for 10 minutes to enable those issues to be resolved.

11:12 Meeting suspended.  

11:25 On resuming—  

We resume our meeting. Brian, do you still have questions for our witnesses?

I do, convener.

I was looking at the thankfully relatively low Covid-19 activity that you have in the Borders. With that in mind, can you explain why performance in relation to out-patient and in-patient waiting times continues to be such a problem?

There are a couple of things to say about that. First, we need to be careful when we say that the rate of Covid activity is low. That is certainly not an impression that I want to give our local community. The numbers in the past week show that the rate per 100,000 people has more than doubled, so we need to be very careful about that.

I will bring Nicky Berry in on this in a moment, but there is a broader point. Regardless of the level of Covid activity in the community, the implication of there being some Covid cases in the community is that we need to provide services in a way that keeps patients safe when they come into the hospital or primary care, and in a way that also keeps our staff safe. Regardless of whether we know that patients who come into the hospital have Covid, we have to behave as if they might have it.

The way in which our staff have to manage patients through the system is having an impact on the percentage of patients that we are able to treat compared with what we did before. As I said, our staff are also delivering a number of services that we did not have to provide previously, and that has an impact on activity levels. I ask Nicky Berry to say a little more about the practicalities of providing services in a Covid-safe way.

The board is also challenged by the situation. For example, we have lost 60 per cent of our waiting rooms. Because of social distancing, we have had to put in place measures to ensure that patients are screened before they come in for face-to-face appointments, and there are delays because of that. We are trying to maintain services as much as we can, through Near Me and telephone appointments. However, as Ralph Roberts said, it is a question of balancing the risks.

We were at level 2 until last week, and we are now at level 1. We want to ensure that we do the right things for the public in the Borders and make the right decisions about Covid prevalence in the community, including when people need face-to-face appointments. We are doing that alongside the Scottish Government guidance, and we are maintaining the safety of residents who come into the hospital.

That is helpful. In the interests of brevity, I will combine my final two questions. I would like to hear an explanation of the rationale for reducing allied health professional services to such an extent. Why are minor injury services not operating at all? Most importantly, why are CAMHS running at such reduced capacity? We know that mental health has been a big issue during Covid and that that will continue post Covid.

There are several issues in there, some of which are linked to specific issues in particular services. I will take CAMHS as an example—[Inaudible.] It is fair to say that our CAMH services were challenged through 2019. We recognised that and did a number of pieces of work to address some of those challenges. We recruited additional staff. Last year, our performance went from a position that none of us was comfortable with to one, which by the early part of the year was meeting the national CAMHS target.

11:30  

I am afraid that our connection with Mr Roberts is not going well. Perhaps Karen Hamilton can comment on the overall position of the services that have been reduced or are not operational.

My sincere apologies for the chaos that there has been in trying to make contact with the committee. Unfortunately, because I have been running around trying to make the connections work, I have not been following the conversation so far. However, I will say a couple of words from my position as chair of NHS Borders.

During the Covid pandemic, my focus has been on supporting the organisation and enabling the non-executive director cohort to maintain their connections and links with the organisation. On the governance and scrutiny of our performance, we managed to maintain all our governance committees bar two minor issues around public and staff governance. Other governance issues have been maintained during the pandemic and are still on-going. From my perspective, it has helped to keep that helicopter view of how the organisation is performing at the same time as ensuring that things such as workforce support are also continuing. We have also had to manage public expectation to some extent. Communication with the public through the whole process and at present, given changes to the levels and so on, is absolutely crucial.

I hope that that is helpful in relation to the conversations that have been going on this morning and our presentation.

Thank you very much. Would Nicky Berry like to add anything?

I am sorry—my connection was removed.

We are certainly not delivering on the CAMHS standard and the board is currently focusing on that. We are working with the Scottish Government and there is enhanced support around CAMHS and psychological therapy. Previously, we have delivered on the CAMHS standard, but our issue is that it is a small board and a small service and so vacancies, sickness and absences bring many challenges that impact on the CAMHS standards.

We are working with the Scottish Government on how we can improve the standard. I am involved in that work along with the leads for mental health and psychological therapy.

The Covid pandemic has brought an increase in referrals to mental health and we need to manage the impact of that and ensure that we can put processes in place to develop the standard, while maintaining a sustainable service. Being a small board is not an excuse—we need to ensure that whatever happens, we have a sustainable service. We are looking forward to learning from other boards from across Scotland.

In the annual review, the board suggested that 120 full-time equivalent staff would be required to deliver services connected to the response to the pandemic. Were all those extra staff secured and the services delivered?

To give some perspective, I point out that more than 100 staff were required in corporate services, nursing and for the flu vaccination programme. We are in the midst of recruitment—I cannot say exactly how many staff we have recruited, but we will be able to give the committee that information at a later date.

It is quite challenging to recruit registered nurses. Last year, I spoke to the committee about the need to be innovative in that area and across any discipline. We are looking at that, as is the whole of Scotland. The 126 staff are required across many services, not just nursing. We will come back to the committee with an update on how we have progressed the recruitment for those posts.

That will be helpful.

Have you been able to put wellbeing support in place for permanent staff as well as anyone who has been brought in to assist during the current circumstances?

Yes, we have been delivering wellbeing support for any staff. Our here for you service is run by our head of psychology and the occupational health department.

Approximately 20 retired staff have come back to the board to help with flu vaccinations. The support is there and we have made sure that it is signposted on the intranet so that staff are aware of where they can go for it.

I am sorry about all the glitches that we have been having.

I will ask about the interaction that the board has with general practitioners and about the Covid assessment centre. We know that GPs are being paid to action those assets—as we say in the committee.

How have you interacted with general practices since March, and can you tell me about practice capacity issues? Have practices incurred extra costs? I mentioned that GPs get paid for those services. What additional payments have been made to practices and for what purpose? What interaction has there been with regard to referrals to secondary care for mental health assessments and chronic conditions, for example?

Those are three separate questions, but I will roll them into one.

Would Andrew Bone like to comment on the financial aspects?

Primary care has suffered significant disruption during the Covid period. The issues with access to services as a result of social distancing and infection control measures have meant that practices have not always operated at the level that we would have expected pre-Covid. I am sure that my colleagues will speak more about that.

Provider sustainability is the first element of the immediate payments to GPs that have been arranged on a national basis. That is about making sure that existing contract payments are paid, irrespective of whether elements of the contract were not able to be delivered in line with original expectations. Those sustainability payments have provided a floor for practices to ensure that they have a level of cash flow.

On top of that, the Scottish Government has made a couple of announcements about additional funding support to practices that specifically relate to Covid. There have been payments for some of the additional response that has been required in relation to infection control measures and support with things such as PPE.

The board’s financial response has mainly been about trying to work with practices to enable our service to be delivered safely. We work through our primary care and community service management team to liaise directly with the practices to identify measures that can be taken to improve accommodation and make treatment rooms safer. We have put in additional investment in that regard. In the order of our overall resourcing, it is not particularly material—it is a few hundred thousand pounds of additional expenditure, which is largely constrained by the ability to make those facilities safe.

There are certain activities that we simply cannot do, as we cannot redesign a building in six months. However, we can make changes to treatment rooms to make them safe, such as through the cleaning regimes, and we can try to provide wraparound support in relation to the environment that is available for practices to operate in. I think that Nicky Berry will be able to speak better than I can about how the clinical services have been supported.

It is probably worth saying that, throughout the pandemic, one thing that we have been committed to, and have worked with practices on, is making sure that the primary care investment plan that was agreed has continued to progress in line with the contract. That has remained broadly on course throughout, so we are on target to have recurring investments of just over £3 million through the programme, which is seen as part of the main contract. That has had its own implementation challenges during the pandemic, but the board has been committed to making sure that the plan progresses.

I will pick up on Andrew Bone’s point about the work that we have done with primary care to continue to build sustainability. That work has continued, and we have engaged regularly with our GP leaders on it. In one example, that work specifically led to our agreeing the roll-out of a new mental health service. The roll-out started in October and November, and it will continue to expand through the winter until it is at full capacity early in 2021. The service is a response to building capacity to support GPs, given the number of patients that are coming in with mental health or distress issues. The service has been welcomed by our primary care colleagues, and it has addressed one of their key priorities associated with the implementation of the primary care improvement plan.

I will come back on one of the answers before I ask about the Covid assessment centre.

Is it correct that practices have incurred no extra costs—they have been reimbursed—and, apart from the Scottish Government moneys, no additional payments have been made to practices?

Bear in mind that the Scottish Government is the primary source of financing for the GP contract. Practices have received additional payments, largely in respect of offsetting their additional costs and expenditure. We have tried to work with them to wrap support around them as much as possible, but it is not really a case of the board having introduced additional payments.

We have made sure that we honour the provider sustainability agreement, and we have tried to make sure that all the local—[Inaudible.]—we continue to maintain cash—[Inaudible.]—that the contract is fully in place at this point, recognising the level of challenge that primary care faces. It has not been a matter of direct investment in primary care to expand practice capacity, because the opportunities to do so are limited. It has been about trying to give them as much stability as possible, and making sure that the support that the board can provide in a wider context is available to them.

If I am correct, GPs have had extra moneys from the Scottish Government, as you mentioned. The contract that you have with GPs has been honoured in monetary terms as well, even though they have not been able to continue with what they normally do. You mentioned £100,000 of additional moneys. Was that to GP practices?

11:45  

I am sorry—that point was probably a bit more specific. The money relates to additional costs that have been incurred by the board to make facilities as fit for purpose as we can through adapting the environment and supporting cleaning. It is not a direct payment to practices; it is about enabling the environment in practices to be as safe as possible. It is really about what we can practically do in the circumstances to help them operate in their facilities.

I have a couple of questions on the Covid assessment centre in the Borders. How have you organised the assessment centre? You mentioned staffing previously, but what arrangements have you made with local general practices during the pandemic for staffing the centre? Will you describe and explain how the CAC has been operating alongside out-of-hours services? Lastly, what support has the board made available to general practices to supplement that provided through Government guidance, which you mentioned in your earlier statement?

We created a Covid assessment centre right at the beginning of the Covid pandemic. We located it in the Borders general hospital in what was previously an out-patient day hospital area. It is co-located with our out-of-hours service, which we also moved, and which was previously immediately adjacent to the emergency department. That also gave us a bit of additional capacity and space in the emergency department to help to make it Covid secure.

The service has run alongside the out-of-hours service and the Covid assessment hub and is staffed through a range of staff, including ANPs, GPs and so on, with some support, at various times, from secondary care throughout the Covid pandemic. In addition, we are involved in the current discussions about creating a redesign of our unscheduled care service, which is being run out of the same location.

I think that that picks up on the initial comments. Nicky Berry might want to come in with more detail.

I will add something on engagement, as Sandra White asked about that earlier. As Andrew Bone said, the primary care management is part of the governance and decision-making process. Any decision making regarding the Covid hub and assessment centre has come through the gold command, and clinicians are involved in it. From a GP perspective, in the lead for the Covid hub, they had a link to any decision making in the gold command, which the chief executive chairs.

In relation to the roll-out of the Covid-19 vaccine, will you describe the arrangements for your health board area?

Obviously, that will be one of our key priorities over the next few months. In a second, I will hand over to Nicky Berry, who is leading that work for us. I will make the general point that we recognise that it is a really important priority and we are absolutely focused on delivering it as quickly as possible, but we need to do that safely and we need to recognise that we are planning for the roll-out with a significant level of uncertainty, particularly in relation to vaccine supply.

I have been pleased and impressed with the way in which staff have responded, but we are adapting almost daily as more information becomes available, as members of the committee will understand. It is early days yet, but at the moment we are focused on delivering the first stage of the vaccination programme to our staff, care homes and social care staff.

I will hand over to Nicky Berry to give you more of the detail.

As the executive lead for the Covid vaccination programme, I agree that it is one of the things that we are committed to delivering, but it is challenging. We are the lead agency, but we have a governance structure involving Scottish Borders Council and NHS Borders to ensure the successful delivery of the programme. We expect to receive 11,700 vaccines in wave 1, which is the two doses. Waves 2 and 3 will be huge, logistically, which is why it is critical that we work alongside Scottish Borders Council to ensure that we can deliver the programme. We have delivered an extremely successful flu vaccination programme, vaccinating more than 45,000 people. Our potential numbers were just over 60,000, so delivering 45,000 is testament to the staff and a high take-up rate.

Nicky Berry makes a good point in comparing the roll-out of the flu vaccination with that for Covid-19. Perhaps you can put some flesh on the bones of a technical point. Our understanding is that temperature control is vital. I think that -70°C is needed for the vaccine that is currently available. Do you have facilities in NHS Borders for storage of the vaccine at the correct temperature?

Yes—we have the cold storage in the pharmacy in the Borders general hospital. Deliveries of the Pfizer vaccine come to the hospital and it is stored there at the correct temperature. There is a logistical issue in managing the transfer of the vaccine out to the wider Borders area, which we can do at fridge temperature—if I can use that as a description—but there is a fixed window of time in which to do that.

There are some detailed requirements in terms of moving the vaccine in its powdered form and only being able to constitute it and dilute it for vaccination on site, at the point at which we are delivering the vaccination. There are practical issues with getting it into every care home and out into individual communities. There will also be a particular issue when we deal with the housebound population.

I have a question about a national issue that will affect boards throughout Scotland, which is that there are question marks around the security of the vaccine. Without breaching confidentiality, obviously, can you say whether you have had discussions with the local police or with security services about that?

I can confirm that I had a conversation with one of the police commanders at the back end of last week on exactly that issue.

My question is on the vaccination programme. How does the board co-ordinate and report on who has been vaccinated and by whom?

There is a mixture of approaches to that. With regard to the Covid vaccination, there is an app that allows the person administering the vaccine to record the information as the vaccination is given. The information collected by the app transfers into the general practitioner records, so that we have a record of which vaccination a person had and when they had it. Obviously, that will be critical, because we must ensure that we call people back for the second dose within the appropriate timescale.

What local mechanisms and procedures are in place to monitor and deal with any adverse reactions to the vaccination, given that it has been tested on a healthy trial population and not on those with underlying conditions?

It looks as though Nicky Berry has lost her connection, and I am not sure whether she has come back in.

The arrangements for that comply with all the guidance. Individuals are required to wait for 15 minutes after they have received their vaccination, to ensure that they have not had an immediate negative reaction. We are administering the vaccination in places where we have the appropriate kit to deal with any issues. The staff who are administering the vaccinations have been given training on the specific aspects of this vaccination.

As committee members are probably aware, on the back of the initial couple of incidents that occurred in England following the administering of the vaccine on the first day, a decision was made that any individual with a known allergy would not be vaccinated with the vaccine at this point. That is part of the consent process and the discussion that we have with individuals before we give anyone the vaccination.

Therefore, there is a range of control measures in place, and an alert mechanism is available to staff so that, if they see any negative reactions in anybody, those are fed into the national alert system. That is exactly what happened in those first instances. The information can then be transmitted across the country, so that people can understand what incidents have happened.

Finally, Nicky Berry wants to come in.

To be honest, Ralph Roberts answered the question beautifully.

Every ward has an immunisation co-ordinator, who would manage any adverse event. Such events are escalated and there is a process for dealing with them. I have nothing else to add, as Ralph said everything that I would have said.

I thank all our witnesses from NHS Borders. I apologise from our end for the technical issues that we have experienced. A number of witnesses wished to add additional points, which they were not able to do live, so to speak. However, please feel free to write to the committee on any points that you were unable to address during the evidence session. Likewise, we might write to you on one or two areas that we have not fully explored. I thank everyone for their patience.