Health and Sport Committee

Meeting date: Tuesday, September 29, 2020

Official Report 663KB pdf

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Scrutiny of NHS Boards (NHS 24)

Good morning, and welcome to the 25th meeting in 2020 of the Health and Sport Committee. We have received apologies from Alex Cole-Hamilton.

We have a busy agenda today. The first agenda item is an evidence session with NHS 24, as part of the committee’s on-going scrutiny of national health service boards and special boards.

I welcome to the committee from NHS 24 Dr Martin Cheyne, who is the chair; Angiolina Foster, who is the chief executive; Stephanie Phillips, who is the director of service delivery; and Dr Laura Ryan, who is the medical director. I wish a good morning to you all.

We will ask questions in a prearranged order, because that works best in a virtual meeting of this kind. I will start with the first set of questions, after which I will ask each committee member in turn to ask their questions and invite witnesses to respond. I will generally invite one witness to respond. If others wish to offer additional responses, they should indicate that by typing “R” in the chat box.

I will start by considering the position of NHS 24 in relation to the NHS generally. Clearly, NHS 24 is a national service that deals with a broad range of health conditions. I guess that it deals with pretty much every other part of the NHS in one way or another.

Do witnesses agree with the proposition that NHS 24 sits in a position that is useful for surveillance of the rest of the NHS? If so, in what ways is that true, and to what extent is the position utilised? How does the organisation feed intelligence or views to the rest of the NHS ? We will start with Dr Martin Cheyne.

Good morning, convener. I thank you for the invitation to attend this morning’s meeting. NHS 24 does, indeed, have a very unique position and role to play in the wider system of the NHS. We are very data rich, in that we serve the population of Scotland. We have a collection of data that is used by Public Health Scotland to enable it to analyse and inform health services and service delivery.

Although we are unique—indeed, we have become more unique in the past six to nine months because of the data that we have collected during the Covid pandemic—we certainly have information that has enabled the NHS and Scottish Government officials to analyse and inform forward planning.

Does Angiolina Foster want to add anything on the interrelationship between the intelligence that NHS 24 provides and the direction or advice that it receives from elsewhere in the NHS to make best use of that?

Absolutely. One of the things that characterises NHS 24 is the range of channels through which we deliver our services, which we do principally through telephone and a number of digital sources. As my chair, Dr Cheyne, explained, that means that we are very data rich, because so much of our interaction with our callers and patients is recorded in one way or another.

I will quickly give two examples of the services. Our 111 service is a strong example of our telephony-based services, and NHS Inform is a strong example of our digital services. Both those services are being used to feed intelligence to other parts of the wider system, exactly as you have suggested, convener. I will give a couple of examples of that.

For wholly understandable reasons, much of the focus in the public narrative around the pandemic is on the requirement for intensive care capacity. However, because NHS 24’s service comes much earlier in a patient’s journey, our data acts as a lead indicator. For example, for the purposes of predicting a second or third wave, our service-demand patterns will begin to show demand some weeks ahead of an intensive care unit peak. That is a volume indicator.

Equally important is that we can, at geographic level, use the data from our call patterns. We share that with Public Health Scotland, among others, to help public health colleagues to anticipate and predict very localised outbreaks.

Those are just two examples. The committee might want to hear more detail on that from Laura Ryan, our medical director, who leads on engagement with public health professionals, and would, I am sure, be happy to expand on that.

As Angiolina Foster has outlined, we have worked very closely with Public Health Scotland over the course of the Covid pandemic. Prior to that, NHS 24 intelligence and data went into the unscheduled care data mart, so data sharing is not something new to us. We use it for live service monitoring and planning, and strategic planning. An example is mental health services provision. We noticed over the course of the pandemic that mental health services provision had quite rightly been expanded; our intelligence made clear the demand for our mental health services.

On our data on equality and diversity, we became aware that we had to make information, guidance and our 111 service accessible. As we have done that, we have developed dashboards of data that allow us to monitor and report on that intelligence. That digital information, as well as information from our 111 service, is shared with Public Health Scotland to ensure full and in-the-round gathering of data and sharing of intelligence, with a narrative.

Good morning. I have several questions on evaluation of your service. What should the public expect from NHS 24?

The public should expect a wholly accessible, clear, reliable and trustworthy clinically assured service. Evaluation clearly underpins your area of interest; we evaluate our services on several levels. Structured evaluation is an inbuilt part of our service development process, which I will illustrate with an example.

In March 2019, we launched a new mental health service and after six months of operation there was a structured evaluation. More often than not, evaluation is, for reasons of objectivity, carried out by an external party, as you might expect. The subsequent expansion of that service would not have happened had the evaluation and feedback not demonstrated the strong appreciation, value and so on of our service. Evaluation is inbuilt and is very structured.

Evaluation also works at a more organic level, which is every bit as important. That involves our day-to-day interactions with our public, our patients and our partners in the delivery pathway, and it happens live. We listen to many evaluations extremely carefully and we aggregate them in order to hear what the thematic messages might be.

There is another important part of our evaluation work. Because we deliver through a number of channels, the same service can be available to the public through different routes. We very carefully analyse the effectiveness and the value to the public of the different routes.

A specific example is our Breathing Space service, which is a compassionate listening and advice service for people who are experiencing low mood and anxiety. That is available through the telephone and on web chat. My colleague Stephanie Phillips, who is our director of service delivery, might wish to expand a little on that, if the example is of interest to the committee. We see different demographics coming through the two channels, and we see different levels of need coming through them. Through evaluation of the channels, we are learning an important point about potentially more accessible routes for delivery of the service for certain sub-groups in the population. That is a level of nuancing that we are working on almost constantly.

I will pause to see whether that has been of help, and whether the committee would like my colleague to expand on the web chat versus telephone evaluation.

Thank you for that. It was very helpful.

You have touched on my next question, but perhaps you can give a few more examples. Are you basically saying that external evaluation helps your organisation to learn and improves it? Is that a fair summary of your comments?

Absolutely. That is a perfect summary. We have a small team in the organisation that is engaged in quality improvement work, and we have a patient-experience team that draws proactively and responsively on feedback from our users. All that feeds into our thinking on improvement.

I want to move on to other questions about evaluation, and to take you back to the early days of NHS 24. As you are aware, there was some criticism then about delays in answering calls and staffing problems. Have those issues been fully resolved?

The very high-level answer is yes. I point out that the difficulties preceded the tenure of colleagues who are at committee this morning, but we are aware of that background. My understanding is that the difficulties related to the setting up of what was, at the time, a radical new service model. All those issues have been addressed.

A core challenge for all contact centre based organisations is what is described in our language as the “call arrival patterns”. It is clear that there are peaks and troughs. Members of the public will find that, if they call at a time when the service is under less pressure, they will often wait merely a matter of seconds to get through to us, but if they call in a period of extremely high demand, they might have to wait a few minutes. We try to manage that in real time with the recording that callers hear. With the 111 service, callers hear a message that gives an indication of how long they might have to wait, and they can make their own decision on whether to call back at a less busy time. We try to empower the caller to make their own judgment and we try to help them to have the best experience.

09:45  

This is my final question. What assessment have you made of the benefits of NHS 24 to the rest of health and social care services? Is the average patient—obviously, that is a difficult concept to quantify—aware of the architecture of the NHS? Are they aware of when they should telephone the general practitioner, and when to go to an accident and emergency department?

You will be aware that, in England, the problem arose from a minority of people who were using A and E disproportionately. I know that there have been studies on that. Do you face a similar issue in NHS 24?

That is such a good question. You have put your finger on a real issue for us. It is a big and, arguably, unfair ask of the public to work out exactly the most appropriate access routes across the entire health and care system. First, the onus should be on the various providers, including NHS 24, to make access routes as clear and simple as possible.

Secondly, it is for us, as a system, to make the quality of public communication and explanation as good as possible, rather than expecting the public to navigate an inherently complex set of choices. Therefore, a key role for NHS 24 is to guide people through the system.

NHS Inform is used by many citizens to work out where best to access services. That is a key role that we play. I ask the committee to appreciate that, in normal times, services are in development, so it might well be that the correct access route for the public changes as services are brought on stream. That has been even more the case during the pandemic.

I illustrate that by saying that, before the pandemic, 90 per cent of NHS 24’s 111 case load came to us in out-of-hours periods, which is as the system was designed. As was alluded to in the question, GPs are the principal port of call for citizens in in-hours periods. I point out that out-of-hours periods account for 71 per cent of the week—a big chunk of the week.

On 23 March, and in direct response to the pandemic, NHS 24 has also been the front door for Covid-specific assessment both in hours and out of hours. That has been done in order to give the public an unmissably clear and accessible route into Covid clinical assessment. It was also—this alludes to the first part of the question—a way taking pressure off the wider primary care system by drawing Covid clinical assessment towards a national service.

The other thing, in a similar vein, that NHS 24 has done in response to the pandemic is the setting up of a non-clinical helpline—an 0800 number that is available nationally from 8 o’clock in the morning until 10 pm, seven days a week. It is not 24/7, but the opening hours are long. It deals with general inquiries about Covid.

I am conscious that I have not yet picked up on the detail of the question on evaluation of the benefits to the service. I am happy to do so, but I am conscious that I have spoken at length. I will therefore pause to check that my comments have been helpful, and then I can pick up on the question about how we measure the benefits to the wider system.

Thank you. That was a very full answer. I am conscious of time, and other members wish to come in, so perhaps you could drop a line to the committee.

I will do so.

My question is around performance targets and relates to your answers to David Stewart’s questions.

NHS 24 provided the committee with a summary of performance against its targets. It shows that NHS 24 is meeting most of its targets, but the area of poorest performance relates to the time taken to answer calls. Will you expand on the reasons underpinning the missed targets?

I will start the answer, but the committee might find it helpful to hear from my director of service delivery, Stephanie Phillips.

I reassure the committee that all our clinical targets are not only met, but exceeded, which is an important patient safety observation. You are absolutely right that the targets that we have missed relate to the time taken to answer calls. There is an important patient priority that sits underneath that, which allows me to refer back to the earlier discussion about evaluation.

We talk to our user groups all the time about what is important to them in our services. A little over a year ago—possibly 18 months ago—we did an important piece of research with our callers. We asked them, “What is more important to you: to have the phone answered extremely rapidly—in seconds—or, once you get through, to be dealt with in one single transaction?” Please bear with me while I explain that, regardless of high levels of demand, in order to answer the phone in seconds, which can be done, the service requires to quickly deal with the immediately presenting need and put the patient in a queue for a call back. That was the key feature of the previous operational model—there was a rapid response, and the patient was put in a queue for a prioritised call back.

The strong message from our public engagement was that the unequivocal preference of our patients is to be dealt with without the need for a call back. In our dialogue with them, we explained the trade-off between speed of answering and not requiring a call back, and they clearly said that they would rather wait a little longer for access to the service in order to be dealt with in one transaction. That is an important underpinning factor. For that reason, we and the sponsor department in the Government are reviewing the target in order to identify a target that better reflects what I have just explained.

I will pick up on the points that Angiolina Foster has made. We recognise that the average time taken to answer calls is a key measure. However, in recent months, the challenge for us has been the sharp increase in call volumes, which has a direct impact on our capacity requirements as an organisation. As Angiolina said, that was driven by a discernible shift as we took on the role of the national access route into the Covid pathway. We saw a shift from predominantly out-of-hours provision to increased in-hours activity, and we had to shift our workforce and capacity to accommodate that. That is another factor that is part of the consideration.

As Angiolina Foster said, we manage the process in real time. We make use of up-front messaging, which means that, when a call is answered, callers are advised how long they might wait. We also encourage people to take decisions at that point, such as whether they could access information through NHS Inform. Callers might choose to access that route first.

We try to keep the public and callers informed at all times when they come into the service, but clearly that remains a challenge. As we have moved towards the new model and tried to focus on the overall patient journey time, one important thing that we have seen is a significant reduction in the total time for which people engage with NHS 24. We are putting minimal numbers of people in a queue, and we now manage the calls in a single transaction more than 90 per cent of the time, which is a significant shift from where we were previously.

The data shows that, between 8 and 9 per cent of calls are abandoned altogether. What happens to abandoned calls? Can you call those people back?

One thing to say up front is that the abandonment rate is not always reflective of a bad thing. As I said, the first message that someone hears when they phone NHS 24 is that, if they have a life-threatening emergency, they should put the phone down and dial 999. We encourage people to go to the emergency services if that is appropriate. It is important to point out that we are not an emergency service.

As I said, when callers come in during the in-hours period, they hear a message that encourages them to think about contacting their GP, if that is a more appropriate route. We also try to route people to NHS Inform. It is about choices that people make at the start of a call.

The abandonment rate is directly linked to levels of demand. I do not want to get too technical, but there is a correlation between those things. Clearly, at times of acute system pressure when callers are waiting longer to get in, they might choose to abandon. However, we monitor the volumes of people who try again and we can track and analyse that information. We can be assured that there is a degree of safety, because we know when people have attempted to recall. We cannot call them back, because we do not have a connection with them and we do not have a number to call them back on, but we can track whether someone has attempted to come back into the service.

We monitor the abandonment rate, as that is a fairly standard measure of contact centre performance, but we are cognisant of the fact that it is not always a bad thing if somebody has abandoned, because they might have made the right choice rather than hanging on for us to answer.

I want to ask about staffing. NHS 24’s most recent annual review said that staff attendance was at 92.6 per cent as opposed to a target of 95 per cent. That is in your annual report, but in paperwork that you have provided to the committee, we see that, in some quarters since 2019, the figure has fallen below the target again. For example, in quarter 2 of 2020, it was 93.1 per cent. Can you explain what that is all about?

I say up front that our attendance levels are not as good as they need to be, and that the issue is a key priority for the board and our executive management colleagues. There are a couple of historical systemic or structural issues, which I suggest Stephanie Phillips explains to you.

I will give a more up-to-date sense of what we are doing at the moment. We have a very detailed action plan, which has been constructed in collaboration with our staff side, because it is clear that our staff side needs to work well with management on such an issue. Our partnership colleagues on the staff side are wholly supportive of the actions that we are taking. We invited a critique of the attendance management action plan by our internal auditors to put a bit of stretch into it, and they gave us some very helpful comments. Therefore, we have further strengthened the plan.

10:00  

We have also taken very seriously the fact that attendance management is not all about the human resources rule book; it is also very much a staff wellbeing and support issue. A contact centre environment can be very pressured, so we need to be very supportive of our staff, as well as firm where that is appropriate.

There are two things that we have changed in the past year or so in order to address the structural issues that we believe contributed to that situation. With the convener’s permission, I suggest that Stephanie Phillips explain those two things to the committee, because they are pretty fundamental to our work. At the moment, things are getting better in the area—they are moving in the right direction—and we have set a further 2 per cent improvement target.

It is important for me to reflect that, obviously, one of the biggest challenges for us is that we work primarily on a shift basis, and a lot of the shifts that our staff work are the less favourable ones—out-of-hours, evening and weekend shifts. That is a factor without a doubt. From listening to staff, we gained an understanding of the fact that shift working and the shift arrangements that we had in place were quite a driver of absenteeism.

A contact centre can be quite an isolating environment. People go in and plug in, and that is their day. We recognised that we needed to create a sense of teamworking—to really think about how we could bring staff together to work in discernible and identifiable teams. The shift review that we undertook last year, which took us 18 months to do and involved 900 staff, and was therefore quite a significant undertaking, was geared towards aligning staff more closely with one another. We aligned them not only with the team that they would work in but with their manager, and created time for interaction with and support from their manager and their peers.

There was a real desire and intent to create a learning and working together culture and discernible teams in the organisation through that review. That included building in protected time at the start of shifts and within rota patterns for development, learning, sharing and general wellbeing. We have expressly built that into the patterns that we have in place.

My question is for the chief executive. If we take on board all the challenges that you have said you face, and accept the figures that you are struggling with, how do you propose to deal with the added pressure? You are going through a major recruitment drive to prepare for a potential second wave of Covid-19. How are you dealing with that, knowing the challenges that you already face plus the extra challenge? Where are staff being recruited from?

Two main staff groups are relevant to that question—our call-handling staff and our nurses. The answer is quite different for the two groups.

We have found it extremely easy to recruit call-handling staff successfully for the expansion to the numbers that we need. The sad truth is that that is a reflection of the deeply difficult labour market facing the population. Large numbers of skilled people with first-class customer care skills are without jobs at the moment. People have been casualties of some of the economic impact of the pandemic, and we have been the beneficiaries of that. In the expansion of call handling, our challenge has been less around recruitment and more about the logistics and time pressure involved in training those staff at the rate of knots that is required.

Our recruitment of nurses has also been relatively successful so far, but that is a pressure point across the entire health and care system, as I am sure the committee is aware. We have to work harder to find our nurses. In recent months, however, where appropriate we have been very successful in borrowing nurses from other health boards—nurses who have found themselves stood down in certain areas of service. There has been good sharing of that key clinical capability across the system.

In the past few months, we have also brought other clinical disciplines into the organisation as we have developed the service in response to the different needs of the pandemic. There has been good permeability between different health boards to move our scarce clinical colleagues to exactly where they are best placed.

I have two final questions on the points that you raise. How long does it take to train staff and what will happen to them in the mid to long term when the pandemic subsides, and how many redeployed staff has your organisation benefited from during the pandemic?

I will take the question on what will happen first. The answer depends on which area of our service staff have been recruited to work in. We anticipate that the expansion will be permanent in some areas—for example, the expansion of our mental health hub to a 24/7 service, which is the example that I mentioned earlier in relation to the role of evaluation. We anticipate that the population’s need for that service will not diminish in the foreseeable future and that those staff are therefore likely to be with us post-pandemic.

However, a number of the staff who have been recruited for the increase in call-handling capacity, for example, are on temporary contracts and they wholly understand that. What happens to them will very much depend on where the service model and pressures land at whatever point we decide that the country is emerging from any final wave of the pandemic. It is not possible to say with any certainty or reliability exactly what proportion of staff we will keep and for what proportion we will need to end their temporary contracts.

The point on how long it takes to train is different depending on which bit of the service staff join—my colleague Stephanie Phillips could give you some detail on the matter—but the training is intensive and of quality.

I personally do not have the number of redeployed staff at my fingertips, but I am happy to follow up with a note to the committee so that I do not guess that number but give you a wholly accurate figure.

That would be helpful. Thank you.

I want to differentiate up front between what normally happens and what has been happening throughout the pandemic, during which we have brought in a considerable number of additional staff into the organisation. Normally, we have a four-week training programme, which is a mix of two weeks of classroom training and two weeks of supported working in what we call protected pods, in which staff work on the floor and deal with live calls under enhanced supervision. That programme reflects the need for call handlers and clinicians to be able to deal with, and manage, anything that comes into the 111 service.

During Covid, we operate one single clinical pathway—the national pathway—so we have brought in additional capacity to provide it, and condensed the training period to reflect that need. We now train people in one week, during which we teach them how to use our system, because the additional staff are not required to deal with anything other than that one pathway and they are supported to do that.

I have a couple of questions on digital exclusion or, more positively, digital inclusion. The submission from NHS 24 said that there are a number of ways in which existing services are being enabled online and mentions the growing role of the provision of digital services.

A number of examples have been provided: translators from NHS Greater Glasgow and Clyde and NHS Lothian are being brought in to help translate Covid public health information; the NHS Inform website has expanded its availability of translated material; and NHS 24 worked with the community to create a glossary of terms to be used for translation, taking account of local dialect and nuances in language.

Are there particular groups of people at risk of exclusion from any of those digital services? What can be and is being done to engage people who might be excluded, such as black, Asian and minority ethnic people, Gypsy Travellers and others who might not necessarily have digital access?

We have a small but passionate and energetic team in our organisation whose core focus is participation and equalities. That key group engages with members of the public across all those groups at risk of a range of sources of exclusion, of which digital exclusion is one, and actively and constructively engages with the many representatives of that wide range of interest groups and potentially excluded people.

In the digital context specifically, our online NHS Inform content is, at today’s date, available in 11 minority languages, many of which pick up the BAME grouping to which your question referred. In addition to those 11 minority languages are British Sign Language, easy read and audio files, which reflect our engagement in addressing exclusion through disability as well as potential exclusion through race and language. The team that I referred to also actively engages with the Gypsy Traveller community and its representative groups, so that community is also within our range.

10:15  

Although we work hard on inclusion and on closing down any risk of digital exclusion, it is not the job of my organisation to attempt to fix the root causes of digital exclusion single-handedly. There is a national issue with connectivity. The most recent programme for government included a clear commitment to address infrastructure at a national level.

Digital access can address other forms of inequality. For some individuals, travel to a clinical site for a consultation might pose financial hardship due to the cost of travel. For someone with a disability, taking public transport to a clinical site can be a major issue. For those people, the offer of a digital route is welcome and can provide access to advice that they might otherwise not have been able to secure for themselves.

Another, more subtle area is that there can be forms of emotional and psychological exclusion. For some areas of need, particularly in mental health, some people feel unable or disinclined to articulate their issues face to face or even by telephone. However, when they are offered a digital channel, that provides an access route through which they can reach out for the help and support that they need. Digital channels offer an interesting mixture of risk and opportunity.

In addition to what Angiolina Foster just outlined, it is also worth describing the benefits that come for everyone when we recognise potential digital exclusion and respond to and provide for that, particularly during Covid.

Telephony is always an option for the public. We recognise that 85 per cent of callers phone us on a mobile, but the option to call us from a land line remains. That option continued during Covid, even though huge numbers of those who accessed our services did so through nhsinform.scot.

I will highlight two other examples. Digital development benefits all patients. We can now prescribe remotely and share the record with community pharmacies. No matter who you are or how you access 111, your prescription can be sent by clinical email, with clinical detail that the caller has shared. That ensures maximised safe prescribing and the best patient experience.

We have also identified groups of people who did not have any digital access or who could not use the technology for some reason. Because NHS 24 is positioned at the very start of the patient journey, we recognised that those people needed appropriate access to signposting for testing. We collaborated with our partners to make arrangements for that group of people who could not access signposting for testing via digital means. We speedily passed those people on to our partners so that their needs could be responded to and so that they would not be delayed in the system, either digitally or through the telephony routes that are normally used.

I have another wee question about the public’s involvement in designing the services. I am wondering how the public are engaged. The NHS 24 submission states:

“NHS 24 had the opportunity to accelerate the GP Web Services programme to increase the availability of GP Practice websites to enable their local populations to access local information”.

Do you have any information on how many GP practices participated in that programme, with NHS 24 supporting them to widen their website provision to include education, for instance?

I will start by picking up on the question of how the public are involved, and Dr Ryan can pick up on the point about GP websites.

On the question of how the public are involved, NHS 24 has adopted the Scottish approach to service design, which is a four-stage process. The first stage is called discovery, which is a little bit of jargon that refers to talking to our customers. That is an in-built part of how we would start any process for either creating a service from scratch or redesigning an existing service. We would sit down with our user groups and the public and make a point of engaging not only with people who use our services but—importantly—with those who do not. We believe that, in a service design moment, it is just as important that we listen to the people who, for some reason, are not yet accessing our services.

One example of where good-quality engagement with the public has really improved a service is NHS Inform. In 2016, the service was refreshed, with intensive public input. Before the refresh, the number of visits to the NHS Inform site was between roughly 30,000 and 40,000 a month. After the refresh, over the following months—right up until Covid, to give you a more representative level of usage—the monthly usage was routinely hitting 4 million visits. With good user input, everything—design, accessibility and value—is improved.

Perhaps Dr Ryan can come in on the point about GP websites.

The gp.scot resource was developed to enable us to collaborate with the British Medical Association and GP colleagues to ensure that the front-facing element of primary care and general practice, which the public recognise as their front door to urgent care, gives people access and choice via channels to access primary care. As we know, that supports the GP’s role as the expert medical generalist, as well as supporting the multidisciplinary team and the provision of information in that regard.

As Angiolina Foster described, our design is user centred, engaging not only with citizens and patient groups but, critically, with our partners and the people who deliver that care to patients. Patients want to know that their clinicians and the supporting teams have been involved in designing a service for them.

To go back to the original question, the initial plan was to implement the initiative in 30 practices but, during Covid, we have been able to scale that up to 60 practices. That specifically allows for alignment and visibility so that the end user—the patient, or anyone who is using the practice on the patient’s behalf—can immediately access all the NHS Inform resources. The platform also enables the NHS Near Me service, which offers the ability to consult remotely with patients. As we know, when that approach is chosen by patients, it is a very effective means of interacting clinically with them.

Ultimately, it comes down to the realistic medicine approach and what is important to the patient. We are expanding channel choice and meeting the demand for digital access while retaining the benefits of face-to-face contact for those who need it.

I have a couple of questions about Covid-19. Angiolina, you described the evaluation of the NHS 24 service. Have you seen an increase in activity at the Covid community hubs recently, and might that indicate that there is a second wave?

As we have gone through this pandemic, we have seen different patterns come through, both in our part of the patient journey and in the Covid hubs. At the moment, there is not, to my knowledge, a peak coming through the Covid hubs. However, as I tried to explain, as a lead indicator, an increase in activity in our bit of the service might begin to show.

Perhaps Dr Ryan would like to expand on that, as she is our key interface with that part of the service.

As Angiolina described, we have seen demand increase at different times during this pandemic. Initially—quite understandably—when there was a public appetite for information and a certain amount of worry, there were high volumes of calls. Because of the nature of those calls, we were able to give a lot of self-care advice. That, in turn, meant that only sicker patients were referred to the Covid hubs. We self-cared an average of 25 per cent of callers during the initial wave, but at times of increased demand 50 per cent received self-care.

Another recent peak in activity came when children returned to school. There was a similar pattern to before, with an increased number of calls. That was probably because of the attention and focus on children going back to school. Again, we received very high volumes of calls, but a very high number of people received self-care.

During the pandemic, we have monitored both unscheduled care and Covid outcomes. We have done so for safety reasons and because of the impact on our partners—we realise that Covid hubs and community assessment centres are staffed by a very precious resource. Nonetheless, we need to balance that impact with the risk to patients.

In the early phases, we had an initial requirement for our partners to call patients with a less urgent need back within four hours. However, as time went by that number began to decline and the figure for the one hour outcome began to increase again. It is worth noting that we recorded all the data about patients who were deemed to be “at risk”: those in the shielding group and the flu vaccination group.

We are working with our partners to establish the current demand and impact on Covid hubs. I will probably need to get back to you with our report on that. However, one of the groups that we hear from at this time of the year is people who are post-vaccination. That has the potential to make Covid hubs very busy, but taking an evidence-based approach and working with partner experts has meant that we have been able to come up with a pragmatic approach to that group that means that we are supporting traffic to the Covid hub.

It is interesting that you have seen an increase in traffic due to flu vaccinations, for example. We will have a massive need for more people to have flu vaccines.

Are you seeing any trends, such as a drop—or, conversely, an increase—in calls regarding particular conditions aside from Covid? For instance, are you having more calls related to mental health conditions? Obviously you will be monitoring trends in increases or decreases in calls about particular conditions.

10:30  

As I discussed earlier, we have aligned our Covid pathway to public health data, to allow the patient’s journey to be visualised from beginning to end. That allows a continuous stream of data on the group who, due to a range of conditions, would normally get the flu vaccine, and the shielding group. We have been able to monitor throughput on that.

Five per cent of the people who call us have chronic obstructive pulmonary disease. As we know, that is a group that we need to be careful about, given their respiratory risk.

In answer to your question about normal volumes of callers, I would say that, as well as Covid pathway monitoring, we have consistently been monitoring our unscheduled care loads. That would be the people who phone for reasons other than Covid during out-of-hours periods. Constant monitoring of that has demonstrated that we have not seen any change in call patterns. For instance, we have not seen people presenting with conditions later. The profile of call reasons has pretty much remained exactly the same, and we expect that to continue. Obviously, we will monitor it in relation to winter illnesses.

We have the data. We have flagged the Covid records and we will keep an eye out for particular conditions. That intelligence is extracted hourly to the Public Health Scotland database.

We are hearing about more and more people describing symptoms that are labelled as “long Covid”. Are those patients calling NHS 24 or looking for information on NHS Inform, or are they going to their GP?

Long Covid is a very hot topic—I suppose that is one way of putting it. My understanding is that those patients access services through their GP. It is an area where patients have an understanding of appropriate access and who best to speak to, which would normally be their GP.

Our approach to clinical triage is to assess each person according to their needs, on a person-centred basis. If, through our clinical triage, it was recognised that someone potentially had symptoms that were persistent but did not require referral at that time, they would be directed to their primary care physician, who knows them best and has their medical records.

Good morning, panel. Thank you very much for your submissions.

I want to follow on from Emma Harper’s questions. You will know that the Government is monitoring four areas of harm from Covid-19, two of which are direct health impacts and indirect health impacts. In your answers to Emma Harper, you talked about Covid symptoms. I am more interested in people being directed to dental services, GP services and so on, because of lockdown.

I know that Emma Harper touched on this. Has NHS 24 seen an indirect health impact of Covid-19 and lockdown in that regard? If you have, where is it most noticeable? Emma mentioned mental health. Has there been any other negative impact on people’s health when you have had to direct them elsewhere?

Yes, that is the case principally in mental health. As the committee may expect, there are much higher levels of anxiety in the population. The root cause is a mixture of economic worries due to furlough or job loss and family and relationship stresses and strains that are, if not triggered by lockdown, certainly exacerbated by it. I am very sorry to say that there is a higher level than usual of people with suicidal thoughts—that is a discernible and alarming trend. The short comment on that is that a range of internal wellbeing issues are coming through starkly in our work.

You are right to mention dental services. A key part of our service is the Scottish emergency dental service, which runs as part of our out-of-hours service. It is one of the options available through our 111 service. Because of the standing down of community dentistry for safety reasons, we rapidly changed our working model and we benefited from some dentists who could not work in the community working for NHS 24 on a pro bono basis, and with no public thanks. This is a good opportunity for me to give them credit and thank them. That allowed us to offer an enhanced service through our digital and telephony routes with the additional workforce there, and that has been a good model. Because that has been so well received by the public and clinicians, we are now running that to evaluate it as a possible longer-term service change.

I think that Dr Ryan would like to contribute on the wider Covid harms point.

I will build on Angiolina Foster’s point about the dental service and an earlier point that I made about expanding our service in response to user feedback. Working with our partners in the community, we have expanded prescribing in the dental group. Not only did patients get that extra level of triage, but—although dentists were not able to work for safety reasons in the community—we made the patient experience and journey quicker through the system in general, because dentists were able to prescribe through NHS 24.

The other benefit was that dental staff were able to directly refer to advanced services in our hospital system—for instance, to maxillofacial services. The addition of dental staff expanded our advanced clinical support team in NHS 24, advanced prescribing and improved the patient journey.

You talked about dental services. Emma Harper mentioned patients with COPD. Has there been an increase in more severely ill patients presenting to the service with Covid-19?

Sandra White caveated her question with reference to Covid-19. Through our data and intelligence, we monitored that daily and, as I said before, shared it with national data pools so that the patient journey could be monitored all the way through. NHS 24 understood from the very outset, working with the Scottish Ambulance Service, that we needed to manage resource appropriately and get the safest outcome for patients. Over the course of the Covid pandemic, we have seen a gentle increase—but nonetheless an increase—related to Covid time trends as people got sicker. That aligns with the increase in one-hour referrals in the Covid hubs and, although we had a very high four-hour referral figure initially in the Covid hubs, as the pandemic progressed, probably within three to four weeks of the first wave, we began to see a trend of more unwell people. All that data goes to Public Health Scotland. Part of that was about measuring at-risk groups—people who have chronic disease or disorders who would normally get the flu vaccine or those extremely at-risk groups that were shielding. All that data was being monitored.

Thank you. I have one more question. I do not know how you might want to answer this, but do you think that the restrictions that we have in relation to lockdown and Covid-19 are striking the right balance between minimising direct health impacts and indirect health impacts? That might be an unfair question.

I have to say that I am tempted to dodge it, if I may, given its complexities and its policy nature. I think that that is not a question for us to have a view on, if that does not sound too defeatist on my part.

It is very honest. Thank you; those are all my questions.

I would like to put a variant of that question to Martin Cheyne. Does the board of NHS 24 feel that its role in dealing with direct and impact impacts is properly reflected in the tasks that it is being asked to undertake?

NHS 24 has worked very closely with Scottish Government colleagues to try to ensure that we respond to the demands of the service that we have seen. This is a rapidly changing situation, and the board’s governance mechanisms over the period have been slightly enhanced to ensure that we are responsive and fleet of foot, so that we are able to respond to the changing situation.

There have been lessons to be learned as we have gone through this. We are all aware of the redesign of urgent care programme that is coming forward, which we as an organisation are participating in actively. We see clear benefits from that.

There will be a time to review the lessons learned from all of this—although that time might not be now, we will have to do that. We have done some work on lessons learned on the governance side; we have been part of a national group, through which all health boards have been reporting to Scottish Government colleagues on national lessons that have been learned so far, and that will continue.

My answer to the committee is that it is an evolving situation. We are receiving all the support and help that we have been asking for, from Scottish Government colleagues, health boards, territorial boards and other national boards. We are very grateful for that.

My questions are about mental health. The panel has helpfully addressed some of the issues in answers to the questions that were just asked. You have provided a striking graph, which shows a fourfold increase in mental health calls since the onset of lockdown, and you have covered what those have involved. How, as a service, has NHS 24 adapted to address that very steep increase in demand?

I will start, but I might suggest that my colleagues follow on.

As a point of clarification, we run mental health services that are clinical and services that are less clinical, in the formal sense of that term. The mental health hub that we have mentioned, which has gone from operating four nights a week to operating 24/7 over a relatively short period of time, runs on a psychosocial model. In other words, the approach recognises that, often, people are not clinically unwell; their issues might be, at root cause, loneliness, isolation and so on. Our response has been to develop a skill set in the organisation that is designed around the more psychosocial model—our colleagues are called psychological wellbeing practitioners.

In other areas, there is a rather more clinical focus. There is a resourcing issue in both instances—I am looking to my colleagues, particularly our director of service delivery, Steph Phillips, who might like to contribute.

10:45  

Thank you. It is fair to say that there has been quite an expansion in our offering in the area. As Angiolina Foster said, the hub has gone from being available four evenings a week to being a 24/7 operation. Some of the increase in demand reflects that additional availability, but undoubtedly there is a clear and evident need to access the service in and out of hours, so we will look to maintain it—without a shadow of a doubt.

We have been heavily involved with a number of partners in the evolution of our mental health services over the past couple of years, and particularly in response to Covid. In June this year, we became a level 1 responder as part of the distress brief intervention programme that is being rolled out nationally—there is a commitment in the programme for government to sustain DBIs. We get about 300 referrals a month through that system, which means that we can link to and help people to access services locally, in their communities.

We have been doing collaborative work with Police Scotland over the past few months. That work has come to fruition and enables callers who access the 101 service to be routed to our mental health hub. Often, a police officer turning up at someone’s front door is the last thing that is required in such a situation, so we have worked closely with Police Scotland to develop a pathway whereby our hub is able to take the call. More than 65 per cent of those calls are not being referred anywhere else in the system, so we are managing that demand very successfully within our mental health hub.

Again, we get about 300 calls a month in Scotland through that system, so we can see that it brings strong benefits across the wider system beyond health—I am thinking about the resources that Police Scotland requires in dealing with such activity. We are keeping people out of emergency departments, too, when those are not the appropriate places for them.

Thank you. I am grateful to Stephanie Phillips for addressing not just the non-Covid element of what has been happening over the past few years but interagency working, which I think that we all accept is very important.

Is your approach working? Are we seeing a drop in attendance at accident and emergency departments? You touched on that.

We get roughly 2,000 calls a week to the mental health hub, and fewer than 10 per cent of those result in a 999 call or an emergency department outcome.

The challenge for us now is to understand whether that is new activity or a change in existing activity coming into the 111 service. As part of our work with Police Scotland, we will evaluate the approach and its benefits in terms of police attendance and transfers to the ED. We are confident that we are reducing the requirement for other bits of our system to deal with such calls, because our staff can deal with them in a more appropriate way.

I should add that we are endeavouring to put in place a similar pathway with the Scottish Ambulance Service. Then we will really start to join up the response in a more appropriate way. I believe that that will result in a reduction in attendance at the ED from all three agencies.

I have one final question, on dental services. Sandra White has covered most of the questions that I wanted to raise.

I appreciate that you will have a partial view of this issue and that dentists themselves will have a more direct view. However, what barriers are there to the resumption of full NHS dental services, with safeguards such as appropriate equipment?

I am sorry, but I do not feel sufficiently informed to give you a useful answer to that question. I am not sure that any of us is. I think that we all feel that that is a little bit beyond us, and we do not want to waffle.

Okay; thank you.

You have given us a good insight into the dental side of your operations already; that is much appreciated.

Good morning. We have been looking very much at the issues that the pandemic has raised with regard to putting the NHS on an emergency footing, as it were, which resulted in quite a few services having to be paused, for obvious reasons. As Sandra White alluded to, there is a concern that the Covid restrictions might have led to indirect harm and might have resulted in unmet need in relation to people presenting with other health conditions.

Which services do you think should be at the forefront of remobilisation, and which are under most pressure to restart?

If the question relates to NHS 24 services, you must allow me to start with a point of clarification. Like other health boards, we use the phrase “remobilisation”—we are part of that corporate family, so we adopt the language—but it is a bit of a misnomer with reference to NHS 24 and the pandemic.

As you are aware, our territorial board colleagues had to stand down large swathes of plans, elective procedures and so on, but that was not the case with NHS 24. To the contrary, we were standing up additional quantities of pre-existing services and establishing completely new pathways and services. Therefore, the concept of remobilisation is a little bit misleading, and that will slightly colour my response to your question.

In response to Covid, we did four main bundles of things. We set up the new national pathway for Covid; we stood up the non-clinical helpline, which is the 0800 number that I mentioned; we significantly expanded all our mental health services; and we rapidly developed and expanded all our digital services.

With regard to your question about our priorities, at the moment, and until global and United Kingdom circumstances change, my answer must be that all four of those areas remain core service priorities for NHS 24.

I will look at the issue from another direction. You will be on the front line of calls coming in about medical issues, so you might be able to shed some light on which patients are most at risk, what conditions they have and which are getting worse.

We are trying to put a picture together of the services that have been stood down and the conditions that patients have. We have heard a lot about chronic pain; chest, heart and stroke; heart conditions; and cancer treatment and referrals. You also mentioned mental health. Which conditions most concern you?

I will start our response, but I suggest that our medical director is best placed to give a fully informed response.

We know that there is a top 10 for the conditions that tend to account for the majority of our patients’ needs. Dr Ryan will want to say a little bit more and perhaps tease out for you what those 10 conditions are, but at this stage my strong sense is that they remain a stable package of top 10 conditions.

As Angiolina Foster said, we closely monitor all our outcomes on a daily and, indeed, hourly basis. The top 10 conditions can vary seasonally. In general, they follow that seasonal pattern, as well as abdominal pain, headaches, fever in children and respiratory conditions. From my description, you can see that some of them overlap with Covid. Nonetheless, there is a reasonable public understanding that, in the context of Covid, there are three very specific symptom groups.

Because of the monitoring, we are also able to look at 999 end-points, which might be a good indicator of severity of illness and the presentation of life-threatening conditions such as heart attack or stroke. I can confirm that we have not seen any increase in the number of 999 calls for ambulances for those conditions; the figure remains consistent at 6 per cent. Nor have we seen a clinical analysis in NHS 24 or any feedback that would reflect the fact that people were not presenting with those life-threatening conditions. Nonetheless, I should go back to the point that when people call NHS 24, those two conditions are highlighted at the beginning of our initial voice directions, and at that stage, people might choose to self-refer to an emergency service.

To answer your question, therefore, there are no obvious safety issues around presentation of life-threatening illnesses, and no evidence thus far in relation to the cases that you mentioned, such as chronic pain.

I am slightly surprised, I have to say. Is the data analysis set up to monitor that? For example, we are aware that the reduction in the number of chronic pain clinics is causing specific issues; we are also aware of similar issues with other conditions. Is the data analysis set up to give us that in-depth analysis?

If I may, convener, I would like Dr Ryan to respond to that.

We have what we call keywords in NHS 24, and the keyword comes from what the patient tells us is their main concern or issue when they call. “Pain” is one of those keywords. To again go back to a previous point, if someone needs pain to be dealt with urgently, they will be referred either to the usual out-of-hours routes or, if they call during the day, they will be redirected to their general practitioner. Therefore, there is a person-centred approach. Chronic pain would be part of our clinical assessment but it would be covered under the umbrella of the “pain” keyword.

Finally, I come to finance. I note that your submission mentions the extra costs as result of Covid. Has the Scottish Government committed additional financial support to NHS 24 in the current financial year and, if so, how much?

11:00  

Our year-to-date figures for Covid-related costs are just a little more than £3 million, and we are projecting a little under £10 million by the end of the full year. I need to caveat that heavily by saying that those are based on current service demand patterns and so forth. At the moment, trying to predict even a month ahead feels a little long term. Those numbers may well change as the pandemic progresses. As you would expect, we are in constant dialogue with the Government about those costs. In turn, the Government properly challenges those costs and ensures that we are driving them down as much as we can and offsetting with anything that we may can through an internal financial offset. That all goes without saying.

We have not yet had a formal allocation letter, but we have had indications from the Government that those costs appear to be robust; therefore, we are running our budget this year in the expectation of receiving those funds, which we require for Covid-specific purposes.

Will that allow you to balance the books in the usual way?

Indeed.

If I may, I would like to take the opportunity to clarify a point. It may well have caught the committee’s eye that NHS 24 is in receipt of brokerage. I would like to clarify that although we are in receipt of brokerage it is not for the normal reason of there being an underlying financial deficit—NHS 24 is in balance, in both the short term and the medium term. The brokerage was atypical and was to allow a more value-for-money purchase, several years ago, of a major new information technology platform for the organisation. It would have cost the public purse more to have paid that up year-on-year and therefore, in agreement with the Government, a better deal was achieved. However, for that reason, a brokerage lump sum of £20 million or so was given to the organisation. We are on track to pay that back and we have kept all those payments going in a stable way, as planned. The year after next there will no longer be any brokerage. My main point is that there is no underlying financial deficit, which might otherwise be the assumption when one sees that there is brokerage.

Thank you for that clear explanation. We look forward to receiving additional information in those areas that you have indicated. I thank all the witnesses for their helpful responses and for outlining the work of NHS 24 over time and in the current circumstances. No doubt we will hear from you further in due course.