Public Audit and Post-legislative Scrutiny Committee

Meeting date: Thursday, February 25, 2021

Official Report 612KB pdf

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Section 23 Report

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“NHS in Scotland 2020”

Item 3 is consideration of the section 23 report “NHS in Scotland 2020”. I welcome Stephen Boyle, Auditor General for Scotland. I also welcome from Audit Scotland’s performance audit and best value group Angela Canning, audit director; Leigh Johnston, senior manager; and Eva Thomas-Tudo, senior auditor. I understand that the Auditor General has a brief opening statement.

I bring to the committee our annual report on the national health service in Scotland. This year, the report focuses on the response of the NHS and the Scottish Government to Covid-19. It also includes a brief overview of the NHS’s financial and operational performance in 2019-20.

The NHS has faced unprecedented challenges as a result of Covid-19. NHS staff have worked tirelessly in difficult circumstances to deal with the demands that the pandemic has created, while maintaining access to essential services, which reflects their extraordinary commitment—[Inaudible.]

The Scottish Government had difficult decisions to make about how to prevent the NHS from becoming overwhelmed during the pandemic. During the first wave, non-urgent treatment and national screening programmes were paused. Longer-term risks are associated with some of those decisions, but the Scottish Government needed to create additional capacity for Covid-19 patients. There is therefore now a significant backlog of patients who are waiting to be seen, but the pandemic is on-going. Continuing to respond to that is resource intensive and is taking priority over resuming the full range of NHS services.

The way in which the NHS delivers its work has changed drastically, and many new approaches have been established. Several large-scale initiatives, such as the Covid-19 community hubs, the widespread use of virtual appointments and the procurement and distribution of huge amounts of personal protective equipment, together with the NHS Louisa Jordan hospital, were implemented at pace and required partnership working to an extent that we have not seen before. Stable and collaborative leadership will be required to remobilise and renew the NHS so that it can build on the innovation and learning from—[Inaudible.]

Covid-19 has not affected everyone equally. Those from our most deprived communities and from certain ethnic minority backgrounds are more likely to have been hospitalised or to have died after contracting Covid-19. Scotland’s long-standing health inequalities need to be addressed.

The Scottish Government could have been better prepared, and planning for a pandemic had not been sufficiently prioritised. Improvements that were identified through pandemic preparedness exercises were not all fully implemented. There is an opportunity to learn from that.

Covid-19 is expected to cost an extra £1.7 billion of expenditure across health and social care in 2020-21. NHS boards are being fully funded—[Inaudible.]—but there is uncertainty about the longer-term financial position.

As ever, my colleagues and I will do our best to answer the committee’s questions.

Thank you very much, Auditor General. I invite Colin Beattie to open the committee’s questioning.

PPE was a major issue, particularly earlier in the Covid-19 outbreak. Your report says that, in some instances, NHS boards had to procure PPE directly. Were there any unintended results from taking that direct approach to procurement?

The report says that there were issues in the pandemic’s early stages and that NHS boards had to take direct steps. In general terms, some procurement activity required regional boards and particularly NHS National Services Scotland to use the emergency procurement arrangements that were introduced in March 2020 to recognise the urgency of the situation and the need to go beyond the more standard public sector procurement arrangements. The report recommends that it is important, as matters stabilise, to reintroduce at the earliest opportunity the more general approach to safeguards for procurement arrangements.

We are looking closely at the issue. Through our annual audit of NHS National Services Scotland, we are looking at the detail of some of the contracts, as part of all the arrangements around judgments on best value for public spending. We will report on the specifics in 2021, as we have more work planned on PPE.

Angela Canning will talk about the detail and specifics of health boards’ approach to procuring PPE.

Thank you, Auditor General. As I think we all know, the pandemic has brought unprecedented challenges to Scotland and to the NHS. At the start of the pandemic, there were huge challenges around PPE. There was huge global demand for PPE, and NSS played a key role in ensuring that health boards and social care providers got what they needed. As the Auditor General said, we are planning to do some further work on PPE, and it will be an important part of the external audit of NSS this year, as well.

There is something else that I am very interested to know. In the early stages of the procurement of PPE, we read horror stories about substandard PPE being delivered, with hundreds of millions of pounds-worth coming in through London. Did any of that have a knock-on effect in Scotland? Did we end up having to bear some of the cost of the substandard PPE that was subsequently not used at all?

That is not something that we saw in our work on assessing—[Inaudible.]—this report. However, as Angela Canning mentioned, we still have more work to do. It is probably a bit early for us to be definitive and say that there were no procurement difficulties or value-for-money concerns where arrangements were made for PPE. We will return to that work during 2021, but I assure you that we have not seen that thus far.

Again, we are focusing very much on the early stages of the supply of PPE. Your report refers to the findings of a British Medical Association member survey, which highlighted a lack of access to correct or sufficient PPE. Similarly, a Royal College of Nursing survey found that a fairly high proportion of those working in high-risk environments had not had their mask fit tested and that others were asked to reuse single-use equipment. Has any analysis been undertaken to try to assess the impact of those issues on the health of the professionals and on patients?

[Inaudible.]

Auditor General, will you start your answer again? We cannot hear you.

I will try to wait for the signal that my microphone is live before I speak.

You are right, Mr Beattie: those are incredibly serious issues. If you will indulge me for a second, I will note that the scale of the change in use of PPE—[Inaudible.]—try to illustrate that in the report. Before the pandemic, NSS shipped around 97,000 items of PPE in a typical week. That was the number during February 2020 but, by April, that had grown to nearly 25 million items a week. In the space of six weeks, there was truly exponential growth in the extent of PPE.

It is clear that there are issues. We set out the results of the survey by the Royal College of Nursing and the feedback that the boards reported at the time, which was that the availability of PPE at the earliest stages was not what it needed to be and that there were also issues about the quality of the PPE and the extent to which staff were given the appropriate equipment. That is captured in the surveys, and it was well documented at the time.

On your question about the extent to which that led to health issues for health workers, we have not covered that in the scope of our work yet. My assumption—it is no more than that—is that there will be many reviews of the circumstances of what happened and what would allow the country to be better prepared for any subsequent pandemic. Indeed, that may well feature as part of the public inquiry. We will follow that closely as the Government moves through that work.

This is probably a matter of judgment, but is it actually possible to quantify the impact on health professionals and patients?

That would probably stretch the boundaries of our work. That is perhaps more a question for the Government and health professionals, who are better placed to make that judgment. It probably strays beyond what we, as public auditors, can make judgments on.

I would like to touch on one other area. Paragraph 18 on page 12 of the report says:

“The Scottish Government has been providing PPE across health and social care, free of charge”,

and that it has undertaken to continue doing so

“until the end of June 2021.”

However, the report states that plans are unclear about what will happen in relation to those who were previously responsible for their own PPE supplies and about which groups will be responsible for purchasing their PPE after that date. Is the Scottish Government doing any work to identify the financial impact on those groups and what the consequence might be?

We have tracked the financial cost of that through our work. Angela Canning might be able to say a bit more about our understanding and to share any insight on the Government’s plans.

During the pandemic, NSS’s remit was extended so that it could distribute PPE to social care providers, such as those that run care homes or care-at-home services, and directly to general medical services, such as general practitioner surgeries and community pharmacies. Before that, those bodies purchased PPE directly themselves. The Government has committed to continuing to provide PPE across the health and social care sectors until the end of June this year, but we are not clear whether there are plans to continue to provide PPE for another while or whether we will revert to the circumstances before the pandemic in which providers purchased such items themselves.

I assume from what you have said that, at this point in time, it is uncertain when the Scottish Government will clarify that.

Yes. That is right.

Okay.

I have two questions. The first is about video consultations and the second is about leadership changes. On the first topic, the report highlights digital improvements that have been introduced in response to the pandemic, and it notes that there has been a significant increase in the number of video consultations. Do you have a sense of whether NHS boards expect the demand for remote consultations to continue beyond the end of the pandemic? Have boards made plans to continue facilitating such consultations?

I will answer that first and then I will invite Leigh Johnston to give any insight on future plans.

In general terms, there has been remarkable innovation during the pandemic. We say in the report that there have been about 600,000 video consultations using the Near Me facility. On the face of it, the introduction of that level of innovation in how the NHS conducts its services is very worth while. However, there needs to be a full assessment of where video consultations should be placed in the future of NHS services. NHS boards, in consultation with patients who have used the service, should take a rounded view on how useful the service was, its pros and cons, planning, access to technology and the equalities points that we have touched on in previous discussions.

Our sense is that, although the introduction of video consultations during the pandemic was a worthwhile innovation, a fuller analysis is now needed to see where they should be placed in the future. I ask Leigh Johnson to illustrate the scale of the change in the number of consultations and to say anything that she wishes to add about the Scottish Government’s thinking on where such consultations should be placed in the future.

10:30  

Video consultations during the pandemic increased from about 300 per week in March 2020 to more than 18,000 per week by November 2020. By December, more than 600,000 video consultations had taken place, as we outline in our report. The Government has outlined in “Re-mobilise, Recover, Re-design: the framework for NHS Scotland” that it has every intention of continuing to use that technology.

As the Auditor General has said, some analysis will be needed of who it suits and who would rather have face-to-face consultations, as some people would. However, I think that the opportunities that it offers, for example for our remote and rural communities—[Inaudible.]—a safe environment that suits people.

Thank you for those answers. Auditor General, your point that it needs to be looked at is very valid. I can see the administrative benefits of seeing more patients in a shorter time and better use of clinicians’ time. However, do we know the clinical ramifications of somebody just being seen on a screen versus, for example, the doctor seeing them come into a room with a limp that they did not come in to discuss? Will that be on your agenda?

Will people be able to get face-to-face appointments if they want them? I can imagine there being a slight pressure, as I have experienced a little with telephone consultations. There are things that we might not immediately think about. For example, if an elderly person needs somebody to help them with logging on, there could be some confidentiality issues. Will you be looking at all those things in the round?

That is a really interesting point, Mr Bowman. It is clear that video consultations have happened by necessity during the pandemic as direct access to services has been restricted during the various lockdowns. Video consultations have been a suitable alternative given the circumstances that we have been in. However, you are right that they raise wider concerns about clinicians’ ability to diagnose through physical sight as opposed to what they may be able to—[Inaudible.]. Equally, I accept your point about confidentiality. All those important safeguards will need to be in place.

We will retain an interest in the subject and return to it in our 2021 NHS report, looking more generally at the pace of the Government and the NHS and the steps that they have taken through the—[Inaudible.]—programme. In the report that we are discussing today, we make a recommendation that the use of video consultation be considered and an analysis done, which should involve both clinicians and users of the service, in order to come to a view about where it can best be used and the right balance between video and face-to-face consultations for the future.

Your report highlights an incredible number of leadership changes at senior level since April 2019, with 32 new senior appointments of board chairs, chief executives and directors of finance across 21 NHS boards. How will the Scottish Government achieve its ambitions for remobilisation if there is a lack of stable leadership?

One of our key recommendations in the report is about the importance of stable leadership. At any time, but particularly in coming through the pandemic, it matters greatly that there is stability of both executives and non-executives. When we did the analysis, the rate of change in senior leadership posts in such a short time seemed quite surprising, as it does to you, but it perhaps illustrates some of the challenges that have gone before. We know that the Government is thinking carefully about it.

The committee might want to explore directly with the Government the extent to which it and the NHS are taking steps to provide support and training to new leaders in those senior posts so that the Government can fulfil its ambition through the renewal programme. We will return to that in our work during 2021, but it may be something that the committee wishes to explore more directly with the Government.

Let me suggest a few issues that you might consider. They are whether the recruitment procedures that we have at the moment are fit for purpose, whether the factors that have influenced the high turnover have been clearly identified and whether there is adequate engagement with that challenge at the top level of the Scottish Government.

Those are all valid suggestions. We will undoubtedly follow and track that, report on it and make additional recommendations—[Inaudible.] However, the topic is not particularly new. We have talked about it before and, in recent times, the committee has been interested in exploring leadership in the NHS and the wider Scottish Government. We will certainly return to that, but I think that now is the time for definitive steps and action.

More generally, we cover in the report the importance of integrating workforce planning. Again, that is not a new topic, but it now seems to matter more that, as the renewal of the NHS and care services progresses post-pandemic, there is a clear plan for what that will mean for the workforce at all levels. It is difficult to get away from the importance of clear, stable leadership and the impact that it can have.

We may hear more from the Scottish Government about that. Thank you.

I note that a survey of patients that the Scottish Government conducted—you refer to it in paragraph 27 of the report—showed that the number of people who said they would avoid going to their GP or a hospital decreased from 45 per cent in April 2020 to 27 per cent in October 2020. Do we have figures for the number of people who have actually gone to the doctor compared with the number who did so pre-pandemic, to back that up?

I will ask Eva Thomas-Tudo to comment on that as she did a lot of the data analysis to support the work in the report.

We found that people’s behaviour had changed during the course of the pandemic, as it has for all of us. We look to illustrate that in exhibit 4, which shows the extent of changing presentations at accident and emergency departments and how they have fluctuated during lockdowns and with people’s confidence.

There are undoubtedly wider and longer-term health implications around potential missed diagnosis, and we refer to the Government’s the NHS is open campaign and its importance in that regard. As you rightly say, another issue is the extent of people’s concern and anxiety about presenting at a GP surgery. I ask Eva to say a bit more about the data on that—what we have seen and what it translates to in numbers.

As the Auditor General mentioned, we have seen quite a significant decrease in the number of presentations at A and E departments. That happened during the first wave in particular, and it reflects the significant number of people who said that they would avoid going to GP surgeries or hospitals.

We have not looked specifically at GP attendances, but you can see in the report that, following the peak of the first wave and the Government’s the NHS is open campaign, attendance at A and E departments recovered slightly. It remains below pre-Covid levels, however. We will monitor that in future to see whether attendance gets back to pre-Covid levels.

To me, attendance at A and E is only part of the picture. The first port of call if something is wrong is normally your GP, so I would be interested to know the figures for GP consultations, even if they are video consultations. I am keen to explore whether people are avoiding even contacting their GP. I suspect that the answer is yes, but we will know that only if we can see the data.

We know that, across a range of services, there have been fewer referrals to hospital services. Those referrals largely come from GPs, following consultations. There is an indication that there is an issue with people not making GP appointments when they have certain concerns that they would usually have gone to see their GP about. Again, we will be monitoring that.

That leads me to the issue of excess deaths. Auditor General, you mention in paragraph 24 of your report that the number of excess deaths from non-Covid conditions is up. In exhibit 3, we see that, from April last year onwards, excess deaths due to things such as stroke, cancer and dementia were up across the piece. Going back to my first point, I wonder whether that is because people are not presenting to doctors or hospitals, or because they are just unable to get appointments.

Exhibit 3, which shows the impact of the pandemic, is sobering. In particular, the spike that develops in March and tails off towards June illustrates the point about excess deaths. The potential for missed diagnoses, changes in people’s behaviour, concerns about lockdown, and the perception that the NHS was unable to treat people other than Covid patients might all have been factors in that regard.

We have looked to present that data in the report. As I said in response to Mr Beattie’s question, our ability as public auditors to interpret that, make connections and establish causality is limited. That is probably best left to clinicians and a fuller review of the circumstances around Covid at the time. All the factors that you mention with regard to patients’ concerns about the extent to which NHS services have been open will, no doubt, be considered more fully.

I am sure that you will monitor that. My concern is that the number of excess deaths due to other conditions will go up once we are through the pandemic. That needs to be monitored.

In exhibit 7, which consists of two bar charts, we can see the NHS boards that have achieved their savings targets. Some have not achieved their targets, and some are more reliant than others on non-recurring savings. Last week, the committee spoke to NHS Tayside representatives, who seemed to be quite happy with where they are on non-recurring savings. Looking at your chart, I note that some boards are doing a lot better than NHS Tayside in that regard, and that there are huge variations between the boards that are relying on non-recurring savings. What is an acceptable level of non-recurring savings—if there is one—that boards should aim for?

I recognise the variation, which seems quite stark when set out in the charts. There will undoubtedly be factors behind it. Some of that will be driven by the need to make savings, and the difference between the forecast cost of the operating model and the budget will drive some of those numbers.

More fundamentally—the committee spoke to NHS Tayside about this—I suspect that it has as much to do with the nature of the operating models and cost bases in different health boards, which provide different services to different populations. There will be legitimate reasons why boards do not all have the same levels of recurring and non-recurring savings.

10:45  

There is a wider point about the extent to which the Scottish Government health and social care directorate has a view on that and—[Inaudible.]—position on an acceptable range to deliver financial balance, allowing for the fact that there will undoubtedly be variation between boards from one year to the next.

Your point is fair, Mr Beattie. To have a difference of nearly 70 per cent between NHS Orkney and NHS Ayrshire and Arran does raise a question. I invite Leigh Johnston to say anything that she want to add, as she has looked at this in more detail.

I do not have much to add, other than to say that we have seen this consistently over the years, as the committee knows, in relation to recurring and non-recurring savings. The point is that non-recurring savings are challenging to on-going financial sustainability. They have fluctuated over the years. Increasingly, boards try to increase their recurring savings, but there are fluctuations.

I asked the question just to get some guidance. Our successor committee will undoubtedly keep an eye on the matter. There are massive variations between boards. For example, 84 per cent of NHS Ayrshire and Arran’s savings were recurring, while the figure for the aforementioned NHS Tayside was 40 per cent and for NHS Orkney it was 15 per cent. It would be helpful for the committee to know what figure would be acceptable, or “manageable” might be a better word.

The only thing that I would add is—[Inaudible.]—NHS Tayside last week, when it benchmarked itself, as I recall, with what we could almost describe as a family group of health boards. I would need to check whether it was referring to the figures that we are discussing, which go to the end of 2019-20, or to more up-to-date figures for the current financial year, but its judgment was that there is commonality between it and the other teaching boards.

I think that that is possibly borne out to some extent, but there will always be outliers. NHS Orkney and NHS Tayside, which have similar models, have savings that are not terribly different. However, it is undoubtedly a complex picture. I think that the committee explored with NHS Tayside how that ties in with the NHS Scotland resource allocation committee funding model and what pressure or demands that puts on boards with the need for savings.

We have looked to report the numbers. As you know, Mr Simpson, we have commented many times on the need to move to a sustainable operating model that is less reliant on non-recurring savings. Beyond Covid and the implications of the pandemic, there is now a much wider analysis of what a sustainable operating model for the delivery of services—one that encompasses all aspects of those services—would look like.

The impact of Covid on care homes has been devastating. Sadly, more than 2,000 people have died. Serious concerns have been raised about discharge policies, and trade unions and staff have expressed concerns about care homes being unprepared.

Your report mentions the independent review of adult social care and its recently published report. What is the timescale and scope of Audit Scotland’s work in that area? What will it cover?

Good morning, Mr Bibby. We clearly agree with you about the scale of the pandemic’s impact on our care homes and the very tragic deaths that have taken place, and about the important need for all of that to be looked at in the round, not just by us but by others, to establish the circumstances so that we can ensure that we avoid it ever happening again.

You might recall that, in the consultation that we had with the committee and others on our forward work programme, we signalled that we planned to undertake some further work on the care home sector, particularly in relation to the sustainability of its financial model and the call on public funds. In the meantime, we have seen the Feeley report on the independent review of social care and the Government’s consideration of the recommendations.

The issue remains in our plan, but we are following very closely what a future operating model, if there is one, might mean—whether a national care service will be introduced, what model would flow from that and what implications that would have for health and social care—[Inaudible.]. With others, we are tacking that very closely. We still plan to do work on care homes and social care more generally towards the end of the year. We will continue to engage with the committee as that—[Inaudible.]

It is vital for us that lessons are learned in relation to what happened in our care homes, so thank you for that answer.

I also want to ask about inequalities, which you talked about in your opening statement. In your report, you mention that people from deprived backgrounds and ethnic minority backgrounds have been harder hit by Covid. The Scottish Government’s expert group has highlighted the need for improved data; as you are probably aware, that issue has consistently come up in the committee’s scrutiny. In your audit work, did you see evidence that data to measure long-term impacts was being collected? Was it the right type of data, and was it collected consistently across bodies? Will you undertake future work on the impact in relation to inequalities?

I will start and then ask Eva Thomas-Tudo to come in, as she has done much of our work on data. The impact of the pandemic in relation to inequalities will be a key feature of our work across a range of factors. We have already mentioned care homes and, with the Accounts Commission, we will report next month on education outcomes, so we will capture further aspects of the pandemic that involve children and young people’s education. The impact in relation to inequalities will feature in all our reporting as we move forward.

On data, in paragraph 34 we report some of the stark differences in the pandemic’s impact. People have said many times that the impact has not been universally felt and that it has been more significant in the most deprived communities in the country. Paragraph 34 presents the stark differences in death rates between our most affluent and most deprived areas. It also refers to the disproportionate impact that the pandemic has had on our black, Asian and minority ethnic communities. We make reference in the report to the vital need to understand better the reasons behind that as our health and care services renew and recover, and take the necessary steps to take to avoid it happening in the future.

Eva Thomas-Tudo might wish to say more on the quality of the data and the extent to which—[Inaudible.]

We looked at the data on deaths in various groups that the Auditor General has just mentioned. Other than that, we did not delve too much into health inequalities, although we have reported previously on the extent to which health inequalities are wide and have worsened over the past 10 years. That is one of the Auditor General’s priority areas, so we will definitely be looking at it in more detail in the future.

Thank you.

I have a final question. For me, the stand-out element of the report is pandemic preparedness, which is an issue that has been raised outwith the committee.

Auditory General, the issue is quite concerning. Paragraph 42 of the report states:

“The Scottish Government had no plan in place to manage this specific kind of outbreak, so its response was informed by the UK Government’s ... UK Influenza Pandemic Preparedness Strategy.”

There were also three exercises in which Scotland was involved: exercise Silver Swan, exercise Cygnus and exercise Iris. However, it seems that many of the recommendations from the exercises were not followed up in Scotland. Can you comment further on that, please?

I am happy to. We think that there are lessons to be learned on pandemic preparedness from what was done in advance of the pandemic and from the steps that have been taken during the pandemic. As we touch on in the report, our audit work has shown us that the three pandemic preparedness exercises, along with the general framing of the strategy that you mentioned, were typically based around a flu pandemic scenario, as opposed to the type of coronavirus pandemic that has unfolded over the past year.

We reference the fact that not all the actions and recommendations that arose from the three exercises had been implemented by the time that Covid—[Inaudible.]—took hold. Two of the themes in those exercises involved exploring the extent to which our care homes were adequately prepared, and whether we had sufficient stockpiles of PPE and whether our health and care workers were fully trained in its usage. It is significant that both those scenarios unfolded, as we saw so vividly during the pandemic. The wider point that we make is about the importance of ensuring that all the recommendations are still correct and valid, given what we have learned during the pandemic, and that the lessons that we now need to learn from the past 12 months are implemented quickly.

Of course, we do not know whether the pandemic is a once-in-a-generation event or one that happens only once in 100 years, such as the Spanish flu, or whether it will be with us on a much more regular basis. There is therefore a degree of urgency around the steps to be taken, particularly in relation to the need for appropriate guidance for our social care settings so that they are better prepared the next time around.

I agree that we did not know for sure what would happen, but there was plenty of warning. The fact that the three preparation exercises took place shows that it was widely anticipated that a pandemic would happen at some point. Of the three areas in which improvement was recommended, two—social care and PPE—became the two scandals of the pandemic in Scotland. If you asked anyone in the street, they would agree, given the tragic number of deaths in care homes and the slow response on PPE.

The third area in which improvement was recommended was clarification of roles and responsibilities. I conclude that that is about leadership, which is a theme that the committee has dealt with previously. Who, ultimately, was responsible in the Scottish Government for receiving the three recommendations and making sure that the health boards were dealing with them? Whose desk would they have landed on?

I will invite Leigh Johnston to say a bit more about the chronology and responsibilities. However, I acknowledge your point about roles and responsibilities, particularly in relation to the extent to which care homes were sufficiently covered. The report refers to the emerging role of NHS board directors of public health with regard to care homes during the pandemic, which was a welcome and important step. However, that was not implemented in advance of the pandemic to give the clinical leadership that we now see in that setting.

The importance of the multifaceted nature of the roles and responsibilities is now much clearer as we come out of the pandemic. I ask Leigh Johnson to say a bit more about what that means.

11:00  

Before Leigh Johnston comes in, do you have the detail of the recommendations on increasing the capacity and capability of social care to cope during an outbreak? The reality is that the NHS released patients—old people—from hospitals into care homes without testing them. I am interested to know whether the detail of the recommendations warned against that in the first place.

We can provide the committee with the information that we have about the three exercises. I am more than happy to do that; I am sure that the Scottish Government has that information, too.

On the point about roles and responsibilities, I will ask Leigh Johnston to come in to explain what we saw in the recommendations and the extent to which we know that they have now been implemented.

The question of who is ultimately responsible is a difficult one. Ultimately, as we have seen, the pandemic required a cross-Government interagency response. As we outline in the report, despite the fact that a flu pandemic was rated as highly likely to occur and could have a severe impact, it was not on the corporate risk register and was not a stand-alone risk in the health and social care risk register.

Risks within those risk registers are allocated a director who then has oversight of them, but because the pandemic was not a stand-alone risk within the risk registers, we feel that it did not receive sufficient oversight. Had it been a stand-alone risk, some of the priorities and actions would have been taken through to conclusion.

For example, the Scottish Government set up the short-life working group on flu, and one of its priorities was to issue guidance to health and social care. Health and social care had guidance, but it was guidance for NHS England, which was issued in 2012, and one of the priorities was to update that guidance. That should have been issued for consultation in March 2018, but it was not issued for consultation until 2019. Even when the consultation responses came back, the guidance was neither updated nor published. That guidance would have provided insight into things such as access to the PPE stockpile.

Your other point was about the detail of the capacity and capability of social care. The documents from exercises Silver Swan, Cygnus and Iris are fairly high level and do not go into a lot of detail, although they talk about social care capacity.

What do you mean by “social care capacity”? Can you give me more detail on that?

It is about social care being clear about things such as access to PPE, the role that it would have, and, within the Scottish context, the roles and responsibilities of our health and social care partnerships in supporting social care in order to sustain the sector throughout the pandemic. That goes wider than care homes and includes care at home and other factors.

Auditor General, as you know, we have the option to hold a session with the Scottish Government on the issue. Do you have the documents on those three exercises and can you release them to us?

We have certainly seen those documents, convener. We saw them when we were making the judgments that we set out in the report. I have not spoken to the Government about any plans to release them, but I would not imagine that there would be any issue with that and I will look to do that. However, I will confirm that first with the Government.

Members have no further issues to raise with Audit Scotland on the report “NHS in Scotland 2020”. I thank all four witnesses for their evidence this morning.

11:05 Meeting continued in private until 11:31.