COVID-19 Recovery Committee

Meeting date: Thursday, March 17, 2022

Official Report 677KB pdf

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Excess Deaths Inquiry

Good morning, and welcome to the ninth meeting in 2022 of the COVID-19 Recovery Committee.

This morning, we will conclude our evidence taking on the inquiry into excess deaths in Scotland since the start of the pandemic. I welcome to the meeting Humza Yousaf, Cabinet Secretary for Health and Social Care, and Professor Jason Leitch, national clinical director for the Scottish Government.

Cabinet secretary, would you like to make some short opening remarks before we move to questions?

First of all, convener, I apologise for being slightly late. In view of the fact that I am slightly late, I am more than happy to pass back to you and go straight to questions and answers so that we have as much time as possible for that.

Thank you very much. What is your interpretation of the data on excess deaths during the pandemic? In particular, what is your view on Public Health Scotland’s submission, which says that

“from July 2021 onwards the pattern changed, with almost all causes of death being in excess”?

I will say a few things about that. First and foremost, I welcome the committee’s inquiry into the matter and its detailed analysis. I have had time to read over and, when I have been able, listen to the evidence that you have taken. It has been a reminder for every person around the table of how sobering the data is and how every person in Scotland has been touched in some way by tragedy involving Covid. That could be anything from an individual in a family who has suffered from long Covid right through to people who have been bereaved by Covid. People talk a lot about statistics and numbers in the committee, and with good cause, but I remind everyone that, behind each of those statistics, there is a human tragedy.

We know that, since the start of the pandemic, there have been 12,140 excess deaths from all causes. That figure is 11 per cent higher than the five-year average, which demonstrates Covid-19’s impact. Over the same period, there were 13,429 deaths involving Covid, and Covid was the underlying cause of 11,443 of them—85 per cent of all the deaths involving Covid. Therefore, the excess death measure during the pandemic clearly demonstrates Covid’s impact.

On how the pattern changed in the latter half of 2021, I strongly associate myself with remarks that you heard in previous evidence sessions such as those by Dr Lynda Fenton, who is a public health medicine consultant at Public Health Scotland. She recognised that, in view of the breadth of the situation, it is likely that there will have been health service factors—I am certain that we will get into that in the committee discussion—as well as factors that are related to the determinants of health. Peter Hastie from Macmillan Cancer Support—I have a lot of time for him as an individual and for Macmillan Cancer Support—made the undebatable point that people with cancer are being diagnosed later than they were before the pandemic. That is also a factor in the figures.

In the latter half of 2021, the vaccination programme was well into its stride, and there is no doubt that vaccines have played an important role against the severest impacts of Covid and, of course, Covid mortality. That might be demonstrated in the figures, too.

Professor Leitch might want to add something to that, given his clinical expertise in the area.

I will go back a step, because we have had a two-week break since we last spoke, which is unlike us. Last week, a very important paper on excess mortality was published in The Lancet, which looked at the whole world for the first time. We always knew that such work would take time, and we all knew that the chat about the United Kingdom having the worst mortality in the world would not be true in the longer term—and sure enough, it is not.

The authors of that paper on excess mortality looked at data from pretty much every country that they could get their hands on, which was about half the world. Death certification in the UK and in most of western Europe is exemplary, but in much of the world it is not. On excess mortality, the global average in the first two years of this horrible infectious disease is about 100 deaths per 100,000 of the population. Twenty-one countries have more than 300 deaths per 100,000. India has among the highest rates, and Russia and the United States have 300 deaths per 100,000. The raw numbers are eye watering. Four million people in India have died of this disease, which is remarkable; almost the population of Scotland has died of Covid and Covid-related disease in one country.

The UK’s numbers—126 deaths per 100,000—are around the global average, but there are confidence intervals, of course, because of the nature of the statistics. All four countries of the UK are—forgive the shorthand when we are talking about death—in the middle of the pack, which is roughly where we all thought we would be. We have been trying to get there through vaccination, lockdowns early on and the provision of safety measures since.

It is important to put excess deaths in context, because we now have Covid but have no flu, and we have Covid but have the economy open and so on. The number of excess deaths in a week is irrelevant, but the number over a period such as a global pandemic is crucial. That is how we will judge the public health measures of the world over the long term. I was shocked and once again miserable when I read the toll that this disease has taken, but the UK has behaved and performed relatively well from a public health perspective, if we look at the whole thing.

I will give some final headline numbers. The number of Covid deaths that have been announced by every country in the world is about 5 million. The actual number of Covid deaths is 18 million. That gives you the difference. Our numbers—the UK and Scottish numbers—relate almost exactly to the numbers that we have announced. Our excess mortality number is pretty much the same as the number that we announced for deaths from Covid. There are massive differences in those numbers in other countries because they do not have a mature death certificate system and so on.

It is important that we consider Scotland in comparison with the rest of the globe, if we have had that information in the past week.

I know that there are constant staff pressures on the national health service at the moment, but do we have any indication of when screening services—for example, breast screening for over-70s—will be fully back up and running?

You are right, of course, to couch that question in terms of those pressures. I hope that I am not speaking out of turn by saying that, in the conversations that my officials and I have had with health boards this week, many of them gave us the consistent message that they feel that this week is probably the toughest week that they have faced in the course of the pandemic.

We have not had today’s numbers of those in hospital with Covid—they have not been published yet—but yesterday’s number was just under 2,000, and we can add to that a high level of delayed discharge. Yesterday, I talked to the Glasgow health and social care partnership, which is unable to discharge people to care homes, given the scale of the outbreak. If we add to that staff absences and the accumulated pressure, it looks like this week is shaping up to be, if not the worst or most challenging week of the pandemic from a health service perspective, certainly one of the most challenging.

09:15  

With regard to routine screening programmes, all adult screening programmes have resumed safely. However, although they have restarted, it is fair to say that they are playing catch-up in some respects. Breast cancer screening has restarted, and, of course, anybody with signs or symptoms of breast cancer should seek screening.

We have taken action to address our screening capacity challenges. On cervical screening, we are having to clinically prioritise higher-risk participants in non-routine pathways. Bowel cancer screening has resumed and new home testing kits have been sent out. That programme is generally operating in line with pre-Covid performance. The triple A—abdominal aortic aneurysm—screening has resumed, and men in the highest risk cohorts are being prioritised. Diabetic eye screening has resumed and is targeted towards those with the greatest risk of developing diabetic retinopathy. Therefore, screening has resumed, but there is clinical prioritisation, given the backlogs and capacity constraints.

For complete clarity, we do not routinely offer breast screening to women over 70. Routine breast screening stops at 70, but women over the age of 70 can self-refer, if they are worried. Self-referral just to the breast screening clinics was paused in order to prioritise in exactly the way that the cabinet secretary has described. That does not mean that women over 70 cannot access breast screening; they should do that by going to their general practitioner. If they have any worries about lumps, bumps or bleeding—anything at all—they should go to see their general practitioner.

Breast screening for women aged 50 to 70 is back and working at full capacity. Self-referral to breast screening buses and clinics has been paused for the over-70s, but we never did such screening routinely anyway—that was for people who wanted to self-refer. The route for that is presently through general practitioners.

Having had a conversation yesterday with the screening team, I know that the position in Scotland is different from the position in, for example, England and Wales. Therefore, we are looking to see how we can quickly resume the self-referral process. I hope to do that and to be able to say something more on that in the coming weeks. We must bear in mind that allowing self-referral for those aged 71 and over could cause slippage between screening cycles for those in the 50 to 70 category, but we might judge that the benefit of allowing that self-referral outweighs that risk. That is the conversation that we are having and which I had yesterday with the breast cancer screening team.

That is helpful, because I have a constituent who is over 70 who has a history of breast cancer.

Good morning. Professor Leitch, I was glad that you mentioned The Lancet paper, which is a very interesting study that gives us quite a lot of reassurance about the choices that we have made about tackling Covid. Another interesting aspect of the paper is that it argues that there is no clear relationship between levels of excess mortality and the different levels of restrictions that have been applied; it puts the emphasis much more on vaccination. However, I suspect that we will have that debate later this morning.

I will go back to the committee’s inquiry. We have taken a lot of evidence over the past few weeks on reduced access to services. At the core of many of the issues is the fact that people have not been able to see their GP or access basic screening. Cabinet secretary, do you agree that that has had an impact on patient outcomes? Are there particular parts of the patient pathway, such as primary care, that have been the major cause of problems leading to the current level of excess deaths and that will cause future excess deaths?

Yes, I agree. It would be foolish not to agree with that statement. It is absolutely the case that the pandemic—I often describe it in these terms—is the biggest shock that our health service has faced in its existence. It is impossible for that not to have had an impact on access to services and, therefore, on outcomes for people’s health and public health more generally. I have looked at the evidence that the committee has taken thus far, and clinicians and third sector organisations have given compelling evidence that people have not presented in the way that they would have done before the pandemic, which undoubtedly will have had an impact. There will have been an impact right across the country and right across the patient pathway, from diagnosis through to treatment and aftercare.

In asking your second question, which was about particular parts of the patient pathway, you referenced primary care. That is often the front door, as everybody round the table knows well, and the first port of call. Doctors, dentists and people across the range of primary care have been affected. I was at a surgery that Murdo Fraser probably knows well: the Taymount surgery—

I am a patient there.

I did not know that.

I do not trouble it very much, to be fair.

Patient confidentiality is clearly working very well, because I was not told that.

I was seeing Dr Shackles and some of the rest of the team at the Taymount surgery, and they have done exceptionally well. They are part of a group that also has a surgery in Scone, as Murdo Fraser will know. They told me that they have had challenges even though their surgery is a relatively large one. Other surgeries are much smaller, such as my medical practice, and their ability to see people face to face has been even more constrained. As we recover from the pandemic—we are recovering and will recover—we will need to look at a hybrid model, of which telephone consultations, video consultations and increasing face-to-face consultations must all be parts.

Dentistry has been hit really hard because of the nature of the aerosol-generating procedures that are undertaken and the infection prevention and control measures around that. Again, it is recovering, but that will take time, particularly as we continue to have the IPC measures in place.

Many of the patient pathways give me concern, but the one that gives me the most concern—I suspect that I am not alone in this among those who are round the table—is probably the cancer pathway. You heard, again, compelling evidence from a range of organisations that represent those with a variety of cancers. We have evidence that there are some 5,000 so-called missing cancer patients from 2020. During the first nine months of the pandemic, 2,681 patients were diagnosed with breast cancer, 1,958 patients were diagnosed with colorectal cancer and 3,287 patients were diagnosed with lung cancer. Those numbers are, respectively, 19 per cent, 25 per cent and 9 per cent lower than would have been expected in that period if Covid had not happened.

There are a range of pathways that I am concerned about, but cancer causes genuine concern, and that is why it is such a priority for the Government.

Thank you for that very helpful response. Going back to the question of GPs, as I said, I am a patient at that GP practice, although fortunately they do not see me very often—

They would say the same, I think.

We are both happy. [Laughter.]

One issue that has come out of our inquiry is access to GPs. We heard from Dr Andrew Buist from the British Medical Association, who pushes back really strongly on the notion that people have not been able to access GPs, but we still hear that anecdotally from constituents. Is the position with GPs now back to where it should be or are we still facing challenges?

I would like to see an increase in face-to-face consultations, but as part of a hybrid model. That is where I agree with Dr Buist, Dr Shackles and many others who represent GPs and GP services. I do not think that anybody, including anybody round the table, would suggest that GPs have not been working hard throughout the pandemic. They have.

We need to make improvements on data. I know that committee members asked questions about that during the inquiry. We are working on a project to get better data extraction from primary care. I have seen the first cut of that data extract, but it needs to be quality assured and so forth. I promise the committee that it will be published as soon as it has gone through that appropriate process. However, the first cut of the data is unsurprising in that it shows that GPs are working incredibly hard, but as part of a hybrid model.

I think that that hybrid model should remain. I contacted my GP a number of months ago, and it was much more convenient for me to be able to telephone, have a video consultation and pick up my eczema cream at the pharmacist. That saved me a journey to the GP’s clinic and the time that would have been involved in that. We want to see an increase in face-to-face appointments, but as part of a hybrid model.

What Murdo Fraser hears anecdotally from his constituents and what I hear anecdotally from mine is also something that I hear from nurses in admission wards in acute hospitals, for example. There is more to do to increase the number of face-to-face appointments, but we have to recognise that GP practices are still operating under really difficult infection prevention and control conditions.

Cabinet secretary, you made reference to the evidence that we have taken. Last week, Lawrence Cowan from Chest Heart & Stroke Scotland mentioned that the British Heart Foundation had done a study

“that showed that there have been significant increases in unhealthy behaviours, such as eating unhealthily and smoking, and an increase in isolation and loneliness.”

That then went on to look at poverty specifically.

Peter Hastie, whom you mentioned, said:

“Health inequalities remain at the heart of everything that Macmillan Cancer Support wants to do. If a person lives in a deprived area in Scotland, they are more likely to get cancer, to be diagnosed later and to die. I cannot see how it would be possible for the pandemic to have improved that situation.”

In the same evidence session, Rob Gowans also said:

“A number of things need to happen. We know that the number of excess deaths in the most deprived areas is twice what it is in the least deprived areas. We need better data and, in particular, data that is disaggregated by age, sex, race and other aspects”

of socioeconomic background. There is a question in that about the data that we are collecting, as well as a question about prioritising and focusing on the most deprived areas, and what we will do about that.

At the meeting, I asked Lawrence Cowan about joined-up working. I assume that we all agree that we do not see the NHS as being just about acute services; we know that there is a primary sector and a local authority sector. It is quite worrying that he said:

“At the moment, we are doing a lot of partnership working with health boards, which is really positive. However, we are doing the running on that and it should be an automatic system, so that when a patient is discharged from hospital, they are discharged automatically to a wealth of services. That happens in some areas, but not in others.”—[Official Report, COVID-19 Recovery Committee, 10 March 2022; c 8, 10, 9, 9.]

I recognise the pressures that NHS services are under, but it seems to me that there is massive resource that we are not pulling together—that is, joined-up government. What is your view on that?

Thank you for giving that important context to your comments and questions. I do not disagree with the notion that we could do even better in relation to integration. The third sector plays a massive role in that.

Not too many months ago, I was in a meeting on the issue of delayed discharges—I know that Alex Rowley has raised that issue on many occasions in committee and in the chamber. The local third sector interface was part of that conversation, and a number of people from the third sector said exactly what Lawrence Cowan said. They felt that they were having to be proactive. I have certainly communicated to health boards and local integration authorities that they should be using every single resource in the community that they possibly can.

Over the past two years, and in deprived communities in particular, our welfare rights and money advice services across 150 primary care settings, and our community link workers—probably all MSPs have a good relationship with our community link workers—have been vital in helping to make those connections. However, I will be frank in saying why—a more detailed debate on what I will say is for another day—the national care service is so important. Social care is vital in helping us to deal with the pressures that we are facing, and it is under enormous pressure. However, we know that, if there is consistency of care throughout the country, that could make an important difference to the pressures that our NHS faces. I do not disagree with that.

Just last week, we published a really good piece of work by our primary care health inequalities short-life working group. Dr Carey Lunan, who is, I suspect, known to everybody in the committee, and some of her colleagues from the Scottish deep end project have done some brilliant work in that regard. I commend that piece of work to anybody who has not seen it.

09:30  

I put to you the point that, although there is massive pressure on all resources, I believe there is a lot of resource out there. During last week’s evidence session—and sessions before it, with Dr Buist and others—when we asked whether health and social care, and social work in GP practices, is working on the ground, the answer was that it is hit and miss. The issue is not just about resources; it is also about leadership and management. I would have thought that that must be about leadership from the top.

I had a look at a Public Health Scotland statistical report and at a Scottish Parliament Information Centre report, which said that the number of cancer deaths recorded as having taken place at home or a in non-institutional setting in the early months of the pandemic was substantially higher than those that took place in hospital. That trend seems to have continued.

In the NHS Fife area, the average number of daily occupied beds for palliative—hospice—support dropped from 20 down to nine, although 22 beds were available. The percentage drop in occupied beds was down from 86.3 per cent to 39.7 per cent.

Fife has the lowest number of occupied beds, by the way. I think that NHS Highland is next, with about 53 per cent occupied. What will be done about that massive drop? We know that some people want to stay at home when they are dying, but some families want a higher level of support and that seems to be missing.

I am shortly due to meet NHS Fife, local government and the local health and social care partnership. Nicky Connor and her team at NHS Fife do an excellent job. I had very helpful conversations with them about delayed discharges last autumn and winter. We were going in the wrong direction, but we managed to pull that back. However, I am afraid that, because of the most recent wave of the pandemic, we have begun to go in the wrong direction again. I will consider the specifics of the question and raise those issues directly with NHS Fife.

We know of the pattern that Alex Rowley has mentioned in relation to palliative care, and we know that more deaths have occurred at home throughout the pandemic; further investigation is needed on that.

We have committed to producing a palliative care and end-of-life care strategy to ensure that people and their loved ones get the care and support that is right for them when they need it most. To help inform the strategy—because I think that some of the data could be more robust—the Scottish Centre for Administrative Data Research is already undertaking research to investigate home deaths during the pandemic. That work will help us to understand what strategy we should develop, so that we can understand more clearly the causes of the shift in place of death during the pandemic and whether that will be a long-term trend. If so, we need to ensure that the appropriate structures and, where necessary, the appropriate funding, are in place. That answers the more general part of the question, but I will take up the specifics with the appropriate partners in Fife, whom I am due to meet relatively soon.

I want to return to the issue of excess deaths. It was mentioned that most of those are due in part to Covid. If I remember correctly—I am sure that you will correct me if I am wrong—Covid is a contributing factor. For example, a high proportion of people—more than 60 per cent—of those who died of Covid, or whose deaths were Covid-related, were obese. For a third of deaths, diabetes was a factor.

Do we have an opportunity to reassess and reset how we deliver healthcare, and link that to factors that are outside of the NHS? I am talking about looking at the education system in the broadest sense. As Alex Rowley mentioned, there was a high incidence of Covid deaths among those in poverty. Do we have an opportunity, looking ahead, to reset healthcare? If you agree with that, how will the Government take up that opportunity?

I agree with that. I acknowledge that Brian Whittle has a long-standing interest in that area and has advocated for a preventative model of healthcare. A preventative approach is incredibly important. Many years after the Christie commission, we invest heavily in that space, but we could definitely do more.

Education can play a role in prevention, as can social prescribing, which we are looking to expand. I mentioned the community link workers that we have in place. We have also committed to providing 1,000 additional mental health support workers, whom every GP practice in Scotland can access for assistance with social prescribing. The ability to do that is incredibly important.

Sport plays a huge role in that respect. I recently had a really good meeting with the Scottish Football Association on how we can use Scotland’s most-loved sport, and the grass-roots network of football clubs across the country, more strategically to address some of our health aims as we move forward. We are doing a lot in that space, but there is plenty more that we could do.

Brian Whittle is correct to say that there is an opportunity, although it comes from tragic circumstances, to improve our public health outcomes.

I point out that it is not about sport for sport’s sake—it is about education through sport and physical activity. I would rather use that phrase, because everybody thinks, when I talk about sport, that I want to make people run eight 400m laps. That is not quite where I am at—I would not attempt that myself.

Moving on from that aspect, I go back to the question of data. Perhaps it would interest the cabinet secretary to look back at the work that the Health and Sport Committee did in the previous session of Parliament on sport and social prescribing. The data is incredibly important, as Professor Leitch highlighted when he discussed the importance of global data.

A lot of the evidence that we have gathered, which has followed the committee through from the previous session, shows that there is a lack of co-ordination in relation to data collection. That will hamper our ability to plan ahead and to reassess—recreate, if you like—the way in which we deliver healthcare.

On top of that, we do not have an information technology system in the NHS that is fit for purpose. For example, the data does not follow the patient from primary care into secondary care, and it does not link up with the third sector. We need all of that to happen.

When we discuss IT platforms, it is incredibly boring, but they are an incredibly important first step. I do not know where the Government is with that.

I actually find that incredibly interesting—perhaps I am in the minority, but it is genuinely interesting.

We have a lot—a plethora—of data. As cabinet secretary for health, I regularly get reams of data. However, is that data joined up in the way that I would want it to be? Absolutely not.

I commend to Brian Whittle—he may already have seen it—and to any member who has not seen it our recently published document, “Enabling, Connecting and Empowering: Care in the Digital Age—Scotland’s Digital Health and Care Strategy”, which is available online. I was looking at the strategy again as Brian Whittle was talking. On page 8, it lists three important aims. The second aim—I am paraphrasing the strategy—is to ensure that our health and care services have the important digital foundation that can allow access to, and the ability to share, relevant information across health and care systems. Care is a really important part of that, too.

This is not necessarily about uprooting every digital system that we have—that way of thinking could almost be described as old school. Instead, on page 18 of the strategy, we go into more detail about how we create the cloud infrastructure that will allow data sharing to happen. We do not have to upend every element of our digital IT infrastructure in primary care, various health boards and so on; we just have to create the cloud infrastructure that will allow greater sharing of data.

We have got to do that, but how do we do it with the third sector and those who are external to health and care? My direction to my digital team—the approach goes across Government, too—is that, while obviously being mindful of and aligning with various frameworks and obligations around data, including data protection, we should not be putting up any artificial barriers to sharing data with the third sector, where that is appropriate. We still have work to do on that, but I would commend the digital health and care strategy to those who have not had a chance to look at it, as it goes into a fair bit of detail about our ambitions in that regard.

I should probably declare an interest at this point, as I was a director of a healthcare tech company that worked on collaboration and communication platforms before I became an MSP.

The technology in question is not new and is available. On your point about not having to reset everything, I would say that we need to be able to suck data into a central platform, allow those data to talk to each other and then see how we can use the output. As we discussed the last time that you were here, I am suggesting that we do not have an IT system that can do that at the moment. If we are to move forward, that issue needs to be addressed, and I am happy to discuss that with you offline.

I am happy to do that. Again, though, I would highlight page 18 of the strategy, which refers to a national digital platform. As you have rightly pointed out, we are not talking about a single product but about a collaborative and integrated approach to delivering cloud-based digital components that will allow us to share data in a way that we might not have been able to thus far. I am certainly more than happy to have that discussion offline, Mr Whittle, if you wish.

We have already touched on a number of issues, but I just note—this has been said already—that this week has perhaps been one of the worst that we have had, and the hospitals seem to be absolutely full. However, evidence that we have received suggests that non-Covid conditions have really suffered over the past two years. Should our focus now move from Covid to non-Covid conditions? Has that already happened or is it still to happen?

Jason Leitch might want to respond to that, too, but I do not see and have never seen such things in a binary way. For example, a number of people who are in hospital with Covid might have been admitted for other reasons and have caught Covid while there, and we know that Covid can exacerbate underlying health conditions such as respiratory problems and diabetes. I do not think that we can say, “Let’s stop focusing on Covid and start focusing on other conditions.”

It is also true to say that the pressures that we are facing will diminish significantly when we are able to control Covid. Although 2,000 Covid patients might in the grand scheme of things seem like a small enough number, given how many beds that we have in our hospitals, the IPC that goes around those patients puts significant pressure on the health service. With community transmission as high as it is at the moment, levels of staff absence in our health and social care system will tend to be higher, and there has also been an increase in delayed discharges, because, as I have mentioned, our ability to discharge people into care homes has been severely diminished as a result of the increase in outbreaks. Controlling Covid will therefore be essential in helping us recover with regard to the non-Covid conditions that John Mason has mentioned.

At the same time, though, we are focusing on those very conditions. Before I became health secretary, we had the cancer plan, which was backed by £114.5 million; when I came into post, the early cancer diagnostic centres were being rolled out; and we have recently launched the “Endoscopy and Urology Diagnostic: Recovery and Renewal Plan”. We are looking to recover our position with regard to non-Covid conditions, but I do not see it as a binary choice of focusing on one thing or shifting the focus to something else.

09:45  

We know that this probably will not be the last wave of Covid, or even the last period of concern in relation to Covid. The real challenge is how, when we have waves, we protect the diagnosis and treatment of non-Covid conditions, including carrying out elective surgery and unscheduled care, while managing and treating Covid. We have not been able to crack the answer to that yet. Part of the answer must be some of our work in and around the hospital at home programme, which includes a treatment pathway for Covid. Another part is about how we treat people with antivirals at home as opposed to admitting them to hospital.

There was a lot in that. I do not know whether Jason—

Before going to Jason Leitch, I would like to pick up one point. You have talked about staff absences. Clearly, that has been a problem for the health service and elsewhere. With the rules changes in the coming weeks, will there be less need for isolation? I assume that some of the staff absences are people who have either tested positive but have no symptoms, or whose family members have tested positive and who must stay at home. Do you anticipate the situation improving in the short term?

You will remember that one of the things that the First Minister made clear in her announcement is that testing for health and social care staff will remain, including the testing of asymptomatic individuals; that will not change.

As we move from the transition phase to the steady state, might that have an impact on staff absences? Potentially, but the biggest impact will be if we can control transmission. The more that we can control community transmission, the more impact that will have on staff absences.

The general number of staff absences sometimes masks the detail. If we look at staff absences that are not just related to Covid but related to those who are testing positive themselves, we find that we have unfortunately seen rises in the past few weeks—that is the case in the community, too—which have exacerbated the pressure that we were already feeling.

One advantage of opening up a little is that I have been able to get back to meeting people in the health and social care system, although I am not sure whether those in the health and social care system think that that is an advantage. I spent the beginning of this week in Tayside and Grampian, meeting and thanking those who have led us through the pandemic. It is not as straightforward as moving from Covid to non-Covid, although I wish that it were; I wish that we could switch off the pandemic.

The cabinet secretary is right. The fundamental change is that we need to get prevalence down. With the eye of faith, the rate might be beginning to flatten just a little. We are a few weeks behind Northern Ireland, which is on a downward slope. We have no reason to believe that we will be any different. England and Wales are on an upward slope, and are a bit behind us. I think that they will have exactly the same pattern with B.A2 as we have had.

I saw health and social care staff and third sector organisations working hard to fix, frankly, anything that turns up, but Covid makes all that more complicated. We do not want Covid to spread from one individual to a four-bedded bay in Ninewells hospital, which is 50 years old. Some of the estate in Grampian where patients must be cohorted if they test positive or their contacts test positive is much older than that.

Covid makes hand surgery more difficult, even if that is not to do with the surgery itself. I mention that because I happened to meet some hand surgery patients when I was visiting. Everything is about getting down the prevalence of this infectious disease. That would be true if it were norovirus or if it were flu—it is just that we have a new version to deal with.

I saw encouraging signs of pressure beginning to come off services, particularly in critical care, which is kind of back to its normal footprint. When I last visited, the unit was three times as big; now it is back to its normal size. The unit is full, but it is full of patients requiring post-op care, those who have had strokes and the occasional Covid patient. It definitely feels different. The clinical teams are transitioning to that more common way of working. However, we do not have slack in the system.

The only other thing that I would add is that staff are tired. They are looking forward to time off at Easter or during summer, because many of them have worked for two and half years without a break. We need to be careful not to overload an already fragile community that has saved tens of thousands of lives over the past two years.

The staff who I met were enthusiastic; they were still smiling, although maybe I met only that type of staff. They were terrific. However, I was conscious of our having asked a lot of them. I met a care home manager who, in a previous wave, slept in her care home for three weeks after there had been seven deaths in the home. She is keen to keep going, but we have to give people time to recover.

In response to Murdo Fraser’s question, dentistry and a few other things were mentioned. Clearly, recovery is different across the board. I have not seen my dentist for more than two years. I have chipped my teeth during that time but, fortunately, that has not caused me a lot of pain. Where are we going with dentistry? How soon can we get back to six-monthly appointments? Is that entirely up to individual practices? I dislike the idea of going to a private dentist, but is that the advice in order to take pressure off the NHS?

No, we are not giving that advice. There is no doubt that the dentistry sector has been hit hard, for all the reasons that I gave to Murdo Fraser, particularly given the aerosol-generating procedures that dentists have to carry out. However, dental practices are opening up and are taking the appropriate precautions. We have provided dental practices with support and grant funding for ventilation and for drills that can be used to mitigate the effects of aerosol-generating procedures.

Through what is in essence a multiplier, we will reward dentists who do more NHS activity. We had a good debate about dentistry in the Parliament recently. I am sure that this is happening only in a minority of cases, but we heard some concerning stories of dentists upselling private plans to their patients. That is, of course, not allowed within the regulations, but it is also deeply unethical. Through our funding arrangements, we will reward dentists who see more NHS patients.

We will recover, but I cannot give an exact date for when the recovery will be complete because, as we have discussed, we are still in the midst of the pandemic. Until we get to pre-pandemic levels of activity, I am afraid that the backlog will continue to increase. That is true across the health service. Only when we get to pre-Covid levels—or, I hope, above pre-Covid levels—will the backlog begin to reduce. Given that we are still in the midst of a global pandemic, it is difficult to give a definitive date for when we think the recovery will be complete.

More constituents have been on at me about not having access to a dentist than have been on at me about not having access to a GP or probably any other service. We say to people that, if they cannot get a dentist in Baillieston, for example, they should try ones in Shettleston, but they say that they have tried all the dentists in the area and that none of them will take them. What should I say to those constituents?

You should say that, through the Government’s funding arrangements, we will see a step change. I am certain of that. Dentists will still have to operate within the IPC constraints, so they will not be able to see as many people as they saw before the pandemic. Before omicron, activity levels in dental practices were beginning to rise, and as a result of the new funding arrangements that incentivise and reward NHS activity, those levels will rise even more.

It might be worth asking Professor Leitch whether he has anything to add, given his expertise in dentistry.

Dentistry is one of the best examples of why the situation is so hard, because dental procedures pose a particular Covid risk to patients. Earlier this week, I went to the dental school in Dundee and met new students, who are working in an entirely different environment, with little pods being used so that we can protect them and patients during AGPs. I met a patient who had been coming to that dental hospital for check-ups every year since 1964, and he was on his 40th student. That was fantastic. The students were full of enthusiasm, but they were working within the constraints that we have set for them.

This is slightly easier for an adviser to say than it is for a politician: dentistry and optometry use a mixed model in this country. Such services are not free at the point of delivery for every member of the population. Governments have made that decision for 70 years. However, if an NHS patient wants NHS treatment, that should be available to them. That is not the same as saying that private care is not available. There are also independent providers as well as very expensive private providers.

There are three layers of dental funding: there is the NHS layer; the insurance system, which a lot of people use and that might involve someone paying £25 a month to get X care; and the high-end private providers in Harley Street and in Glasgow and Edinburgh. That mixed model is available to people, but the NHS model, which has had to adapt in the past two years, is now coming back. My colleagues say that they are beginning to see an increase. That is partly because the tech has changed and we are now able to give them new technology, and because the funding streams are now adjusted.

My advice to your constituents would be to be just a little bit more patient. If the issue does not fix itself within the next six months, they should come back and ask again.

I want to go back to Murdo Fraser’s original question about access to GPs and the hybrid model. Last week, I asked our witnesses whether we should give people the understanding that the hybrid model will be the way in which they see their GP in future. One response that I found interesting—I apologise, but I cannot remember the name of the lady who said it—was that it would very much depend on how the patients accept it, or words to that effect.

You say that we are going to proceed with the hybrid model. Does the Scottish Government have to do a messaging job to get people to understand that? How will you put people’s minds at ease about how they will be seen going forward?

There is a need for communication. I think that it was Dr Shackles who said that there needs to be an open and honest conversation with the public. If it was not Dr Shackles, I will be happy to correct the record, but one of the clinicians who gave evidence to the committee talked about having an open and honest conversation. I hear that from clinicians day in and day out, time and again, and I do my best to be up front about the fact that the recovery will not take just weeks or months—it will take years. People are now coming to accept that, and the reasons for it.

I should say that we had a hybrid model before the pandemic. People were able use telephone and video consultations, but those were being used nowhere near to the scale that they were used during the pandemic.

There is a balance to be struck. My direction, which is spelled out in the recovery plan, is to increase face-to-face access to GPs, because we know that there are possible issues with digital exclusion and we must work hard to narrow that exclusion and eliminate it altogether. I hope that I am not overgeneralising, but we know that some of the older constituents that we represent might want to see their GP face to face, and it is important that, when people wish to see their GP face to face, and when it is clinically appropriate, it should happen.

However, we must also continue to invest in telephone and video consultation facilities. To go back to the question that Brian Whittle asked, there is something about how we access the NHS and health and social care through digital that is going to increase. There are good pilots that show how we are doing that, and we probably need to upscale those.

I know that this is an inquiry into excess deaths but, as you said, staff are exhausted. A recurring theme that we have seen is GPs feeling as though they are being blamed for a lot of the early diagnoses not happening and for a lot of the problems that we have seen as a result of Covid. GPs are feeling a lot of the pressure of that. We need to rebuild trust and a relationship with the public.

Last week, we were told that some GPs are being incentivised to retire earlier than they might have done because of the existing pensions and tax arrangements. I know that I am going off piste here a wee bittie, but we cannot deliver good healthcare if we do not have comfortable well-paid staff who want to be there and want to do the best that they can. If they are not enjoying the job any more, the healthcare system will suffer.

We can go through the situation for all staff, such as nurses, porters and doctors, but the specific issue of GP retirement was raised with the committee. I know that the Scottish Government has looked at that, and that you have spoken to the UK Government about it previously. What progress have you made? Has anything happened with regard to not incentivising GPs to retire earlier?

10:00  

I have a few points on that. There has not been any progress on the matter that I raised with the UK Government. I always thought that it would be a long shot, given the financial pressures that everybody is under. That said, I will continue to pursue the issue to see where pension changes could be made, if it is possible, to help with retention. I have given the BMA a commitment on that.

The BMA has rightly challenged the Scottish Government and asked what more we can do in this space. For example, it has asked me to give active consideration to a recycling employer contributions scheme, and to giving health boards the ability to activate such a scheme if it would be in their interest to do so. As I said, that is, and continues to be, under active consideration.

However, I go back to the point that Jason Leitch made. Of course we have to deal with any financial disincentives that might be in the system. However, if we can control Covid—or rather when we control it, because we will—and begin to recover in stages, in a managed way, we have to do so in a way that does not exhaust a workforce that is, to be frank, already knackered.

In a GP practice, that is not just the GP alone—although, of course, they will be knackered. It is the multidisciplinary team, including the receptionist, who will always be the first person that people talk to. Receptionists tell me that they have experienced an increase in abuse over the phone and in person, so we need to ensure that they and their wellbeing are well taken care of. We have invested record levels in the wellbeing of NHS and social care staff, and we will continue to do so.

We will do what we can to rid the system of financial disincentives, and we will actively consider that issue. We will ensure that staff are well paid. As you would expect me to do, I reiterate that we have the best-paid NHS staff in the UK. We will also ensure that we do what we can to retain staff. There is a whole section in the recently published workforce strategy on nurture—in fact, it is a thread throughout the entire strategy—which looks at what needs to be in place for the wellbeing and retention of staff in order to help with recovery.

That issue has been a challenge for health service employees at the higher end, in salary terms, for years now. It affects not only dentists and doctors in particular, but some healthcare managers who are in the NHS pension scheme. The issue has been a matter of controversy between the devolved Administrations and the UK Government, and the cabinet secretary continues to make the point in meetings. It needs resolved, and the BMA has been forceful in asking the UK Government—principally, because much of the power is reserved—to resolve it, while also asking the other three Governments to do what they can.

It is quite a hard message to sell to the highest-paid members of our service, but the other option is that they will leave and retire at 57, and we really need them to stay. It is about lifetime allowance, and people coming back and effectively working for free because they have to pay 70 or 80 per cent tax on what they continue to earn. I know that there are some around the country who will not have a huge amount of sympathy for those on that level of pay, but we need to retain them.

I understand that there might not be a huge amount of sympathy, but it takes 10 years to get a GP up to that standard, and we do not want them leaving the service 10 years sooner than they might otherwise have done.

And they may be the GP on Barra or in Elgin, where it is very difficult to recruit, so I agree with you.

I am conscious that the cabinet secretary has to leave at 10:15, but I will bring in Murdo Fraser, followed by Alex Rowley.

I want to pick up on the issue of emergency medicine, which we have not touched on much this morning. Some of the most striking evidence that the committee heard was from the Royal College of Emergency Medicine, which told us that, in 2021, there were 500 excess deaths related to people accessing emergency treatment too late. That is 10 people per week dying because the ambulance does not turn up on time or because, although the ambulance turns up on time, when it gets to the hospital, it cannot get its patients out into the emergency ward in time. That was really striking.

The royal college highlighted the continuing lack of capacity in the workforce. On Friday, you announced a new national workforce strategy, and I was interested to see the comment that the royal college made to the press on that yesterday. Although it welcomed the strategy, it said that it was

“disappointed … not to have been consulted”

on it

“and by the limited mentions of Urgent and Emergency Care.”

Will you meet the royal college to discuss that and take on board its real concerns on the matter?

Yes, I will. I am somewhat surprised by the comment, because I meet the Royal College of Emergency Medicine regularly. I think that Dr Thomson gave evidence to you. I have met him in the past, and those meetings helped to inform our strategy. No doubt, that is why he welcomed it. A lot of the issues that he raised with me are core components of it. Of course, as we say in the strategy, it is an iterative document that will continue to develop and evolve as we make our way through the pandemic and into recovery.

Of course, I will meet the RCEM, as I do regularly. We consulted a number of stakeholders. I take on board what the RCEM said yesterday. The royal college can be assured that I am keen to meet with it early doors to get its further thoughts on our workforce strategy.

Will you give us a sense of where we are now on the delays with ambulances? Clearly, there is a lot of pressure on NHS emergency wards. Are those issues still happening?

Yes. That goes back to what I said. I am happy to state on the record that, in the conversations that health boards have had with me and my officials this week, they have said to us that this feels as though it could be the worst week of the pandemic—or, if not the worst, certainly among the worst weeks. There is an accumulation of factors that I have already spoken about.

Yesterday, I met Pauline Howie and Tom Steele, the chief executive and chair of the Scottish Ambulance Service, and they said again that they are under severe pressure. We know the knock-on effects—I will not go into detail on them. In fact, from my reading of previous evidence sessions, I know that Murdo Fraser has previously raised the issue of ambulance waiting times and turnaround times at hospitals.

We are seeing those pressures play out this week. My hope—it is not just a hope; we are working to do this—is that we will alleviate as much of that pressure as we possibly can while realising that, as Professor Leitch says, we will get through the peak that we are currently at. The question is how we will insulate our health services, including emergency medicine, when we have a future peak. We are working as hard as we possibly can on that. However, it is a challenging time at the moment.

I will ask a question about the redesign of urgent care. I read an article this morning that suggested that £40 million had been spent on that but the results were not great, so you have now commissioned consultants at a cost of £84,180 to review that redesign. Where is that work at, and what is working and not working?

There have been some positives on the redesign of urgent care. If any programme has been needed during the pandemic and is needed into recovery, it is the redesign of urgent care. It is not unusual for the Government to take feedback on what areas of any programme can be improved and to take advice on whether it needs to be readjusted.

We are implementing the redesign of urgent care programme, which is supported by significant investment. For example, a hub has been established in every health board to directly receive referrals from NHS 24, offering rapid access to senior clinicians and using telephone or video consultation, where possible, which minimises the need for people to attend A and E.

There has been good innovation, but we are never against seeing how we can improve programmes, including the redesign of urgent care.

You have spent £40 million on it. Is it delivering the results that the Government expected?

We have certainly seen a positive impact, although it is difficult to judge that during the pandemic. The redesign of urgent care programme will be vital to our recovery, as we will have to reduce the demand on acute care. The redesign of urgent care will help with that, as will the hospital at home work that we are doing. Addressing the issues on social care that Alex Rowley raised will also help with it.

We will have to reduce the demand. The redesign of urgent care programme has helped to an extent, but I have no doubt that we should consider what additional improvements could be made to it.

That concludes our consideration of this agenda item and our time with the cabinet secretary. I thank him and his supporting official for attending.

I suspend the meeting briefly to allow a changeover of witnesses.

10:12 Meeting suspended.  

10:19 On resuming—