Health, Social Care and Sport Committee

Meeting date: Tuesday, November 9, 2021

Official Report 712KB pdf

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Seasonal Planning and Preparedness

Welcome back. Our third agenda item is an evidence session on seasonal planning and preparedness. There seems to be an echo in the room; can we get that sorted out, if it is not just in my head? [Laughter.] I think that it has been sorted. Thank you very much.

I welcome Dr John Thomson, who is the vice-president in Scotland of the Royal College of Emergency Medicine; Dr Andrew Buist, who is chair of the British Medical Association’s general practitioner committee; Colin Poolman, who is interim director of the Royal College of Nursing; Sharon Wiener-Ogilvie, who is the podiatry service lead for NHS Borders and is representing the Allied Health Professions Federation Scotland; Annie Gunner Logan, who is the chief executive of the Coalition of Care and Support Providers in Scotland; and John Mooney, who is the head of social care at Unison. All are joining us remotely. I thank you very much for hanging on while we had that extended session with the minister.

I will ask about one of the things that struck me in all your written submissions, when you talk about winter preparedness. I suppose that we are in winter now, so it is all starting to kick off. We have heard all the concerns about the ability of the NHS and social care to get us through the winter in what is—as we have heard—probably one of the most challenging times in the life of the country and in health and social care. You have all pointed to one thing. It is a thread that runs through every submission: the number of staff vacancies, and the issues around recruitment that you are all having, in getting your services up and running at full capacity to meet—or to try to meet—demand.

I will go round the witnesses to get a sense of what the difficulties are in filling vacancies, and to ask where you think action could be taken to assist in that. I will come to each of you in turn, with John Thomson being first.

Thank you and good morning, convener. Certainly, there are significant issues in emergency medicine throughout the country when it comes to vacancies—not just medical vacancies but, as I am sure my colleague from the Royal College of Nursing will also state, nursing vacancies.

The training scheme for doctors in emergency medicine is quite prescriptive, and the numbers are determined nationally. In effect, they are based on the predicted numbers of consultants that will be required six years from when those individuals finish their training. Essentially, the numbers are significantly out of date.

This year, for the first time ever, the RCEM undertook a workforce census. The information that it provided was really quite revealing, and we have included it in our written submission.

The ideal consultant-to-patient ratio is one consultant for every 4,000 patients. Currently in Scotland, we have one consultant for every 6,450 patients. I acknowledge that there has been a significant increase in the number of consultants in the past few years, but we are still significantly understaffed. The college has estimated that Scotland is still approximately 130 whole-time-equivalent consultants short of what would allow us to safely staff our emergency departments with senior decision makers.

Unlike in emergency medicine, general practice has not had an extension of our numbers in recent years. A workforce survey that was published recently showed that our numbers have flatlined. They are no higher now than they were in 2013. We have an agreed policy to expand GP numbers by 800 by 2027, but we have not made any progress towards that.

Last month, we carried out a survey that showed that there were about 225 whole-time-equivalent GP vacancies across Scotland. The key thing is to recruit and retain more GPs. I am worried that we are losing GPs and that the work intensity has risen enormously throughout the Covid pandemic. The survey, which we published on Friday, showed that, in one week in October, we provided more than 500,000 appointments in general practice in Scotland: one in every 10 people in Scotland was assessed by a clinician in general practice in one week.

There is an enormous strain on the workforce just now. Many of my colleagues are extremely tired and their morale is down. I am worried that they are burning out. In such circumstances, individuals might decide that they are, for their wellbeing, going to cut down what they do, or they might decide to leave the profession.

We have a serious situation with general practice, which is so fundamental to our NHS—it is the “foundation of the NHS”, as the previous cabinet secretary said. We need to retain and recruit more GPs.

I want to go back to what Dr Buist said about morale. An issue that has been brought up with me in speaking to GPs in my constituency is how demoralised they feel about the perception of them in the media. They feel that they are constantly fighting against the rhetoric that GPs need to “get back to work”. They have never stopped working throughout the pandemic. I am interested to know your thoughts on that. That seems to be a narrative that is making things a lot worse for the morale of GPs.

Indeed, it has done that. Most of that rhetoric has come from England, but there has been some in Scotland. What newspapers print down south creeps up here—the public see it and some members of the public believe it. In fact, general practice has been very much on the front line of the fight against Covid since March last year. That is not just in practices but in out-of-hours centres and Covid assessment centres, which have been very important in keeping people who have Covid symptoms away from general practice, so that we can see patients who have all the other problems that they come to general practice with, and so that we can reduce the risk of infection transmission.

What we have seen in the media and, sadly, what some politicians have said about what we have been doing is, and has been, demoralising.

Colin Poolman will give the perspective of the RCN.

Thank you for the invitation to address the committee.

Our members are telling us that they have never been under greater pressure and—[Inaudible.]—the sustained levels of stress and pressure in the workforce over the past two years, they are exhausted and worn out.

That brings me to the significant issue for us, which is retention of the current workforce. Every day, when we survey people who are looking to leave the profession, we hear from nurses about the sustained pressure that they and their colleagues are under and the difficulties that they face in delivery of day-to-day services.

Our difficulty is that we do not have thousands of people waiting to be employed. Therefore, we have to think about how we plan our student nursing training in the medium to long term, and about how we can get a better supply of people. We need to be up front about the fact that the workforce planning measures that we have all had in place have not been sufficient to meet what we now require. We need to build on our workforce planning and to plan for what we need instead of what we can afford. In the past, we made the mistake of planning for what we could afford and not for what we needed. That covers the recruitment element.

The other element is retention. As I said, every day, people who are leaving the profession tell us about the demands that are placed on them incessantly. Because they can see no change in the situation, they are making that decision for the good of their own health and wellbeing. We need to think about what we can do to support people and about how we can, through things such as offering flexible employment patterns, retain those individuals in order to ensure that we have in place the right numbers.

People say to me that there have never been more nurses in the NHS than there are at the moment. My response is that there have never been more nurse vacancies in the NHS. We need to do as much as possible to address retention, which is just as important as recruitment. Every person who leaves represents a person whom we need to recruit. That is just logic.

The pressures make the situation extremely difficult. We need to work on that with all stakeholders, including the public, because we need to be up front with them. Andrew Buist just talked about that in relation to GPs. We are hearing accounts of nurses being abused because, quite frankly, of the messages that are being put out about what is possible and what is not possible. We, the media and yourselves need to do everything that we can to be open and honest with the public.

I can see members all nodding at that. A couple of my colleagues will come back to patient frustration and expectation later.

Thank you for inviting the Allied Health Professions Federation Scotland to speak to the committee. We represent 12 allied health professional bodies, including those for physiotherapists, occupational therapists, dieticians, speech and language therapists, podiatrists, radiographers and so on. I will not name them all; that was just to give you some examples.

As the other witnesses’ professions are, we are experiencing significant staffing issues in our workforce and are encountering difficulties in filling vacancies. There are key pressures in relation to radiographers and podiatrists at the moment, but there are vacancies in all the professions that we represent. That affects our ability to help people to stay safely at home and to self-manage at home in order to avoid hospital admission, and it prevents us from supporting the preventative health agenda.

The question was about what is causing the difficulties to be exacerbated. There are two main issues. One is that, in Scotland, we currently do not have a sustainable education model to support workforce development for allied health professionals. We are very much at the mercy of the higher education institutions with regard to how many places are made available. The number depends very much on market pressure—that is, what students want to study. We really need to move to a more sustainable model whereby, for example, the Scottish Government, through discussions with higher education institutions, commissions places across all professions.

The second thing that exacerbates problems in our ability to recruit and retain staff is short-term funding and the lateness of funding getting to boards. A lot of the time, we receive funding around autumn time and are expected to spend that money by March and deliver outcomes. That exacerbates existing challenges that we have in recruitment, because it is very difficult to fill fixed-term posts.

11:00  

We need to take a more risk-based approach to finance and recruitment, because getting the money now from the Scottish Government will make it difficult for us to have an impact on the pressures this winter.

Thank you. I turn to Annie Gunner Logan.

Thank you for inviting me here today and for considering social care as part of the session. We are absolutely delighted that social care now features in the title of the committee—for the first time since 1999. It feels like we are properly included now, so thank you for that.

I will start with a positive. Third sector social care organisations in our membership employ about 43,000 people and have all been operating at high volumes of work and delivering high quality care throughout the pandemic. By and large, they have been able to maintain services for the people whom they support. As others have said, the sector does not need to be remobilised, because we never stopped.

However, staff recruitment and retention issues for social care providers are now acute and are worsening. The staff whom we have are brilliant, but they are exhausted; they are leaving and are not coming back. Recruitment has always been an issue in social care, but we have never referred to it as a crisis before now.

We first raised major issues in recruitment in the summer of 2021, when we conducted a survey of our members. The outlying findings from it are in the written submission to the committee. What are we doing about it? We are not just sitting around; a lot of activity is going on. Providers are constantly advertising posts, and many are taking advantage of the myjobscotland portal, which we are now able to access free of charge, which is brilliant. Members are looking at ways to increase recruitment, including local community job fairs, events at local supermarkets and shopping centres, use of social media and use of local newspapers, but all that requires a lot of resources, including time spent planning and the costs of advertising.

A national marketing campaign for social care, which began yesterday and will run into mid-January, is really welcome. However, there remains a lack of confidence among providers about how successful the campaign will be, because it is about awareness raising, and there is a very competitive job market out there.

On that note, retention remains a significant issue, and our members indicate that that is primarily due to burnout, stress, increased workload because of staffing shortages, and better pay and terms and conditions elsewhere, which is particularly true in remote areas, where retail and hospitality offer much better pay.

The convener asked what we would like to see, and I have a list. The next phase of the campaign needs to focus on recruitment and to tell people, “There are jobs available now—here they are”, rather than just generally raising awareness of the importance of social care, important though that is.

More national and sector collaboration is needed in order that we understand and address the specific needs of remote and rural providers.

We need increased consideration of retention, with national activity around that, in order to understand why people come into social care, why they stay and what needs to change to get them to stay longer.

In addition, organisations such as ours need to be included in more of the national and strategic discussions around that. I said in the submission that we were part of a rapid action group that was convened in the summer to look at recruitment. That group has been stood down, and we do not know where the discussion has gone. Wherever it has gone, we are not part of it, and that is serious.

Fundamentally, in social care what we need is much faster progress towards fair work. There is a lot of activity going on; I am part of that. We are looking at pay, terms and conditions and so on, and there is a great deal of promise. The committee will have seen the proposals for the national care service and what they say about fair work. My worry is that that is still years away. We are talking about this winter, but the national care service will not be here for a long time, so we need to do something much more immediately.

We also need a complete overhaul of the way in which social care is commissioned. In Audit Scotland’s submission to the national care service consultation, the Auditor General, no less, said that current funding and commissioning arrangements make it virtually impossible for employers to deliver fair work. It is not just me who is saying that—the Auditor General is saying it. However, the system persists with short-term and price-driven competitive tendering, and it is killing the sector and recruitment.

Finally, we need a reappraisal of the value of social care. With the greatest respect to my fellow witnesses this morning, I say that our system is very NHS-centric. To the extent that social care is considered to be valuable, its value is often assessed according to how far it relieves, or indeed contributes to, pressure on the NHS. However, social care is a public service in its own right, and it has a value of its own that is entirely distinct from the NHS and requires a distinct skill set and approach. That needs to be emphasised much more if we are going to attract people in. Therefore, there are short-term, medium-term and long-term approaches to recruitment.

That is helpful, and it is a springboard for my colleagues to ask supplementary questions.

I am delighted to be here today to speak on behalf of Unison members who arrange, support and provide social care across Scotland.

As members can see from my written submission, Unison Scotland has finished a survey of thousands of members in social care. There are some really alarming statistics around where they are headed this winter. In particular, I draw attention to the fact that 35 per cent of respondents are already considering leaving or are actively trying to leave the sector. A further 53 per cent are speaking about the fact that they urgently need a break. That should draw members’ gaze to the issues that we are facing.

With regard to the national care service, there are loads of proposals that will be very helpful to social care but, quite frankly, that is years away. We need urgent radical action. I will comment on three areas.

First, we need to boost recruitment. In order to do that, working in social care needs to be made an attractive proposition. That requires the organisations involved to fish in a different pond for people who are seeking jobs in other areas. To put it bluntly, the proposals to increase pay by 52p do not address the fact that those jobseekers are also looking for jobs in retail. We need something far more radical than that. With regard to recruitment, from providers that we deal with, we are sitting at a staffing level of around 90 per cent to 94 per cent, which is really concerning. We hear weekly reports that people are not attending their interviews. Recruitment is therefore an urgent high-priority issue.

The major issue of staff sickness follows on from that. The staffing level drops from 90 per cent to 94 per cent to around 82 per cent to 84 per cent when we factor in staff sickness. The reason for that is that, across Scotland, our members have not stopped since the beginning of the pandemic, and the demands just get greater and greater every day. They have constant shifts, and there is no work-life balance in social care. They are being asked to work to rotas that people in other sectors would not even begin to consider, to be honest. They give up family time, and they are pressured into picking up those shifts. That needs to change.

That takes us on to the issue of retention. We are just coming through the Covid-19 pandemic, and we are now facing a burn-out pandemic. We already have investigations into why there were so many Covid deaths. I am really concerned that, at the end of this winter, we are going to be investigating deaths that have resulted from staff shortages. I cannot impress upon you enough the messages coming from our members that they need help. They need more staff, they need more respect at work, they need to be valued, and they need fair pay and other measures. Those are all needed to keep people in the system.

As members will see, our submission contains a number of suggestions—to be honest, we could make a number more. The Scottish Government very helpfully brought in the social care staff support fund, which helps with sick pay to cover Covid-related absences, but the reality is that many social care workers who are off sick for other reasons do not get sick pay at all. It is therefore easy to see why people are choosing to move to other areas in which there is less stress and the pay is the same.

Colleagues will pick up on some of those issues and others, but I ask them to make a note of which witness they would like to direct their question to. We will not be able to go round absolutely everyone for every question.

Before I hand over to David Torrance, John Thomson wanted to come back in briefly.

I will be brief, convener. I just wanted to echo some of the comments that colleagues have made about demoralisation in the workforce, but I also note that, with regard to workforce planning and what might be called unknown factors in emergency medicine, one in five colleagues has stated that they plan to take early retirement in the next five years and one in two colleagues has stated that they plan to reduce their hours and work less than full time or, if they are already working less than that, to reduce their hours even further. As those factors are not being mitigated in workforce planning, we will be moving to an even greater crisis with a reduced workforce as a result of the pressure that colleagues are facing.

David Torrance has some questions on that very issue.

Good morning, panel. With regard to staff shortages in the NHS and the social care sector, what impact has Brexit had on your ability to recruit internationally?

I guess that we will want to hear from a couple of different disciplines. Perhaps the Royal College of Emergency Medicine representative can respond first, followed by the RCN and GPs representatives.

I am not aware that Brexit has had any significant effect. We tend to have full recruitment at the start of training schemes in emergency medicine although, unfortunately, we lose colleagues along the way for a variety of reasons. Those gaps, which become apparent further down the line and only several years after those colleagues start their training, are very difficult to fill, because people with similar experience who are not already working in the specialty simply do not exist. We therefore have to have multiple rotas at many different levels with significant gaps. However, we do not struggle to recruit to the specialty in the first instance.

Mr Poolman, have Brexit and immigration caused you any issues?

There has been a reduction in the number of individuals coming from European countries under the Nursing and Midwifery Council register, but that is a difficult issue to assess truly. After all, we have been dealing with the pandemic. Thankfully, we have not had huge numbers of people who have been recruited from the European Union leaving but, given the figures that have been reported, I think that the issue is causing difficulty in social care. Individuals who came to this country to work in social care have gone back, while individuals from the European Union have not continued to be recruited.

Has that had an impact? There has been no assessment that would allow me to give you the exact numbers, but there is no doubt that that, like all the other difficulties, has contributed to the situation.

Perhaps Annie Gunner Logan can give us a social care perspective on that.

With Brexit, it kind of depends on where you look. For example, in private sector care homes, which have quite a high proportion of non-UK-national workers, there has been an on-going campaign to get people to apply to the EU settlement scheme to ensure that they can stay.

For us, one of the biggest issues has been that the Migration Advisory Committee still regards social care as an unskilled area of work. Apart from that being a bit offensive to those of us who are involved in it, that does not help here, because we cannot recruit internationally. We have had some conversations with the minister about that, and we are involved in some of the initiatives to tackle that.

11:15  

If you were looking for a social care perspective on that, you would probably want to seek one from Scottish Care, which is the organisation that represents care homes specifically. It could give you chapter and verse on that.

I will come back to the BMA to round this off. I invite Dr Buist to address issues around Brexit and immigration.

Brexit has not significantly impacted on the majority of general practices. Most of our—[Inaudible.]—staff—doctors and nurses—are from Scotland or the UK originally. That is one thing, at least, that has not impacted on us.

It is clear that a range of factors have contributed to the challenges around retention. Brexit is often cited as the key issue.

To pick up on what Annie Gunner Logan said, what mitigation work was done by the Scottish Government for care providers prior to Brexit? Was a detailed piece of work done to tackle what were perceived to be the challenges around staffing as a result of Brexit?

Yes, there was some specific work around Brexit and social care. We were part of the working group, as were our colleagues in Scottish Care. Indeed, it was a much bigger issue for them.

We had a sweep of our third sector social care members on the proportion of EU nationals who were working in social care services in the third sector. That proportion was actually quite low, at about 4 per cent to 6 per cent. However, there are exceptions to that. I specifically cite Camphill Scotland, which has a very positive and strong approach to international recruitment. The proportion was more like 40 per cent for it, but it has to be said that that was a bit of an outlier.

There was a lot of work and preparation, and that work is still going on. For our membership, that is not top of the list of concerns. Scottish Care could give you much more information on that. Its survey of its own members showed that the proportion of EU nationals working in social care and in care homes in particular was very much higher.

I wonder if I might pivot on to a point that Colin Poolman raised. Everyone has spoken this morning about the challenges in retention. It is evidently a huge challenge to keep people in the system and to support people to remain in it. I am keen to understand from Colin Poolman whether he feels that the Scottish Government’s seasonal planning—the winter plan—has done much to support retention, particularly in nursing.

The additional investment in support—whether psychological support or other types of support—has, of course, been fully welcome. It is not great that it has taken a pandemic before further investment has been made to support staff, but it is there, and that is really helpful.

For us, the issue with retention comes back to numbers. It comes back to pressure and stress, and to the policies that we have put in place to support people.

We have been disappointed by the Scottish Government over the past week or so. On the one hand, we are telling our colleagues that they need to get their rest and recuperation; on the other hand, we are now offering to buy back unused annual leave. I do not think that that is a good message, and I do not think that any of my trade union colleagues think that it is.

The problem is that the pressures and the difficulties are on us, and the issue is how we get people through this. I think that there was £4 million of investment in rest areas and in making access to basic things such as food and hydration. That is welcome, and we will be keeping a close eye on that to see whether it actually makes a difference. Our colleagues tell us that they are looking for the basics—to be able to take their breaks, to get access to food and hydration, and to get the opportunity to take time off.

Although, as I have said, the money for the support services that are being set up has been really well received, one important issue is people not having the opportunity to access those services in their work time. We need to work as much as we can to ensure that people have access to the processes that we are putting in place. Last week, I was rightly challenged by a nurse who said, “It’s great that all these extra facilities are going to be developed for us, but they are no good to me if I can’t get off the ward, and actually it causes more frustration to see that being done.”

We have a lot of issues that we need to address and work through. It is all about the sustained pressure. To go back to my point about the workforce, every time somebody leaves, that increases the number of vacancies and the pressure on their colleagues around them. That is where the real difficulties are.

I want to come in on Mr O’Kane’s point about retention. One of the keys to retention is people looking after themselves and taking care of their wellbeing. We have talked about the exhaustion and burn-out that are happening. I want to mention the absolutely excellent resources that are available through the wellbeing hub, which is hosted by NHS Education for Scotland and which we have contributed to. I say that not just because I have recently joined the NES board—although I have just joined it, so I should declare that for the purposes of propriety—but because the wellbeing hub is a brilliant resource.

The challenge that a lot of social care employers and staff have in relation to that is making the time available for staff to access and use the resources. As we have heard from John Mooney and others, people are being asked to do extra shifts and to take on more responsibility, so it is challenging to carve out time to access those really good wellbeing resources.

I also want to mention the announcement in October of additional funding of £2 million for the social care workforce, which is being distributed through local areas. As of this week, only a handful of our members had heard from local authorities or health and social care partnerships about how to access that fund. The guidance on the fund was clear that it was for the whole sector and not just for public sector social care. However, one of our members has already been told, “No—this is just for local authorities; it’s not for you.” We need to tackle that straight away. We want streamlined and agreed processes for accessing the fund, because we find that the money is not coming to us. There needs to be some reporting back to the Scottish Government on how the money is being used.

Thank you for that. I think that you have just reported back, so that is on the record.

A couple of our witnesses who are online want to come back in.

I want to come back in on the spirit of that conversation. From listening to our members, I think that the real answer is recruitment. We need to boost recruitment to take the pressure off the people who are currently delivering the services, because they are so close to burn-out. I will illustrate that with a couple of responses that we have had from members. One said:

“Get us help soon!! It will be too late, if it’s not sorted NOW!!”

Another said:

“Help us before we get burnt out ... I’m on the edge and feel nobody cares”.

Boosting recruitment is probably the best thing that we can do to help with retention.

From an emergency medicine perspective, the one thing that staff highlighted that would improve their wellbeing was improving patient flow within emergency departments. So, actually, improving the experience for our patients was the most important factor that staff highlighted in terms of their wellbeing, which is an interesting conclusion.

One possible untapped resource is the people in allied health professions who dropped off the Health and Care Professions Council register because they had to take a career pause to care for young children or parents, for example. Return-to-work schemes might be very useful in attracting some of those people back. Many health boards have very positive and flexible working policies for people. It might be helpful to try to attract people back into unfilled posts and to provide boards with support to run return-to-work training schemes.

A few members want to talk about recruitment and pick up on issues that have been mentioned. I remind members to direct their questions to individuals, if possible.

My question is probably for Dr Andrew Buist. The Scottish Government has made a commitment to recruit 800 GPs by 2027. Obviously, we have a problem with the number of GPs reducing their hours and working part time rather than full time. Should there be a headcount of 800, or should we focus on full-time equivalent?

When the announcement was made, it was not specified whether the figure related to headcount or to full-time equivalent. Using headcount tends to deliver less—about three quarters of what would be delivered using full-time equivalent. To deliver what we need, 800 whole-time equivalent would clearly be better for Scotland. As I said earlier, I do not think that we have made any progress on the matter so far, so even having a headcount of 800 would be a positive step forward, but 800 whole-time equivalent would be better. We need to up our game in delivering the additional workforce because, four years into the process, we are largely where we were at the beginning of it.

It is difficult to direct this question to one particular person. Given how desperate the nursing situation is, what would be a realistic timeframe for recruiting people from other countries and getting them into the workforce?

I think that that question is directed to the RCN.

International recruitment has its challenges. There are ethical considerations that we all need to think about. The Scottish Government is talking about recruiting about 200 nurses before April. If we are going to recruit internationally—as I said, we have concerns about that—we need to recruit people from countries where there are more than enough nurses so that we do not take away nurses from struggling health systems. We need to consider that.

To be fair to the boards, a number of them have already moved. One board is recruiting nurses from Hong Kong who have shown a willingness to come to the United Kingdom, and specifically to Scotland, which is excellent, so it is clear that more people are coming. Realistically, it takes about three to six months to go through all the processes and get people in. If the people can come straight on to the Nursing and Midwifery Council register, there is an adaptation programme period, which will add a few months before individuals are able to be fully active in the workforce. Recruitment obviously takes time.

It is like everything that we have talked about. We need to look at every small detail around recruitment of individuals, such as people who have left the profession coming back in. We need to look at every opportunity, and the more small numbers we add, the more it will make a significant difference. As I say, it would take months.

11:30  

My question is directed to John Mooney of Unison. I absolutely care about what is happening in the social care sector, and in particular to the workers in that sector. If there was one thing that we could push the Scottish Government to do now, what would you suggest that it be?

At the top of our list are some kind of golden hello and a loyalty payment—some kind of lump sums. A golden hello would, I hope, attract people into the sector, and a loyalty payment would help to retain people as well as make them feel valued for the work that they have done. We have said from the start that it is great to give people recognition by clapping for them, but claps do not pay bills. Low pay throughout social care is still an issue.

In a situation where golden hello payments are being made to heavy goods vehicle drivers so that we can all have the latest iPhone, I would say to the Scottish Government that we need to look at valuing the care that our elderly relatives and disabled people—who are the most vulnerable people in our society—are receiving. I would urge that option to be considered as an absolute starter for 10, to be honest. There are many things I could mention but, as a starter, that would have an instant impact.

I invite Annie Gunner Logan to come in on this point.

On John Mooney’s point, some organisations are already trying to do the golden hello and the enhanced payment, where, if someone has been doing the job for a year, they get more than the real living wage or the basic pay.

The important thing about what John Mooney is saying is that, if only some organisations but not others are able to offer that, the churn between social care organisations will be increased. If there were a national approach whereby everybody starting in social care got a golden hello and everybody in social care got an enhancement after a certain amount of time, that would need to be funded right across the board, and it would eliminate the competition between organisations that characterises social care.

Paul O’Kane wanted to pick up on that.

My question is for John Mooney, and Annie Gunner Logan might be able to comment as well. The point that you have made is essentially that we need to deal with pay in the care sector more broadly. John Thomson alluded to the fact that you can work in a supermarket or do bar work and earn more money than you can in social care. What is your view of trade unions, such as the GMB, Unison and others, campaigning for £15 an hour as a standard wage for care work?

I think that our members are absolutely worth that. To be honest with you, they are worth more than that. It is clear that their pay is currently pitched low. It just is not lifting people out of the pond that is fished in for retail staff. You also need to look at some of the plans for this winter, including putting another 1,000 staff into the NHS. The reality is that, because of the difference in pay and in terms and conditions, those people are likely to be current social care staff.

We need to look at social care in the round. I think that Annie made the point in her opening statement that social care is judged on the basis of its impact on the NHS, and that is true. We need to look at all the different roles in social care. We need to look at what is required to run social care, and to make sure that, in the worst case scenario, it is given a fighting chance to recruit the staff that it needs.

We are going to start drilling down on issues around some of the witnesses’ specific disciplines. Some members have questions specifically about accident and emergency services, which I imagine will be directed to Dr John Thomson.

I will buck the trend, convener, as my question is for Andrew Buist of the BMA, although it relates to A and E.

How does the BMA respond to claims by the Royal College of Emergency Medicine that demand in A and E is now partly attributable to reduced access to GPs and primary care?

Thank you for your question—it is interesting. We are part of one big joined-up system. As I mentioned earlier, when we looked at activity in general practice last month, we saw that in one week in Scotland, more than 500,000 GP appointments were given out. In a typical week in accident and emergency, there are around 25,000 attendances, which means that in Scotland, 20 times as many people have a consultation with their GP each week. If 1 per cent of those GP attendances, or 5,000 people, go to accident and emergency instead, that represents a 20 per cent increase in A and E attendances, so you can see how the gearing affects the numbers significantly.

With regard to last week’s announcement on redirection from A and E, that is a policy that I have supported. Indeed, in July last year, when we were discussing the redesign of urgent care—a policy that I do not support—I suggested to Jeane Freeman that A and E departments in Scotland should adopt the redirection policy that works in Tayside, which has helped our attendance—[Inaudible.]—to stay above 90 per cent consistently. She did not want to do that at the time, but the Government has now decided to go ahead with it. I support that because, as long as we explain to the public how the system works and where the right place is for people with different types of medical problems to attend, and—importantly—if we ensure that there is capacity to deal with people in the areas where they are redirected to, it is something that we should support.

However, as I said earlier, general practice is absolutely maxed out just now. We are providing more than 500,000 appointments a week, which is putting a considerable pressure on general practice. Our numbers have gone up, and our capacities are down because infection control measures mean that we are slightly less efficient. Consultations are up because there is a rising level of mental health issues, which tend to be dealt with in general practice.

There is significant back pressure from hospitals affecting general practice. When someone is referred for an operation and has to wait for more than a year, and they continue to have problems while awaiting surgery, the only place that they can go is general practice. Patients may face long waits for investigations in hospital, and again they tend to come back to general practice. We are actually performing extremely well, but it is taking its toll on us. If some of those people are overflowing into A and E, that is somewhat inevitable, given the pressures on general practice and the numbers of patients that we are seeing. As I said earlier, every week, one in 10 people in Scotland has contact with a general practitioner for a consultation. I do not know whether we can do much more than that. That is why it is desperately urgent that we start to build the GP workforce.

I see that John Thompson also wants to come in on that question.

It is important to say that the Royal College of Emergency Medicine in Scotland has never said, at any point, that people are attending A and E because of a lack of access to primary care. I agree entirely with Dr Buist’s comments about the pressures on primary care. It was a colleague in the college in England who said what Sue Webber has highlighted; it is not something that we have ever said in relation to access to primary care. It is important that that is made clear.

It is clear that the traditional points of entry for access to healthcare are emergency services and general practice, and we are hearing quite loudly from both of you today that those are the services that are suffering the most right now.

I will take a couple of quick supplementaries to Sue Webber’s question from Emma Harper and Sandesh Gulhane.

On NHS 24 referrals to the out-of-hours service and the impact on winter planning and capacity, is there a role for the Government, doctors and the bodies representing wider multidisciplinary teams in helping make the public aware of the solutions that need to be put in place to deal with capacity issues? Do we need to manage the public’s expectations better, especially with regard to all the different ways of referring people to services, whether they be GP out-of-hours services or emergency services? Perhaps Dr Buist can respond first of all.

I am delighted to come back on that question. I have been calling on the Scottish Government to put that sort of thing in place since September last year. We absolutely need to take the public with us by explaining to them what is going on. Right now, we do not have the level of capacity that we would normally have to meet all their needs, so there has to be a degree of prioritisation, which means that, sometimes, those needs will not be met or will not be met as they would have expected. We need to explain that to the public to ensure that they understand and help us get through what we expect to be a difficult winter.

Do you think that the public are still not, for example, using their pharmacist as much as they could be and are not aware of the services that they can get at the pharmacy and which might mean that they do not need a GP appointment? Is that still an issue?

It probably is. Another door drop is planned over the next few weeks to explain to the public the available options, but I think that many people are still not fully aware of the pharmacy first option and how useful it can be for many conditions that might otherwise have to be seen in general practice.

I see that some other panellists want to respond.

Care navigation is still very much needed, although health boards and practices in different areas have it to a greater or lesser extent. However, what we in the Allied Health Professions Federation have noticed is that more allied health professionals are acting as the point of first contact. According to a number of short-term evaluation projects that are being undertaken, those first-contact practitioners in GP practices are getting quite a positive response and are having a positive impact, so it is more a matter of care navigation and signposting patients to others apart from GPs who can meet their needs.

My question is for Dr Thomson and Dr Buist. As we know, 85 per cent of all patient contact happens in primary care, and given that demand, there will be patients who will quite clearly be desperate to go to A and E instead. However, they might then be redirected from A and E back to their GPs. Is there a set of patients who are simply being passed between primary care and A and E, and if so, what can we do to stop that happening?

That is clearly a risk. I have to say that I support the redirection policy, but it needs to be introduced sensitively and with a degree of flexibility by the senior clinical decision maker at the front door.

Once such a policy gets established, the public get to know that turning up at A and E with the sore back that you have had for two months will not get you seen, and in areas such as Tayside, where they have been doing this for a number of years, patients have stopped turning up at A and E and are going to their GP, as is appropriate for such problems.

However, I worry about a merry-go-round and people being passed around. That is why I am strongly against the policy that is being pursued just now on the redesign of urgent care, through which patients who would previously have attended A and E are supposed to phone 111 to get NHS 24. Sometimes, they have to wait 20 to 30 minutes to have the first call answered, and the idea is that they are maybe given an appointment time to go to A and E. That could be for someone with a cut to their leg or a broken wrist. The policy is full of flaws and will have unintended consequences, one of which is the merry-go-round that you refer to.

11:45  

It was good to hear from Dr Buist about Tayside, where the NHS is working together with local authorities to roll out the enhanced community model, which relates especially to older people at home. However, my question is for Annie Gunner Logan and perhaps John Mooney. Integration joint boards have done quite a bit of work on preventing admission to hospital and ensuring that people are discharged as quickly as possible, which fits with the Tayside model. What are your views on how helpful that can be? How much of that model do we need to incorporate in future?

That is an interesting question for our constituency of interest. Most third sector providers support people who sometimes have very complex social care needs but who are not in and out of hospital. The issue goes back to what I said at the top of the meeting about seeing social care through the prism of the extent to which it acts as a pressure valve for the NHS, which is where I think your question is going. Most of our members support people who have learning disability and perhaps mental health issues and who are not being admitted to and discharged from hospital. They use the NHS just as you and I use it.

You are probably referring to delayed discharges for older people. An awful lot more could be made of the third sector in that regard. I recommend that you speak to organisations such as the British Red Cross, which has some fantastic home from hospital services. Those are not registered care services in the way that we conceptualise social care, but they do a huge amount, and that is with volunteers, so the staffing and recruitment issues are entirely different.

The delayed discharge issue tends to focus on old people who are admitted to hospital, sometimes in an emergency as unplanned admissions, and then who cannot be discharged because social care packages are not available for them. There are a number of ways to tackle that, but that is not really the main area of activity for our membership.

On A and E, we have a final question from Gillian Mackay.

I am particularly concerned about regional variations in waiting times between health boards. For example, in NHS Forth Valley, which is in my region, for the week ending 24 October, only 51.8 per cent of people attending A and E were seen within four hours. That was a considerable improvement from the figure of 41 per cent for the week ending 10 October, but it was still considerably lower than the national average. NHS Forth Valley will be subject to the same acute pressures that exist elsewhere. I wonder whether Dr Thomson has an insight into why particular health boards seem to be struggling with that more than others are.

You raise a very valid point. The demands on emergency departments are unrelenting, and the performance on the four-hour standard for the month ending September was the lowest since records began. We have more patients waiting for more than eight hours and more patients waiting for more than 12 hours than we have ever had before, and that results in crowded and unsafe emergency departments.

For the week ending 31 October, there was no major emergency department in Scotland that did not have patients waiting beyond eight hours, and all bar one had a number of patients waiting for more than 12 hours. Indeed, in some departments, some patients are waiting for many days for a bed. That simply reflects inadequate capacity in the system for patients who need to be admitted to hospital. On average, emergency departments admit about 30 per cent of the patients who attend—the vast majority are seen and discharged—but that 30 per cent are waiting far longer for beds, and we know that patients who wait for that length of time come to harm.

Do we have a sense of why certain health boards are struggling with the issue more than others are? Is it because of the number of consultants in particular health boards or is it, say, an issue of geography? NHS Forth Valley, which I have used as an example, is a relatively urban health board and its A and E numbers are worse than those of NHS Lanarkshire next door, which is on a higher crisis footing. Do you have any particular insights into why some health boards are struggling more than others are?

You mentioned the variation across Scotland. Some emergency departments deal only with emergency department patients, while others are the conduit for all admissions to a hospital. In some hospitals, patients who are referred from primary care will go directly to a ward, while patients in hospitals in other board areas will wait for a bed in the emergency department.

There is significant variation across the country, but the main issue that is causing the very poor performance, which equates to very poor patient experience with regard to the length of time that patients are waiting in emergency departments, is the lack of bed capacity in the system. We estimate that, nationally, we are short of approximately 1,000 acute beds, and unfortunately the expectation as we head into winter is that patients will have to spend longer and longer in emergency departments and will therefore come to more harm.

Thank you for that useful insight.

We need to zero in on some specific areas, so I ask colleagues to direct their questions to particular witnesses. First, Evelyn Tweed has some follow-up questions on social care.

My questions, which are for Annie Gunner Logan, are about capacity in the social care sector. I know that there is an acute shortage in my Stirling constituency, but can you give us a flavour of the general picture across Scotland? How can we help with the issues that are being experienced in remote areas?

Capacity is a big issue. As I think I mentioned earlier, we surveyed providers on their recruitment issues, and some of the findings related to capacity. The providers were all pretty large organisations that operate in multiple local authority areas, and of the 30 that responded, 63 per cent—or just shy of two thirds—said that they had already had to reduce capacity for service delivery as a result of recruitment shortages. I have to say that we were surprised that the figure was as high as that.

Also, 53 per cent of those providers—more than half—said that they had refused or would have to refuse any new care packages even if commissioners came to them and asked them to take them on. Those are pretty significant numbers. We have not seen anything like that before the current period, when we are 18 months into a pandemic and approaching the winter.

The situation is serious. What we can do about it very much hinges on how we get more people into the workforce. The social care workforce is very different from the NHS workforce. Typically, the NHS model is that people train, qualify and then start work. In social care, people start work and then they train and qualify. We do it the other way round, and a lot of recruitment is more values based. It asks what kind of person someone is and whether they are the right person to do this kind of work. If they are, we get them in and then we start to train them and get them qualified.

The kinds of issues that colleagues talked about in discussing how long it might take for nursing and medical staff to come through the system do not really apply in social care. If social care was an attractive enough option for people, they could start tomorrow. We need to make it more attractive for people to start tomorrow. In remote and rural areas, that means social care being able to compete purely on pay with retail and hospitality. Overall, it goes back to fair work, making social care something that people want to do and making sure that people understand what it is.

At the beginning of this evidence session, I talked about the value that is placed on social care and what people think it is. It is not just a pressure belt for the NHS and it is not just about “time and task” personal care. It is actually about standing alongside people and supporting them to live their best lives. That is what social care is about, but we do not hear a lot about that. We also do not hear social care mentioned in the list of public services that people like to speak about when they are on platforms. Doctors, nurses, teachers and so on are mentioned, but social care is nowhere. A whole lot of awareness raising needs to be done there.

In the immediate term, we could get people through the door tomorrow if it was attractive enough, particularly in pay terms. It is really as simple as that.

Thanks, Annie. That is really helpful.

My question is also for Annie Gunner Logan. I have heard a lot about unpaid carers being in crisis because they feel that they cannot access the packages that they need or because they have been told by their local authority that their package will have to be scaled or cut back. In relation to care at home, that is the case not only for older people, but particularly for people who have learning disabilities. From the work that you do with providers and your survey work, do you have the sense that there is something of a crisis for unpaid carers, too?

Yes, I think so. Some of that is also a hangover from the pandemic. I said that our sector does not need remobilising because we have been here all the time, but there are exceptions to that in congregate care settings. We know about care homes, but there has been very little focus on buildings-based daytime opportunities, and especially on short breaks for carers—what we used to call respite.

A lot of those settings had to close at the beginning of the pandemic simply because of the restrictions on the numbers of people who were allowed to meet indoors and social distancing. Those buildings-based congregate settings could not admit people any more. That has meant that a lot of family carers have not had a break at all for 18 months—they have had no support whatsoever.

That relates to something that I was going to ask the committee to consider. You have a lot of providers on your panel this morning—including me, as that is who I am speaking on behalf of—but there are also a number of user-led organisations that have a lot of information on the issue. Inclusion Scotland is one of them, and there is the Glasgow Disability Alliance and the Coalition of Carers in Scotland. They have been tracking what has been happening to people’s support, and it is not a particularly happy picture.

It is not for me to tell the committee what its business should be, obviously, but I thoroughly recommend that, at some point, you have a session with those organisations, because you would get some rich information that would come from the people who have lost out on receiving social care. I can talk about the staff, the providers, the impact on the sector and all the rest of it, but the really important thing is what is happening to people who rely on social care. The capacity issues that we have in the sector have had quite an impact on them, for sure.

12:00  

I would like to move on to questions about improving outcomes. That has been alluded to in everything that we have talked about so far. How we improve health outcomes for people over the winter is really the crux of the matter, and witnesses have pointed to quite a few of those areas. Emma Harper has some specific questions on that.

This evidence session is looking at planning for winter and how we can improve outcomes. I am the co-convener of a few cross-party groups on healthcare, including the one on health inequalities, and we know that we need to improve the outcomes for many people. Earlier, we heard from the minister, Maree Todd, about the women’s health plan. Do any of you have specific proposals for improving outcomes, not just for the winter but in the future?

Would you like to direct that question to anyone in particular?

Let us go first to Annie Gunner Logan.

That question goes to the heart of what we are all here for, does it not? Our recipe, if you like, for improving outcomes was contained in our submission to Derek Feeley’s review of social care. There are a whole range of approaches to improving outcomes. For us, fundamentally, it means that we drop the whole idea of competitive tendering for social care. That takes us nowhere in relation to improving outcomes. It is about having a skilled workforce, which is discouraged by competitive tendering and the current commissioning arrangements.

It is also about standing alongside people and letting them make their own decisions. Interestingly, for us, the national care service consultation did not have quite enough to say about that, or about the importance of self-directed support. In social care, that has been legislated for for eight years now. The whole point of self-directed support is that people identify their own outcomes and then the role of social care is to support them to achieve those. That, for me, is the absolutely essential part of all of this. We need to be really serious about self-directed support. We need to implement it properly, put more resources behind it and get it moving.

That is certainly what Derek Feeley said in his report, so at the moment there is a little bit of a mismatch between what he said and the proposals for the national care service, as they stand. I think that the job that we all have to do over the next few months is to make sure that they realign. The best people to tell you what outcomes they want to achieve are the people whom we support.

Unison’s long-time stance is straightforward: having a highly trained and valued workforce is the best thing that we can do to improve standards in social care. We have been pushing for that throughout the Feeley review and the national care service review. That work has got to be centred on the fair work principles, and that is certainly the direction in which we should be going. We talk about an overnight fix for the staff shortage issues. Lots of the fair work principles are not going to deliver overnight success, but in the medium to long term, that is the route that we should be going down.

I will probably not surprise you when I say that the conflict between private profit and care that provides a top-notch service is clear for Unison to see. I am disappointed that private profit appears to be accepted in the national care service proposals. Lots of members who responded to our survey said that, even though they are struggling to provide the services that they currently provide, there are still organisations out there tendering for new services. In essence, members are saying that, if they had the level of training that they need, things would be a lot better for service users on the ground.

We need to shift some of the resources to prevention and early intervention or think more about how we can develop resources for that. Prior to the pandemic, we had begun to see that shift, but the needs of the population have changed because of the pandemic, and there is a requirement for more therapeutic intervention and longer rehabilitation. A lot of the allied professions workforce has therefore been diverted to address those acute issues rather than focusing on prevention and early intervention. For example, it could be about supporting people with low-level or medium-level frailty in the community so that they do not access A and E or acute services. We need to shift resources to that preventative agenda.

My next question is about avoiding harm. The submission from the Royal College of Emergency Medicine states:

“The data show that for every 67 patients waiting 8-12 hours, one of them ... will come to avoidable harm.”

Obviously, we need to think about how that can be avoided. Data on each harm that occurs is required to be entered into a system so that it can be tracked. I think that it is the Datix system, which I know because I am a former nurse who used to enter adverse events into that system. How do we ensure that our GPs and our doctors have a wider ability to utilise the system to learn so that harm can be avoided in the future?

There is clear evidence that, adjusting for all other confounding factors such as age and deprivation, a wait in an emergency department of eight to 12 hours increases mortality for that admission. As you said, for every 67 patients who wait for between eight and 12 hours for admission to hospital, there will be one avoidable death that is related purely to that excess wait in an emergency department. That is absolutely unconscionable and it is completely avoidable with the correct capacity in the system. We do not know what harm that does not result in death is happening to those patients who are waiting for a significant time.

Emergency department staff are not trained to look after patients for many hours after their initial assessment and immediate management. Therefore, those patients, despite the best efforts of all our staff, are receiving poorer quality care than they would receive if they were in the correct bed under the correct in-patient specialty. There is no doubt that, as we head into winter, if we see a continuation in the long waits for beds in emergency departments, that issue will continue. These are not patients waiting to be seen; they are being seen within an appropriate timescale and are then waiting many hours to move to an appropriate in-patient bed.

We have a couple more questions to ask you all before we finish. Staff welfare has been mentioned many times. A number of colleagues wanted to ask specific questions about that. I ask them to make their questions direct and quick.

Okay—I will try. I had a long question, but I will make this as succinct as possible. Given the challenges and restrictions, how feasible is it to provide nurses who work in the acute sector with the opportunity for flexible working, with a view to improving their wellbeing and retaining those members of staff?

I guess that we will go to the RCN for that.

That is absolutely possible, and there should be no restrictions. We should look at all flexible working options for any individual who wants them. If that will retain someone in the service and help them to maintain their health and wellbeing, that is what we should do.

I do not think that there are any barriers to looking at flexible working in the acute sector or across the whole health and social care sector. We need to work much more with our workforce on what suits people’s work-life balance, and that means looking at flexibility of opportunity and employment. I would far rather have individuals who can work some of the time and even extend their careers than—I will use this word—flog people until they feel that they have to leave. There are no barriers; it is about making choices available.

Thank you. That is great to hear.

The Government is looking to attract people who retired early to come back. Would the flexible approach that Colin Poolman talked about help to attract such people back?

That is a huge point, convener. There are people who have left whom we want to attract back. There were some pension implications in that regard, but there was a change as part of the pandemic emergency measures. Moreover, we have an ageing workforce and, given changes to pension provisions, we know that a lot of people are considering retiring now. We need to ensure that we keep that expertise in the workforce, to provide mentoring and support as well as patient care. Both things are important.

When we have got it right, we have seen a number of people come back during the pandemic—although not as many as we would have wanted or hoped to see. We must ask those individuals, “What did we do that made this work for you?” Then, we can improve the offer as well as retain individuals in the workforce. Individuals who choose to retire take so much experience with them, and we need them to support our newly qualified nurses and help them to develop into the best practitioners that they can be.

We absolutely need to look at the issue. We have been talking about it for years, as many members know, but we have not yet got it right.

I support that. In social care—I know from colleagues in the NHS that this applies there, too—staff are looking for a degree of flexibility in their work. Many people are considering moving on to the bank or have already done so, and the only reason for doing that is to gain more control over their shifts and how they work. We need a more modern approach that meets people halfway, so that we maintain service provision while giving people the work-life balance that they want. We really need to go down that route in the future.

The general question was about staff wellbeing and welfare. As I have said before, fair work is absolutely top of the list, and access to wellbeing resources is important, too.

In our sector, it would also help enormously with morale if staff in commissioned services were not treated as second-class citizens, compared with people in the rest of the system. I said in our written submission that the uplift of the minimum wage for care workers to £10.02 is brilliant—it was a fantastic announcement—but the policy is now entangled in a load of implementation problems, which we think will make things worse rather than better for some organisations, simply because we are not viewed as an equal part of the system, compared with public sector employees. That is hugely demoralising for staff in our sector.

The same goes for organisations. In our submission, we talked briefly about some of the financial support that has been made available to the sector. That support is hugely important and we are very grateful for it, but the way in which it is being administered is an absolute catastrophe.

As third sector organisations, we all feel that we are slightly outside the loop. Parity of esteem would help tremendously with staff wellbeing, and for all of us working in the third sector. We are trusted enough to provide very intensive personal support to hundreds of thousands of people, but we are not quite trusted enough to deal with the money and the support in the same way that other organisations are. That really needs to stop now.

12:15  

We are coming to the end of our session, but Paul O’Kane has questions about lessons learned from dealing with Covid last year.

Thank you very much, convener. I appreciate that we are tight for time.

We are still living through the pandemic, and last winter was unprecedented. I am keen to understand how you feel about the lessons learned from last winter. Has the Government learned what worked and what did not work so well, and have those lessons been factored into the winter preparedness plan?

The winter demands that we see year on year are entirely predictable. In my experience, we put in place short-term mitigation measures over that period, and we do not put in longer-term solutions that allow us to deal with fluctuation in demand. For example, over this period, it is entirely normal to reduce the amount of elective surgery to accommodate the increased bed space that is required for unscheduled care admissions. We do that every winter and, as the numbers of admissions decrease, we revert back to normal.

I think that it will be the same again this winter. Short-term mitigation will be required, and I do not see anything having changed that makes things any different for this coming winter compared with any previous winter. There is very much an element of cross our fingers and hope that we cope.

We see those pressures every winter, and I take your point about elective surgeries. However, do you feel that the unusual circumstances of the pandemic and the cancellation of more and more elective surgery will create a problem for us at the other end of winter?

Yes. I think that any remobilisation plan that has been discussed or published in regard to Covid recovery, particularly in relation to waiting lists in surgery, has not taken into consideration unscheduled care. Without doing so, it is likely to fail.

There needs to be a single overview of the capacity that is required for unscheduled care. Although it is unscheduled, it is relatively predictable. We know at which points in the year we are particularly busy and at which points we are not. The concern this year is that, during autumn, which is normally relatively a quieter time, we are at our worst-ever performance. It is far worse than that in any previous winter, and we are not yet in winter.

What will happen again is that medical patients will be admitted to surgery beds, because that is where the capacity is in hospitals.

Annie Gunner Logan wants to come in. We will then have to wind things up.

On the question about what we have learned and not learned from last year, I have long come to terms with the reality that, on behalf of our sector, I tend to say the same things that I said the previous year and the year before that. That is also true this year.

Staying positive, the Feeley recommendations and the national care service proposals would go a long way towards supporting social care in the way in which it needs to be supported in the winter or at any other time. However, that is a very long way off.

On the Scottish Government learning lessons, I think that there is a broad understanding of what needs to be done, but we are not doing that yet. I go back to what I said about the long-term prospects being quite positive but some very rapid action on some of the issues being needed in the short term. Unfortunately, a lot of that action will require money.

Quite a lot of money has already been allocated. The £10.02 per hour pay is brilliant, and we are all very pleased about it, but I am not sure whether it will do the job this winter. Some of the implementation methodology around it and some of the other financial support that we have are just not doing it. We need an injection of urgency and speed into some of the solutions that we already know will work.

Thank you. Unfortunately, we have gone over our time. I thank everyone who has given evidence this morning. If there is anything that you want to follow up on, the committee is always here to receive emails and letters about specific issues on which you feel that you did not get time to express a view. Everything that the witnesses have said this morning is extremely helpful to us.

At our next meeting, on 16 November, the committee will take evidence from the Minister for Mental Wellbeing and Social Care on session 6 priorities.

12:20 Meeting continued in private until 12:38.