Contents
- Attendance
- Covid-19 Health Protection Travel Regulations
- Section 23 Report
Section 23 Report
“NHS in Scotland 2020”
Item 2 is an evidence session on Audit Scotland’s report, “NHS in Scotland 2020”. I welcome the Auditor General for Scotland, Stephen Boyle, who is accompanied by Leigh Johnston, senior manager, and Eva Thomas-Tudo, senior auditor, both from Audit Scotland’s performance audit and best value team. We start with a short statement from the Auditor General.
Good morning, everybody. I am delighted to be with you this morning—many thanks for inviting us to speak to the committee. Our report on the NHS in Scotland focuses on the Scottish Government and the NHS—[Inaudible.]—Covid-19. We also give an update on the financial and operational performance of the NHS during 2019.
The NHS has faced unprecedented challenges as a result of Covid-19. NHS staff have worked tirelessly in difficult circumstances to deal with the demands of the pandemic while maintaining access to essential services, which reflects their extraordinary commitment.
The Scottish Government had difficult decisions to make about how to prevent the NHS from becoming overwhelmed. During the first wave, non-urgent treatment and national screening programmes were paused. There are longer-term risks associated with some of those decisions, but the Government needed to create additional capacity for Covid patients. There is now a significant backlog of patients who are waiting to be seen, but the pandemic is on-going. Continuing to respond to the pandemic is resource intensive and takes priority over resuming the full range of NHS—[Inaudible.]
The way in which the NHS delivers its services has changed drastically, with many new approaches being established. Several large-scale initiatives, such as the Covid-19 community hubs and the widespread use of virtual appointments, together with the procurement and distribution of huge amounts of PPE and the creation of the NHS Louisa Jordan, were implemented at pace, which involved working in partnership to an extent that had not been seen before. Looking forward, stable and collaborative leadership will be required to remobilise and renew the NHS—[Inaudible.]
Covid-19 has not affected everybody equally. Those from our most deprived communities, and those from certain ethnic minority backgrounds, are more likely to have been hospitalised, or to have died, as a result of contracting Covid. Scotland’s long-standing health inequalities need to be addressed.
The Scottish Government could have been better prepared. Planning for a pandemic had not been sufficiently prioritised, and improvements that had been identified through pandemic preparedness exercises were not all fully implemented. Covid-19 is expected to cost an extra £1.7 billion in expenditure across health and social care during 2020-21. NHS boards are being fully funded in this financial year, but there is uncertainty about the long-term financial position.
My colleagues and I are delighted to be with the committee this morning, and we will do our best to answer your questions.
Thank you. You talked about the longer-term risks arising from decisions that were taken early on in the pandemic. You mentioned in particular people waiting for operations, and screening opportunities that were missed. Has it been possible for you to quantify those risks? It is clear that they exist; we know about delayed operations and so on. Is it possible to quantify the volume of cases that might be affected, and the level of risk that is involved?
I will start, and then I will invite Eva Thomas-Tudo to come in, because she has done a lot of the data analysis.
The general point that we make in the report is about the need for transparency around the extent to which services have been delayed, so that patients are clear on their anticipated wait time for future access to services. The report refers to the Government’s intention to pause what had been a significant programme of improvement in waiting times and, in the light of the pandemic, to move to category prioritisation. We emphasise that that needs to be done clearly so that patients understand what it means for their access to services in the future.
There are significant implications arising from the pandemic. However, the report does not assess the extent of the health implications for individual patients as a result of the pause. We emphasise that clarity is needed as to what that means for future service delivery, in order to allow the NHS, as it goes through significant remobilisation and planning, to do that in an open and transparent way.
I ask Eva Thomas-Tudo to say a bit more about what the data has shown us.
Exhibit 5 in the report gives a good indication of the pandemic’s impact on demand for, and activity in, NHS services. It shows that the number of people who are waiting for treatment, and waiting much longer, has increased since the start of the pandemic. It also indicates that referrals to hospital care have decreased, which comes with associated risks. The likelihood is that there are not fewer people needing hospital care, so the reduction in referrals could indicate that people who would otherwise have been referred for hospital care have not been referred since the start of the pandemic. We will be looking at the longer-term impact on health outcomes as a result of that.
To give you an indication of scale, the number of referrals from all sources, including from general practitioners, was approximately 450,000 in each quarter of 2019. That number reduced to 188,000 between April and June 2020, so less than half the number of people were being referred.
The numbers that are involved are really quite substantial.
The report also covers the issue of how far the Scottish Government was able to project the needs arising directly from the pandemic. For example, there are questions around bed capacity in hospitals, intensive-care capacity and testing capacity. Have you drawn a general conclusion as to the effectiveness of those predictions and whether more accurate predictions might have had different results?
Again, Eva Thomas-Tudo can say a wee bit more on the capacity in hospitals. I will start by saying a little about testing capacity and what our work has found. We report in detail on some of the numbers around testing capacity. We note that by December 2020, the Government had in place an effective test and protect system in accordance with the criteria that were set by SAGE. Its capacity was such that it was able to test and trace up to the relative levels of percentages that allowed it to meet those criteria.
We did not go into as much detail on overall bed capacity. In this report, we looked to form initial assessments during the pandemic, with the clear intention, in our next report during 2021, to give much more of an update on the impact of the pandemic, what the health outcomes are beginning to look like and the extent to which public money has been well spent. Eva Thomas-Tudo may wish to say something on that analysis.
At the start of the pandemic, intensive care capacity was increased. That is one of the main reasons why a lot of the non-urgent care was paused: to increase capacity for Covid-19 patients. That meant that the NHS was not overwhelmed during the pandemic. Intensive care capacity was increased from 173 beds to 585. At the peak in the first wave, the number of Covid-19 patients and non-Covid-19 patients in intensive care was 250. That shows that if the NHS had not increased intensive-care capacity, it would have been overwhelmed, so that decision was effective.
I want to follow up on that, perhaps with the Auditor General in the first instance. We have seen two waves of Covid cases in hospitals, and issues have arisen as to how quickly ordinary services—elective operations, for example—have been restored as the Covid numbers have gone down. Did you take a view on that in the first wave, and have you any recommendations in relation to the current position, in which cases in hospital are—we hope—now going down again?
I lost the sound a little bit there, convener. I think that you were asking about the detail of our work on the implications of the clinical choices that were made.
We have heard about how routine work was set aside at the outset because of Covid. The next question is, when does the NHS return to that routine work, now that the worst peaks of Covid are behind us? Did you take a view on that in 2020, and do you have a view on it for 2021?
You are right, convener—that certainly forms a key part of our work during 2021. In this report, we focus in particular on a couple of key points. One is our analysis of accident and emergency attendance. We saw throughout the early stage of the pandemic that attendance at A and E dropped significantly. There were risks around that for patients in all cases, in particular regarding acute instances of heart disease, stroke and other illnesses that might not have been detected at an A and E presentation as they might otherwise have been.
We tracked that attendance during the year, and we report that the NHS is open campaign resulted in a growth in A and E attendance, but the numbers are not yet back to previous levels. Attendance dropped away again in the autumn, during the second wave, and there is still some nervousness among the public about what it might mean if they were to engage with medical services. An important role for the NHS is to continue to emphasise the availability of its services.
We also looked at the early stages of the pandemic, and we report on the pausing of the screening programmes and some of the clinical risks that may have been involved in those decisions. Those decisions were taken of necessity, as Eva Thomas-Tudo mentioned, in order to ensure that the NHS was not overwhelmed. Undoubtedly, however, what we are not seeing, and what we will continue to track through our work, is what that means for clinical outcomes as we move forward. We will pick that up in our report later this year.
Have you seen any reports that describe and explain the rapid responses to address the threat of the pandemic that could be used for future learning?
11:30
Future learning is a key theme in our report. We have undoubtedly seen innovation during the pandemic, in particular regarding the scale of virtual consultations. We recommend that, as the NHS remobilises, it takes a view about what that means and the place of such innovations in the future delivery of health services in Scotland.
We draw on the presence of the community assessment hubs and their rapid introduction, with regard to where they fit in the future model and what that means for NHS services. As the committee will know—we have seen your own reports on this—Audit Scotland has, for many years, been calling for a review of the sustainability of health and care services in Scotland. In the past few weeks, the “Independent Review of Adult Social Care in Scotland” report was published, so there is a great deal of material available on what will influence the remobilisation and the future of health and care services.
We are mindful of all that activity, and we place great emphasis on closely monitoring what that means for the future plan for, and remobilisation of, health and care services across the country.
You have partially answered my next question. What elements of the new structures should be retained?
I am mindful of my responsibilities, one of which is not to comment on policy matters. Ultimately, it will be for Government to determine the future establishment and structures of health and care services. As I said, there is much comment, and much opportunity.
In Audit Scotland’s work, especially in recent years, we have commented on the pace of integration of health and care services and the sustainability of the current model, which was designed—as we know—for an era in which there was a much greater focus on the presence of large hospitals and people receiving health services in large—[Inaudible.]—settings. In recent times, there has been an increasing focus on the provision of care in more homely settings, closer to people’s homes, and more preventative medicine. All those factors will be taken into consideration—[Inaudible.]—and what that looks like.
Are there any risks or unintended consequences associated with any of the new ways of working, such as the new clinical triage arrangements?
We have been clear about that. I had a similar conversation with the Public Audit and Post-legislative Scrutiny Committee last week about what some of those innovations might mean. In particular, we discussed the rapid growth in the use of virtual consultations. Over the summer and during lockdown, of necessity, the number of such consultations has grown exponentially; in our report, we use the figure of 600,000 virtual consultations. However, that approach might not suit everybody.
To be clear, we are not health professionals, and we do not know—which is why we think that there is a need for analysis alongside that rapid change—whether there are any unintended consequences of that shift, and whether anything would be lost, either as a result of people having restricted access to technology, which may prevent their ability to access services, or because face-to-face consultation provides a better interaction for both the clinician and the patient. All those things need to be considered, as we have moved at such pace to implement changes to the way in which health and social care services are delivered. We expect that to be factored into the thinking and analysis that takes place once the pandemic has eased and we are thinking about what the future might mean.
Good morning. I turn to the question of the future, which you have already touched on in discussing the growing backlog and the difficulties that we will face with people who have had treatment delayed or diagnoses missed. What measures do you think should be used to monitor the longer-term effects of delayed treatment or missed diagnosis?
I will start, and then I will invite my colleague Leigh Johnston to come in, as she has done much of our thinking and analysis on remobilisation.
In recent years, there has been much focus in the NHS on reducing waiting times, and we have seen significant investment in that area. However, with the decision that was taken to pause that and to prioritise treatment on a clinical basis, there is a real need for important thinking to be done alongside the remobilisation in order to provide clarity around the investment in longer-term outcomes. Clarity is needed on what that means for all of us, and all the metrics that we would want to measure regarding that very significant investment. I know that the committee has a keen interest in the fact that around half the entire Scottish budget is now invested in health and care services, and there is a need for clarity alongside that with regard to what we are achieving as a country.
As we move forward, not just in implementing the remobilisation of the NHS, but in thinking about its longer-term future and structures, we need to ensure that we, as a country, are clear about what we want to achieve for the very significant investment that we have made.
I will pause there and invite Leigh Johnston to say a bit about what we have seen in some of the material on remobilisation that we looked at.
As we say clearly in our report, we make recommendations for the Scottish Government and NHS boards around some of the things that have been discussed today, and the need to take action to meet the needs of those whose access to healthcare has been reduced as a result of the pandemic, while also monitoring the long-term impact of that on health outcomes. As we have discussed, we recommend the publication of data on performance against the clinical prioritisation categories that have been introduced in order to measure the waiting times and how long people are waiting for treatment.
It is also important to highlight that Public Health Scotland has a key role in that regard through its work around developing different indicators and, in particular, its focus on addressing the needs of the people in our communities who have the poorest outcomes. I know that the data teams in Public Health Scotland are looking at how we expand the range of indicators that are available to look at some of the outcomes and impacts as we move forward.
Thank you for those answers. With regard to monitoring, are you aware of any health board that is planning to mitigate the delays in treatment in some way? Have you been advised of the ways in which health boards are thinking about how to deal with that, whether by increasing hospice provision, providing support for people with a terminal illness, prioritising those who need tests and so on?
We have not looked at any of that in detail. We have to acknowledge that health boards are still dealing with the on-going demands of the pandemic. We are still in the second wave—we know that cases, and hospital admissions, are dropping now, but at the time that we published our report, we were right in the middle of the second wave of the pandemic. Nevertheless, in our next report on the NHS in 2021, we plan to look at the longer-term implications, the new ways of working that are being implemented and how health boards are dealing with the impact of the pandemic on their communities.
As Leigh Johnston mentioned, the Scottish Government introduced the clinical prioritisation framework, which is intended to manage the current backlog in the best way possible. People are being treated based on their clinical prioritisation level, so those whose cases are most urgent will be seen first, and those who can safely wait longer to be seen will have to wait much longer. That is how boards are currently dealing with the limits on capacity. As Leigh Johnston said, we will have to wait and see what the plan is, post pandemic, for how to get on top of the significant number of patients who are waiting.
In addition, through our work, we will follow the implementation of the Government’s winter preparedness plan, which was published in October last year. It begins to explore options around tackling the backlog and the extent to which the NHS Louisa Jordan and the Golden Jubilee hospital, and even the private sector, might be available to support some of the backlog reduction. As Leigh Johnston mentioned, we will pick that up in our 2021 report.
I am glad to hear those responses. I understand that the priority over the past couple of months has been dealing with Covid, but I feel that, as we look forward, the backlog, along with remobilisation, will be one of the biggest public policy challenges that any Government is facing. Therefore, I am pleased to hear that Audit Scotland will be scrutinising that.
Lastly, I turn to the issue of health inequality. There has been a lot of evidence that the pandemic has widened health inequality, especially among deprived and ethnic minority communities. Are you aware of any emerging policy to mitigate the widening of that inequality, in particular with regard to the vaccination programme? For example, have you looked at the issue of widening inequality as a result of vaccine hesitancy?
I will invite Leigh Johnston to comment in a moment. We were struck—others have commented on this elsewhere—by the disparity, and the extent to which the effects of the Covid-19 pandemic have not been equally felt. That is borne out by some of the statistics, in particular the stark difference in the implications for our most and least deprived communities, as well as in the extent to which the pandemic has disproportionately affected our black, Asian and minority ethnic communities.
Government policy makers have some real thinking to do about what that means, how we can take the necessary steps to reduce those inequalities and the extent to which we can learn from this pandemic for future pandemics. Of course, we do not know whether Covid is a once-in-a-century pandemic, or whether there will be a series of pandemics for which we will need to take the necessary action and incorporate that into our lives.
With regard to the vaccine programme, we have not done much work on that yet. There are opportunities for us to do so as we reflect on the success of what will—we hope—be a roll-out across the population in time for us to capture that analysis for our overview report in 2021. That will be a key part of our thinking.
Leigh Johnston might wish to say more about that.
As we have discussed, the pandemic has shone a light on what—as the committee will know—are long-standing issues in Scotland around health inequalities and socioeconomic inequality. Back in September 2020, the Scottish Government established an expert group to look at the impact of Covid-19 on ethnic minorities in particular. That group published two different reports, which contained various recommendations for improvements around data and the evidence on inequalities in health in those communities.
As I said previously, Public Health Scotland has a huge role to play in that regard. It came into being right at the start of the pandemic, and it has been at the forefront of the response, generating some of the data that we have on various issues. However, it has not been able to push forward with what it was originally set up to do, which was to take a whole-system approach in starting to look at health inequalities and the poor outcomes that exist in some of our more vulnerable communities.
Good morning. I have a couple of questions on pandemic preparedness and planning. Your report states:
“Not all actions from previous pandemic preparedness exercises were fully implemented”.
The exercises were Silver Swan, Cygnus and Iris. I am looking at paragraphs 43, 44 and 45 of the report, and other paragraphs. The report goes on to say:
“the Scottish Government did not include an influenza pandemic as a standalone risk in its corporate or health and social care risk registers.”
From the report, it looks as though issues were recognised that could have been taken forward. Do we know why there was a lack of preparedness or action, and why some of the recommendations from those exercises were not taken forward?
11:45
You are right—in our report, we draw the conclusion that there were opportunities, following those exercises, for the Government and the NHS to be better prepared for a pandemic. To answer your specific question, we also report that a pandemic was a known risk in the Government’s thinking. In addition, the implications of a pandemic were identified as being very severe. What we did not see in our analysis was evidence that a pandemic featured routinely as a risk that was being actively managed, in spite of the extent of the implications of the pandemic that we have now seen.
Other risks featured prominently on the Government’s risk register at the time, but the pandemic implications did not. I do not have a direct answer to your question with regard to why that was the case. Although we know that there was visibility of the risk in Government, and there were working groups and exercises, as we set out in the report, we do not have an answer in respect of the extent to which the risk was escalated to the top of a corporate risk register. The committee may wish to explore that further directly with the Government.
Do you think that planning would have made a difference—for example, in access to PPE and how quickly the system for that got up and running? Initially, care homes did not have access to sufficient PPE, or even appropriate training in its use. I am thinking about healthcare professionals participating in training and fit testing in respect of specialist PPE, such as face masks for aerosol-generating procedures. Have you been able to ascertain what difference planning in that regard would have made in the response to the pandemic?
At paragraph 44 of the report, we highlight the three themes in the recommendations that arose from the three exercises, which came to fruition during the pandemic: the extent to which our care homes were prepared; clarity around roles and responsibilities; and—as you mentioned—the use and availability of PPE.
We have not done a detailed analysis of the correlation between the extent to which PPE was or was not available right at the start of the pandemic and what that meant for health and care workers. Instead, we have drawn on the published findings of surveys from the British Medical Association and the Royal College of Nursing, and on what some of our health boards were saying right at the start of the pandemic about the availability of PPE and the need to purchase it directly.
We drew the conclusion that, given the unprecedented exponential growth in the use of PPE, from under 100,000 items in a typical week during pre-pandemic times to more than 24 million items per week, there might have been opportunities for us to respond immediately and to be better prepared for the pandemic. What we have not previously done, but will continue to do through our work and the work of others, is look at and monitor use and availability of PPE. The committee might be interested to know that we will publish further work this year on the extent of the use of contracts for PPE, and we will begin to explore some of the value-for-money arrangements that Scotland implemented.
Scotland’s arrangements are now well in place. We have seen, through the work of NHS National Services Scotland, that there is sufficient PPE to support the needs not just in the NHS but in our health and social care settings. As we note in the report, the arrangement for the use of PPE in social care settings extends through to the summer of this year.
I am sure that everyone has learned so much about preparedness for future pandemics, whether they are coronavirus or flu-type pandemics.
You suggest in your report that, as a priority, pandemic guidance should be updated. How soon should that be done? What should the guidance include? I am sure that a lot of it can be taken from the experiences that we have had in the past year. I am sure that everyone will agree that we started at a level at which we needed to rapidly assimilate and implement measures very quickly in order to tackle the pandemic.
We agree—we think that an update needs to happen very quickly. We set out some of the chronology of the guidance, which dates back to around 10 years ago. The original process of updating that had begun, and there had been consultation on the guidance for social care settings in the event of a pandemic, but it had not been published.
We do not think that there is any real value in publishing it now, given that so much has changed and so much learning has taken place in the past year. That learning needs to be incorporated, so that we can learn from users and staff in health and social care settings. It should be incorporated into what will inevitably be a fairly iterative document, but which will not—to the extent to which we were preparing for and thinking about pandemics previously—borrow our thinking from 10 years ago, given that so much has happened in the past year. That guidance should be produced quickly so that if there are more pandemics, we are—as you say—better prepared and able to respond next time round.
Good morning, everyone—it is still morning at this time. I want to ask about the remobilisation and staffing of the health service. I think that you have answered some of my questions—if you have, you can say so. I thank you for your report; perhaps some of the answers to my questions will be in your 2021 report.
You highlighted in your report the issue of waiting times and the fact that some elective surgery has been put back for a while. However, you went on to say:
“The Scottish Government is committed to rebuilding the NHS differently”,
and you gave some examples, including provision of more care nearer home and recognition of the interdependencies between health and social care services. As your report says, there is a lot of work to be done in that regard. Is the Scottish Government being too ambitious in trying to deal with the backlog at this time while also
“rebuilding the NHS differently”,
as you said in your report?
There is a huge programme in front of the Government in terms of continuing to deal with the pandemic, rolling out the vaccination programme, recovering the backlog of services and assessing the extent of the clinical risk that remains within that. Alongside that is continuation of the programme of health and social care integration and all the matters that you talked about, including provision of care and treatment closer to home and a focus on preventative services as opposed to the large acute hospital setting model. All that needs to be tackled, and we empathise with the NHS and with Government in respect of the need to take such decisions.
Audit Scotland will continue to monitor and track that, and to look at the extent to which the Government is taking steps to implement the ambition that it has set out in its remobilisation, renewal and recovery programme. That is a key part of our work.
I agree that it is not a straightforward undertaking. We recognise that, if that was the case, many of the challenges that we set out in the report would have been dealt with many years ago. Nonetheless, it will remain a key part of our work and commentary.
In your opinion, what priorities should the Scottish Government put forward for the recovery and reshaping of the health service?
I am mindful that it is ultimately for policy makers to decide what the priorities will be, to the extent that there is consensus on that. Again, I have signalled through our forward work programme that we will continue to monitor progress on health and social care integration and on how, as we change the way in which we think about health and social care and move away from the large hospital environment to care in more homely settings closer to home, that is all factored in.
We have stated that we will look closely at the extent to which progress is made on tackling inequalities in the country, with reference to progress on reporting on that through the national performance framework. That all features in the work that we will take forward over the next year and beyond.
When we held our inquiry, we heard from the general public that they preferred services being provided closer to home to having to go to the big hospitals. That gels with what you said.
We are talking about workforce planning reform. Have you been able to identify any specifics in relation to that particular aspect?
In paragraph 57—
I will write that down.
We refer in that paragraph to the wider thinking about what that plan means for the health and social care workforce. We are following closely what might come of the Feeley report on the independent review of adult social care, and whether that signals a significant change for the way in which health and care services are structured. In addition, we will look at what that will mean for the workforce.
We think that there is a real need for a clear plan for the integrated health and social care workforce and to ensure that it is flexed and monitored as necessary in order to deliver on the ambitions for health and social care integration. Again, that features prominently in our thinking and our work as we move forward.
My last question is about the staff who have come through the pandemic. Obviously, they have faced a lot of pressure and stress. Have you identified any long-term planning to support those staff, who have been through such a traumatic time?
We recognise, of course, that the period of the pandemic has been an incredibly challenging and difficult one for all our health and social care workers. My colleagues may wish to say a bit more about the extent to which the wellbeing of health and care workers has been supported. In our report, we said that we will continue to track that.
I do not think that we know yet what the long-term implications might be of the stress and anxiety—even the trauma—of having to deal with not just one wave, but two waves, of a pandemic. I think that it will be some time yet before the NHS and the Government are able to form an assessment of what the implications might be.
Eva Thomas-Tudo may wish to say a bit more about what we have seen and the extent of the support that has been provided so far.
In our report, we mentioned the launch of the national wellbeing hub website. As we have seen, that has had quite a good response; around 50,000 people had visited the website by December. There is also a helpline and a wellbeing champions network, which were launched during the pandemic. We recommended that
“The Scottish Government and NHS boards should monitor and report publicly on the effectiveness of the measures”
that have been put in place to support staff wellbeing, in order to ensure that
“sufficient progress is being made.”
Good morning to the panel. It is still morning—just.
To follow on from Sandra White’s questions, it has come to my attention and the attention of the committee that Covid has highlighted where the weaknesses are in the system and the need to reform and renew the way in which the NHS delivers its services. How could a renewed look at the integrated workforce plan better incorporate new priorities for the NHS, based on staff engagement? How do we ensure that engagement with staff is to the fore in any kind of reform?
12:00
That is an important point. Ultimately, given the scale on which staff are represented in delivery of services, and given the cost of the NHS, engagement with staff and their representative bodies is an essential component of an effective workforce plan that connects with the overall strategy, and the strategy of renewal and remobilisation. I am not sure that we have the detail on the extent to which those conversations have taken place.
Currently, all the activity going on is focused on preventing the NHS from becoming overwhelmed, delivering the vaccination programme, and seeing us through the next wave. I anticipate that, over the summer, the NHS will move significantly into thinking about what renewal and remobilisation will look like. Nevertheless, we agree that staff engagement is an essential component of a well-structured and well-developed workforce plan.
I will amalgamate two questions, if I can. Earlier, you talked about the preparedness exercises that had been undertaken and the lack of preparedness for a pandemic. I will offer an analogy. We all know that an asteroid is going to hit the earth—you just hope that it is not going to happen on your watch. That is maybe similar to what happened with the Government. We knew that, somewhere down the line, there was going to be a viral infection such as Covid; the Government just hoped that that would not happen on its watch.
Moving on from that, the question is: how should front-line staff be involved in future pandemic planning in order to ensure that recommendations are enacted?
The fact that there were three pandemic preparedness exercises in the five years before 2020 demonstrates that a pandemic was part of the Government’s thinking and activity with regard to what risks might be coming down the line. It was not presenting as an issue in the same way as some of the other risks that Government faces from day to day. Nonetheless, our analysis suggests that, if the recommendations that came from those exercises had been implemented, the Government might have been better prepared to deal with the situation that presented itself in March 2020. There were recommendations around the extent to which care homes were prepared and the use and availability of PPE. We effectively drew the conclusion that there were opportunities therein to be better prepared.
We absolutely agree that the experience that NHS and social care workers have gone through needs to be captured and reflected in all our thinking, preparedness and planning for the future delivery of health and social care services. It is really important for the future that staff are engaged and have the opportunity to share their experiences.
I am simply musing, or wondering, about the severe acute respiratory syndrome—SARS—outbreak in 2003, when there were headlines that said that 50,000 deaths were likely. That did not come to pass. I wonder whether that coloured judgment prior to the Covid pandemic.
How should the Government engage the public in the new priorities? As a caveat to that, I always think, with regard to engaging with the public, that “You don’t know what you don’t know.” Perhaps some sort of information would need to be provided prior to that engagement.
On your first question on SARS, or MERS—middle east respiratory syndrome—it is true that there had been pandemic events during the 21st century. However, they were predominantly in Asia and did not reach the UK, so I do not know whether that experience led to any particular thinking in Scotland. I am not able to draw any conclusions about that.
What we have seen with regard to the Scottish Government’s preparedness is that most of the thinking was based on a potential flu pandemic scenario. As significant as SARS may have been, on the question whether it led to our being less prepared than we might have been, we point to the fact that there were recommendations from the reports that had not been fully implemented, and we draw the conclusion that we may have been better prepared if they had been.
On your second question, about options for engaging the public, I am maybe not best placed to say how that could best be done. We recognise recent innovations, such as citizens panels, as an opportunity to engage the public in the development and implementation of new policy ideas, having seen some of the reporting from those panels on climate change and so forth. I am sure that members will be better versed than I am in how best to do that.
I agree with the fundamental point on changing the nature of health and social care services as fundamentally as has been indicated through the plans for renewal and remobilisation. It is clear that we all care deeply about what those services mean for ourselves and our families, and citizens and the public would want to be actively engaged in developments in that regard.
I have one final question, which is about the staff turnover at executive level. You noted in the report that high turnover at that level has been pretty much a feature in recent years. Does that have the potential to destabilise any plans for the future? Are there any reflections on, or insights into, what might happen in that respect?
In the report, we drew the clear conclusion that the NHS needs stable leadership. We pointed to what has been quite a surprising volume of change at senior executive and board chair level in recent times. Even turnover in senior positions in the Scottish Government health and social care department itself has been high.
We agree that there is a need for stable leadership in order to deliver the change that is coming after the pandemic and to steer us through the pandemic, at both national and local levels. It is important that Government is thinking about the extent to which it manages that change and supports its new leaders in those positions so that they are better able to discharge the significant responsibilities that they have.
Good afternoon to the Auditor General and our other witnesses. Auditor General, I was struck by one aspect of your report. It states that
“It is not yet clear … how the pandemic will develop over time and what level of spending will be required to respond”,
or
“what additional funding will be made available through Barnett consequentials”
for 2021.
My first question is on additional Covid spending for boards. As you will be well aware, the funding mechanism for that was not the normal NHS Scotland resource allocation committee funding formula. The funding was given as required, very quickly, in an emergency situation, and it seemed to be demand led.
Is it too early for you to assess the effectiveness of that different formula for spending? If not, can you say whether that will have implications for the use of the NRAC formula in the future? I accept that that is a policy question. Nonetheless, can you say, in your role as Auditor General, whether there is a better mechanism for that funding that would be more effective for health boards?
There are a number of facets to that. A key part of our work during 2021 involves what we refer to as “following the pandemic pound”, which is about making judgments through our work at national level, and through local auditors’ annual audits of NHS boards and integration joint boards. That involves looking at the flow of money and how well it has been spent.
You are right that it will be for policy makers to determine what that means for any changes in the NRAC formula and the wider redistribution of health funding. However, we will think about that carefully in our work and reporting, and in particular what it means for our NHS overview report in 2021.
You are also right that it has been a very unusual year. Typically, until now—as the committee will know—individual NHS boards have been facing financial challenges and using brokerage facilities from Government to support their financial position. However, during the pandemic, Government took a clear position that every body would be fully funded to deliver services on—as you say—a demand basis. Whether that position holds and becomes the new normal or whether we revert to the three-year medium-term plan, with its associated savings and so forth, is something that we will continue to track in 2021.
Thank you—that is very helpful. I move on to Barnett consequentials. Are you convinced that over the period that we are talking about, with regard to both Covid and non-Covid spending, the Scottish Government passed on all the additional Barnett consequentials to the NHS and social care in Scotland?
Eva Thomas-Tudo is probably best placed to answer that. Our understanding is that Barnett consequentials have consistently flowed through to NHS services in Scotland. We draw out a couple of figures in the report. The projected additional spend requirement arising from the pandemic—the forecast spend—was £1.7 billion, but £2.5 billion was available in the round to support that funding. We do not think that there has been a shortfall in funding for delivery of services. Going back to your earlier question, I note that funding is being supplied on a demand basis, as opposed to money being held back.
I invite colleagues to say whether there is an updated understanding on that point.
It is a moving picture. In the report, we stated what the situation was at that point in time. Since then, further consequentials have been confirmed. In September, the Scottish Government confirmed that any consequentials based on spend for health in England would be passed on for health in Scotland. So far, £2.9 billion has been allocated for the health portfolio, and £3.7 billion of health resource consequentials have been received.
For 2021-22, we know that the UK Government has so far confirmed £719 million in consequentials, but that relates to quite a limited range of spending, which includes PPE and test and trace. The Government expects further funding to be announced in due course. At present, the Scottish Government has initially committed to £869 million in Covid funding for next year, which is the £719 million that has been confirmed by the UK Government and an additional £150 million to reflect the expectation that further funding will be made available.
There are a lot of telephone-book numbers being thrown around. I suppose that my point is that, although there might appear to be a gap, there will be a lag in spending—the Government will have plans, so that money will not be fully spent at present. In simple terms, is that the point that you are making?
Yes, essentially.
Right—thank you.
I move on to another area. Auditor General, do you foresee any challenges in the audit of additional spending in the current financial year for both health and social care? If so, how do you intend to approach the audit in future years?
The scale of the additional spending that has taken place is stark. We have done some initial analysis on where that money has been spent. As we say at paragraph 62, it has been spent on PPE, implementation of a Covid testing regime and additional bed capacity. We will continue to monitor and track where the money is being spent.
12:15NHS boards’ financial reporting arrangements have largely remained consistent. The position will be clear from our work, which is built up through the audit of individual health boards and consolidated through to the NHS. We have the mechanisms in place, and the audits have continued during 2020 and will continue beyond that, so we will monitor the situation in our usual way.
What is important in our work is that, given the scale of the additional moneys for the provision of health and care services and more widely—we have seen some of the economic support arrangements that have been put in place—we ensure that it is clear how well those moneys have been spent. We have a detailed programme of work that will enable us to report on that in 2021.
I come to my final question. We are looking at a general remobilisation and reshaping of the NHS in the future. We have existing performance standards that are well known and understood. Should those standards be changed in the light of the massive impact of the pandemic? Alternatively, is it the case that the structure is right and the standards simply need to be fine tuned?
The extent to which those measures are measuring the right things and influencing behaviour is an interesting point. It is ultimately for policy makers and Government to decide whether the performance measures are sufficient to measure outcomes, as distinct from inputs and outputs, from the use of public money.
Moving beyond those points, I go back to our conversation earlier this morning. If we are spending 50 per cent of the Scottish budget on health, we can reasonably track what that means for outcomes. For us, that is an important point—[Inaudible.]—in policy terms. From an audit perspective, it enables us to say publicly what is being delivered, in the widest sense, for the investment of public money. That work is focused much more on outcomes than it has been in recent times.
I have a question about new indicators and how we measure outcomes. I am thinking about how we look at existing standards and whether they should be replaced with the national performance framework outcomes, for instance.
In the past year, Covid has had a massive impact on health and social care, especially acute NHS care and primary care. It has also affected care homes, with all the testing of care workers that is going on. In addition, there are various models of care homes. For example, there are council-run homes and private homes, and some are small while others are medium sized. Some homes that look after older persons are run by large corporations. When we are trying to assess all those aspects and audit the performance, should we be looking at replacing existing standards with national performance framework outcomes?
It is a complex picture, and you are right that the wide range and scale of entities that are delivering health and social care is part of the thinking. We will be tracking in particular—I am sure that the committee will do this, too—what happens on the back of the independent review of social care and what that means for any changes to structure.
In the simplest sense, indicators are set that are meaningful and drive the right behaviours. Fundamentally, they are based on outcomes, so that we can all track what we are getting for our significant investment.
With regard to your question about replacing the standards, it is not necessarily about choosing between one system and the other, or ditching all the current indicators and moving to an entirely new set. In the report, we refer to the importance of transparency in the context of the backlog and the remobilisation of services, so that all of us who need to access health and social care services can be clear as to when we are likely to be able to do so.
All of it matters. More fundamentally, we need to look at outcomes so that we can track progress accordingly. It is for policy makers to come up with a suite of indicators that allows Government, parliamentarians and the public to get a more rounded sense of what we are getting for our significant investment.
Is Audit Scotland well prepared to audit services for best value and quality on the basis of outcomes? Is it advising Government on appropriate measures and evaluation strategies?
I am clear that we would not stray into the territory of advising Government. We are independent of Government in our work.
Our work on best value is expanding. The statutory duty of best value is on local government bodies. Through the work of the Accounts Commission, we are developing an expanded approach to our work in that regard and exploring it in the context of integrated health authorities. We will be rolling that out in the next year or so, in order that we can comment in our work on the delivery of social care services and how that duty is being applied in the widest sense.
We keep our methodologies under regular review and we think about how to ensure that we are operating to best effect. Outcomes remain a key part of our thinking, and they will continue to be so throughout delivery of our work programme.
I have a final question on the final section of your report, in which you touch on hospital-acquired infections and antibiotic resistance. The WHO has expressed concerns about antibiotic resistance worldwide in the context of the current pandemic and any future pandemics. Do you believe that the measures that are in place to address and monitor those risks are adequate? If not, what should be done about that?
I will pass that question to Eva Thomas-Tudo, as she has done much of the analysis on that point.
We have not done a lot of detailed analysis on the measures that are used to monitor healthcare-acquired infections. We have essentially used the antimicrobial resistance and healthcare-associated infection service data for that analysis, so ARHAI would be better placed to say what is being done in that regard.
I thank you all for your evidence today. Your input is much appreciated. The Health and Sport Committee’s on-going engagement with Audit Scotland has, from our side, been valuable over the past five years, and we have seen some of our recommendations being reflected in the priorities that Audit Scotland has set. It has been a fruitful collaboration, and long may it continue.
We will move into private session on a different platform.
12:23 Meeting continued in private until 12:38.