Public Audit Committee

Meeting date: Thursday, October 28, 2021

Official Report 614KB pdf

---

“Covid-19 vaccination programme”

The third item on our agenda is evidence from Audit Scotland on its briefing paper, “Covid-19 vaccination programme”, which was produced recently. Our witnesses will give evidence on the research and audit that has been carried out by Audit Scotland. I welcome Stephen Boyle, the Auditor General for Scotland, and Leigh Johnston, who is a senior manager at Audit Scotland. Joining us remotely is Eva Thomas-Tudo, who is a senior auditor for performance audit and best value at Audit Scotland.

If Eva Thomas-Tudo wants to come in, she should put an R in the chat function. If the witnesses in the room want to come in, they should simply indicate to me or the clerks, and we will do our best to bring them in.

I ask Stephen Boyle to give a brief opening statement.

Thank you, convener. Good morning. Today, I am bringing to the committee a briefing paper on the Covid-19 vaccination programme. It focuses on the management of the programme and the progress that has been made so far, and it outlines some of the next steps, including the preparations for delivering the extended flu and booster programme over autumn and winter.

The Covid-19 vaccination programme is the largest mass vaccination programme that has ever been carried out in Scotland. Audit work often highlights where things have gone wrong, but it is important that we also give credit when we see success. Excellent progress has been made in vaccinating a large proportion of Scotland’s population. More than 90 per cent of people aged 18 and over have received at least one dose of a Covid-19 vaccine. The programme has been effective in reducing the number of people who become severely ill and die from Covid-19. Vaccines have been delivered in a variety of settings, and the rate of vaccine wastage has been low.

My paper recognises that there has been variation in uptake across sections of Scotland’s population. The Scottish Government has been taking action to encourage people to take up the offer of vaccination, but a smaller proportion of young people, those in our most deprived communities and those from some ethnic minority backgrounds have been vaccinated so far.

The vaccination programme is being implemented under uncertain and challenging circumstances. Clinical advice from the Joint Committee on Vaccination and Immunisation continues to evolve and has needed to be implemented quickly, most recently through booster programmes. The Scottish Government and national health service boards have done well to respond quickly to newly issued advice, with eligible groups offered vaccines within days of clinical advice being published.

NHS boards and health and social care partnerships have predicted that vaccination costs will be £223.2 million in 2021-22. However, the expenditure that is needed might change, depending on any further advice from the JCVI. The Scottish Government has confirmed that it will fully fund vaccination costs for the 2021-22 financial year. We will continue to monitor the funding and spending and will provide an update in our overview of the NHS in Scotland in early 2022.

Thus far, the programme has relied on temporary staff from across a wide range of NHS disciplines. That diverse workforce has enabled the vaccination programme to progress quickly, but it is an expensive model. The Scottish Government has recognised that a longer-term solution is needed, and work is under way to recruit a permanent workforce.

The delivery of the vaccination programme has been a success thus far, with good collaboration, joint working and new digital tools developed at pace. There are opportunities for the Scottish Government and the NHS to use the learning from the programme to inform the implementation of further stages of the vaccination programme and the wider delivery of NHS services.

As ever, Leigh Johnston, Eva Thomas-Tudo and I look forward to answering the committee’s questions.

Thank you very much. The briefing is wide ranging, and we have a wide range of questions to ask.

I will get us under way with a couple of questions. The briefing is broadly positive, as you said, but there are challenges that lie not behind us but ahead of us. We know that there will be increasing pressures on the national health service, which we normally see during the winter, and that there is a considerable backlog of treatment. There is also the continuing pressure of delivering the vaccination programme. Are there adequate structures, leadership and governance in place to withstand those pressures and to meet those challenges?

I do not think that there has been any attempt to understate the extent of the pressures that the NHS faces in the winter ahead. On a number of occasions over the past few weeks, I have heard the Cabinet Secretary for Health and Social Care try to manage public expectations and to set out what we are facing. You rightly point out that the NHS is facing the challenge of recovering its services in relation to the backlog.

10:15  

It is worth pointing out that, before the pandemic, the NHS was experiencing extreme challenges and Audit Scotland had reported on the challenges around sustainability. Having all those factors alongside the delivery of a vaccination programme will remain challenging. We say in our briefing that the structure, funding and pace of the delivery programme were all done well and that an effective programme was delivered. It remains to be seen whether it will act as a template for the delivery of NHS services over the winter. We have made positive comments about the vaccination programme.

Our next opportunity to pass comment, in particular on how NHS services are tackling the backlog, will come in the NHS overview report that we will produce early in 2022.

We will look forward to that.

Will you confirm whether the costings in the briefing cover the booster vaccination programme that has already started for some categories of the population? Do you have any sense of the projected costs for vaccination programmes in future years? Has your work on this year’s vaccination programme given you any sense of where things are with the booster programme and what any possible future vaccination programme might look like or what it might cost?

I will begin, then I will ask Eva Thomas-Tudo to give more detail about the numbers that are captured in our report.

There are a number of variables, including the predictability of future costs and the extent to which clinical advice about the use of vaccines might change. That creates uncertainty. We have some empathy for the NHS, which will find it challenging to say with much confidence what that might look like.

The figure, which we give in the briefing, of £223 million for the rest of this financial year is based on assumptions about the programme delivery that the Scottish Government gave to NHS boards, including assumptions about staffing and premises. If those assumptions remain static during the delivery of the booster programme, we can have some degree of confidence. We are less able to say what the future cost profile might look like.

There have been some funding announcements in the past few days about additional allocations to support delivery by NHS boards and NHS National Services Scotland activity for the rest of this financial year. Like others, I will closely watch what comes out of the draft Scottish budget later this year to see what the future cost of the delivery of the vaccination programme might be.

Eva can update the committee with any further information.

The figure of £223.2 million that is mentioned in our briefing paper is based on predicted costs from NHS boards and health and social care partnerships as part of a review of quarter 1. It incorporates the predicted costs of the booster programme. As we say in the briefing, the figure depends on the accuracy of the predictions, and the final costs for this financial year will depend on whether the JCVI issues further advice about requirements for the delivery of vaccinations before the end of the financial year.

That is helpful. Are you saying that the figure does not include the cost of the booster programme? Have I picked that up correctly?

We are saying that it does include that cost.

It does include that cost. That is good.

You mentioned recent announcements. An additional £482 million was announced, to include funding for personal protective equipment, test and protect and the delivery of Covid-19 vaccinations. Does the Auditor General or any member of the team have a sense of how that will fit the expected likely demand?

We have not done any audit work on that yet. We have seen the breakdown and the allocation that is applied to the NHS boards, and the national boards in particular. A significant thing that we see in that is the size of the allocation to NHS National Services Scotland, which received £109 million. We mention the extent of the variability throughout the briefing paper and we have seen it throughout our work, along with the pace of change in clinical advice in relation to the allocation of booster programmes.

I think that it reflects the current status of booster programmes. If that changes, we would anticipate that there will be further funding requirements for the NHS and health and social care partnerships. As I mentioned, we will track that closely through our audit work. We will have opportunities to provide an update in the NHS overview report and then in the annual audit work that we will carry out on the NHS boards over the course of next year.

Thank you. Of course, we will come back—it might even be next week—to the PPE report that you produced, which is on part of this terrain as well.

As I said, we have a wide range of questions. I begin by asking Sharon Dowey to come in on an important area for us.

Good morning, Mr Boyle. You have already touched on the subject of my question. In paragraph 18, the briefing explains that

“The vaccine programme has ... been reliant on temporary staff and volunteers”,

including

“nurses, GPs, dentists, optometrists”

and so on, and that that has been expensive. Have you undertaken any work to cost that delivery model? What has been the cost to the public purse?

We have. Our briefing paper captures our work up to the end of September and, as I have mentioned a couple of times, we will continue to track and monitor that with further reporting in the NHS overview report and then through the annual audit work during 2021-22.

Our understanding is that, thus far, about £55 million has been spent on that staffing model. We know that the Scottish Government is beginning to think about its plans for a more medium-term or long-term model for how it might deliver what we expect to be an on-going Covid-19 booster programme. What that might end up costing will inevitably depend on the staffing mix that the Scottish Government chooses to settle on. We have less reliability on what that figure might be, but our understanding is that the model has cost about £55 million thus far.

You said in the briefing that, as restrictions ease and NHS services recover, the availability of the temporary workforce will reduce. With that in mind, do you foresee any implications for the roll-out of Covid-19 booster vaccinations?

It is potentially difficult to be definitive on that point at the moment, but that is generally not what we are seeing. I will ask Leigh Johnston to comment on the rate of progress that we are seeing in the booster programme, which is not captured in the briefing, given the timing. However, we are not seeing any real difference in the pace of the roll-out of the programme.

By way of context, it is perhaps worth mentioning a point that we made in the briefing. As we will all recall, in the early stages of the initial Covid vaccination programme, much of the work was undertaken in large public venues such as sport stadiums and concert halls. As social distancing has eased and lockdowns have ended, the availability of those venues is no longer what it was and much of the programme is now being undertaken in more local settings. That will continue to roll out over the course of the booster programme.

As I said, we are not seeing real divergence thus far, but it is perhaps worth turning to Leigh Johnston for a moment, as she can give the committee an indication of where we see the rate of progress of the booster programme being.

To update the committee, I note that as of yesterday, which was 27 October, 568,373 booster vaccinations had been delivered. We should also recognise that, on top of that, 53 per cent of our 12 to 15-year-olds have now been vaccinated.

To touch on Mr Leonard’s earlier point, I note that the vaccination programme will remain a priority, so I think that, in order to prevent the NHS from becoming overwhelmed this winter with all the other, additional winter pressures that come along, the NHS will maintain the staffing to make sure that the booster and the flu vaccine are rolled out as a priority.

As has been mentioned, the Scottish Ambulance Service was drafted in to support the delivery of the vaccination programme. Is that still happening? That service is, as we know, under pressure, too. Have those staff been moved back, or are they still helping out?

The Scottish Ambulance Service was involved in the mobile vaccination units but, given the pressures that it is under, I am sure that those staff will now be doing their day job, if you like. However, as we said in the briefing, there might be a need to reimplement the mobile vaccination centres to reach the more difficult populations. I also point out that, as demand for vaccinations has reduced and as we have moved on to the booster programme, which involves a smaller number of people than the number involved at the height of the mass roll-out, there has been less need for those mobile clinics.

On the point about the workforce and venues, we also recognise the contribution of the armed forces to the delivery of the vaccination programme and the support that they have provided to the NHS in Scotland, but the expectation is that, as we move to a more predictable delivery of the NHS vaccination programme, such a situation will not continue. It was just one of the other variables that was present in the early stages of the vaccination programme. The need now is to put in place a more permanent workforce to deliver the programme in future, which is what the NHS and the Scottish Government are doing.

That brings me to my last question. We understand that the Scottish Government is undertaking workforce planning to secure a permanent and sustainable vaccination workforce. Do you know how far advanced those plans are? What must the Scottish Government consider in that planning?

I will ask Eva Thomas-Tudo to respond in a moment, as she has been tracking some of that in conversation with Government and NHS officials.

We know that work is under way and that, as we mentioned in paragraph 19 of the briefing, the Scottish Government is, in respect of workforce planning, thinking about the use of registered nurses with regard to having a more sustainable delivery model for the vaccination programme. We also understand that it is thinking about the cost profile in that respect. Those plans and that work are under way.

That is probably a line of questioning that the committee might wish to explore directly with the Government, as that would be a better way of getting a more direct assessment of its progress.

Our understanding is that the Scottish Government is expecting to recruit a permanent workforce. The exact size and nature of that workforce will be for the Government to confirm, but we understand that it hopes to recruit healthcare support workers as much as possible to work alongside registered nurses, which would be a more cost-effective model than it has been able to use so far. The role of that workforce would be to support all vaccinations rather than just Covid-19 vaccinations across Scotland on a more sustainable basis but, as we have said, the Scottish Government will be able to provide a more up-to-date picture.

One area that is highlighted in the report is digital access and the use of digital tools. Craig Hoy has a number of questions on what is an evolving picture, and I think that Willie Coffey might want to ask briefly about it, too.

When it looked at information and communications technology projects, our predecessor committee—and, I am sure, its predecessor committees—often found that their management, or mismanagement, had significant and negative impacts on public funds. Your briefing refers to a number of digital tools being “developed at pace”. Have you picked up on any ICT issues that are similar to those that were highlighted in previous sessions?

10:30  

We absolutely recognise the point that you make, Mr Hoy. Audit Scotland has not come up short in reporting to predecessor committees on troubles in ICT projects. I have made the point a couple of times that that reporting was not always representative of the success or otherwise of Scottish public bodies in delivering ICT projects. As I alluded to in my introductory remarks, the nature of our reporting can often lead people to infer that the troubles that we report on are representative of the entire delivery of ICT projects or public services. However, this feels like a departure from some of the commentary that we have made on troubled ICT projects.

As I also alluded to in my introductory comments, there is a real opportunity to learn from the development of some digital tools. We cited four of those in paragraph 20 of the briefing. They include tools that were available to clinicians, data stores and tools for scheduling—I will say more about that in a moment.

We saw through our audit work that digital was a key driver and an essential component of the vaccination programme roll-out, and that it was done well. There is now an important opportunity to apply some of that learning across the NHS and more widely in the Scottish Government.

I want to look at NHS boards’ use of the system to allocate and reschedule appointments. The national vaccination scheduling system, or NVSS, has obviously been adapted over time to improve its functionality. An example of an issue from my constituency in the early days is that people in East Lothian were not necessarily given appointments there, but were routed to West Lothian, Midlothian and Edinburgh, even when there was capacity in East Lothian. I think that many of those issues have been fixed, but what risks, if any, continue to exist for health boards in using the NVSS?

I recall that, in the early stages of the roll-out, people were asked to travel further than they might have expected, and perhaps without available public transport to make it easy for them to access vaccine services. In paragraph 22 of the briefing, we referred to some of the flexibility that evolved during the roll-out of the programme. Some NHS boards for islands identified that managing the programme and the scheduling arrangements would be more easily done at a more local level, because of their understanding of their patients’ needs.

Stepping back, I think that there is an opportunity to recognise the importance of flexibility as the roll-out extended, particularly with regard to scheduling. We have seen that, when drop-in arrangements have been available, which has enabled people to access services at their convenience rather than by using the scheduling tool, their use has sometimes superseded the use of the prescribed appointment times for patients. They have provided the flexibility for people to make their own choice. People accessing the vaccine, including boosters, in a way that is most convenient for them is now an important component of the programme, and that should continue. We might also extend the use of that flexibility to address some of the lower uptake points in different parts of Scottish society.

A report in The Scotsman this morning, which is based on a Scottish Parliament information centre report, says that up to three quarters of people in certain neighbourhoods of certain areas have not yet been vaccinated. There is a concern that reliance on digital means that some people are hard to reach, because they do not have a reliable internet connection or do not have devices. What is your impression of what more the Scottish Government should and could do to ensure that those who fall into that category are captured and brought into the vaccination programme?

I will ask Leigh Johnston to come in on that, as she has looked in quite a lot of detail at the arrangements that have been used thus far.

From my consideration of the data, I think that the Public Health Scotland data tools are clear in terms of the roll-out of the first stage of the vaccination programme and the second vaccine. Its analysis by age group, NHS board area and local authority area set out interesting findings that are perhaps not what we would expect, given our previous consideration of the availability of information technology for some of Scotland’s older population. That group is almost entirely vaccinated above certain age groups. However, that issue matters.

On access to the vaccination programme across Scotland’s full population, it has not been rolled out entirely to some groups in society, including younger people, people who are economically deprived, and some parts of Scotland’s ethnic populations. We talked about that in the briefing, as well as some steps that have been taken. We also listened carefully to the cabinet secretary speaking in his recent evidence to the COVID-19 Recovery Committee about steps that the Government and health boards are taking for different communities—including in religious settings and with Gypsy Traveller communities—to broaden the reach of the programme and dispel concerns that vaccination-hesitant people might have.

Perhaps Leigh Johnston could talk about the specifics.

It is important to recognise that there are a number of reasons why some groups of people are not getting vaccinated. Those include access reasons; work reasons, such as losing income, which could hit people hard; and psychological and social reasons for not wanting to get vaccinated, such as beliefs about what the vaccine contains.

The Scottish Government has done a lot of work to encourage groups in which uptake has been lower to get vaccinated. We have listed the range of the things that the Government has done, which include work on understanding the data, assertive outreach, and work with organisations to tailor messages.

Public Health Scotland has a Covid-19 vaccination programme surveillance strategy, which sets out how it monitors the uptake of the vaccine among a range of other things, including adverse impacts. It specifically points out that PHS will look at where uptake is lower among certain groups and how to encourage people in those groups to get vaccinated. It also outlines the purpose of an on-going evaluation of the Covid vaccination programme. On 6 October, a report came out that outlined the learning from the flu and Covid-19 vaccination programme. It detailed what PHS has learned about lower uptake in some groups and what helped to encourage people in the different groups to get vaccinated.

One of the Government’s core rationales for the vaccination passport system was the hope that it would lead to an uplift in vaccination rates among certain target groups, one of which is young people. The system is still in its infancy, but do you have any evidence to suggest that it is doing that?

We have not looked at that yet. The timing of our briefing captured data and arrangements up to September, so the decisions on the application of the roll-out of the vaccination passport are not covered in the briefing. However, as we have mentioned, there are opportunities for us to take stock and report further. We will look to do that through our overview report early next year.

I am not sure that we want to dive into a full-scale debate on vaccination passports at the Public Audit Committee.

Willie Coffey is next. Willie—you have questions on the digital stuff and on population reach.

I have just a few, convener.

Were lower rates of vaccination among certain age groups and certain communities attributable to digital access issues, or are there different reasons for lower numbers of people in those age groups and communities coming forward for vaccination?

I will ask members of the team to come in in a moment to express their views on what we have seen through our work.

The answer is that a combination of factors are involved in differences in access rates. It is largely about the timing of roll-out of the programme and perceptions in society that certain people were less at risk. As Leigh Johnston mentioned, people’s working arrangements are a factor that will have played in. That is probably the limit of what I can say. Beyond that, I point to academic research about societal motivations for people to access the vaccination programme.

It is clear from our work that the data tells us that younger people have not been vaccinated to the extent that some more at-risk groups in society have, but there is probably cause for optimism because uptake in the youngest group that is eligible for vaccination—12 to 15-year-olds—is already at more than 50 per cent. That pace of progress feels positive, at this stage.

You have said that the digital apps work really well and had to be developed at pace. Members of the public always ask me where the data is kept. Sometimes, I ask general practices questions about constituents and issues. Where is the data? Who keeps it and who makes it secure?

We will do our best to answer that. Perhaps we will have an opportunity next week when we talk further about NHS National Services Scotland, which provides much of the functionality to support delivery of services across all our health settings. Leigh Johnston might want to say a bit more about that.

In the briefing, we refer to the national clinical data store, which holds the data components that we all have. We all have what is referred to as a community health index—CHI—number that is our unique reference. That forms the foundation for the roll-out of various programmes, including the extensive vaccination programme.

The data comes with huge responsibility. Of course, it is hugely important that it is managed safely and that all the right safeguards are in place to manage people’s personal and private medical data securely. During our work, we did not see any issues that required reporting, although we closely monitor the matter. That is done by our auditors of NSS. Much of the structure and the systems within NSS give the necessary assurance.

All that is in place, but I recognise the point that Willie Coffey’s constituents have made. Much of what is done is done behind the scenes.

I have a query about the compatibility of our digital platforms with other jurisdictions’ systems. We have heard stories from here, there and everywhere that when people have moved from country to country the digital apps are not compatible. Are we largely ironing that out, or are there still issues to resolve?

I acknowledge the point. The issue surfaced in particular when people who had received their first vaccination in another part of the United Kingdom sought to access their second one in Scotland. In evidence that was given to the COVID-19 Recovery Committee earlier this month, it was acknowledged that that had been challenging, but that progress was being made to resolve it. We did not examine that in detail for the briefing paper. My sense is that the situation—although it was, undoubtedly, challenging for individuals—was not terribly widespread. The challenges seem to be ebbing.

Colin Beattie has questions.

Actually, I would like clarification on something first.

You mention in the briefing paper that vaccines were allocated according to the Barnett formula, so I presume that they were allocated on a population basis. Were there any issues with that, given the fact that Scotland has different demographics and, therefore, different priorities for the volume of vaccine that would be needed at any particular time? Was that taken into account in any way and did you note whether any issues arose from it?

Good morning, Mr Beattie. I will ask Eva Thomas-Tudo to supplement my response on the assumptions that were used in the overall planning.

The short answer is no. Our understanding is that there was fairly straight application of the Barnett model, using the population share of Scotland in the UK as the basis for which vaccines were provided. That was done across the four nations of the UK. I will pause now, if Eva wishes to share additional insights.

10:45  

Scotland’s share of the vaccines that are coming into the UK is based on the Barnett formula. Detailed modelling was done by the Scottish Government to allocate the share of vaccine more effectively across Scotland based on what NHS boards were able to deliver at any given time. That seems to have been pretty effective, given how quickly roll-out happened and the high uptake of the vaccine across Scotland.

You are reassured that the demographic differences did not have an impact.

I understand your point about whether there ought to have been a more detailed analysis of, for example, rural components, age profile and risk factors, and whether it should have led to negotiations between the four nations, but as we say, our understanding is that that was done at a higher level on the basis of relative population share.

I turn to some of the points that Willie Coffey raised. Exhibit 4 contains some fairly detailed information, the source of which is, I understand, Public Health Scotland. Given our previous experience with data, are you comfortable that the figures are accurate?

You are right that the source of the information is Public Health Scotland. The exhibit refers to uptake of the vaccine in the 10 socioeconomic groups in Scotland by ethnicity and age. We have not undertaken a forensic audit of the reliability of the data because the work was for a briefing paper, as distinct from an audit. We will have an opportunity to do so, but we are not seeing any data issues. We rely on the volume of the data and transparency in its provision by Public Health Scotland. If we encounter data issues, we will update the committee. We have not seen any, thus far.

I will ask more questions about that in a second. Page 5 of our Scottish Parliament information centre briefing shows the proportion of the population that has received the vaccine. Pretty much all the way down the line there is a discrepancy between those who got dose 1 and those who got dose 2. It is a not insignificant discrepancy, overall. Why is that?

Forgive me, Mr Beattie—I do not have the SPICe paper.

Ah. It is a private paper. It shows that, by local authority area, there is a discrepancy of a few percentage points between take-up of dose 1 and take-up of dose 2. Did you encounter that during your audit? Did you note that?

I will ask colleagues to come in on this. I accept that there was a marginal difference between the number of people who received one vaccination and the number who received two. The numbers do not equate exactly. There is probably a range of factors behind that; again the data is probably drawn from Public Health Scotland.

It is.

Thank you. People might have had the sense that one vaccination would be sufficient. We could also speculate that there were factors in play to do with people’s work. I recognise the data that you are referring to, in which there is a marginal difference between numbers of people who opted for one vaccination but did not take a second.

The analysis of vaccine take-up indicates that it is not necessarily the case that there is higher take-up in the cities than there is in rural areas, which is what I would have expected. Vaccine uptake is below 50 per cent in areas that are occupied by students. Is it possible that that figure is skewed by the fact that many students who were resident in, for example, Edinburgh, went home during Covid and got their shots there? Does the data mask a better situation than the analysis suggests?

The transient nature of student populations is very likely to be a factor—in particular, in relation to whether they registered with a practice under their student accommodation address or under their parents’ address, and where they would expect to receive their vaccine. Given that we are so far through the first and second stages, the matter is important for individuals. That is probably one of the learning points for NHS boards to tackle.

Overall, roll-out of the vaccination programme, in which more than 90 per cent have had their first dose and marginally less than that have had their second dose, has exceeded expectation, which was initially that about 80 per cent of people would get vaccinated. It is important that those points are explored further.

As you have highlighted, vaccine take-up has been lower in some groups of the population than it has in others. Your briefing states that the Scottish Government is taking action to address that lower uptake. What action is being taken and is it sufficient?

Leigh Johnston might comment on steps that have been taken on specific groups. Whether the Government’s actions are sufficient is a question that we will return to in order to make a judgment for the overview report and beyond. We will return to the question of what steps have been taken in relation to younger people, economically deprived communities and ethnic groups.

I do not have access to the SPICe paper, so I cannot see the data to which Colin Beattie referred. Our briefing does not break down the information by local authority area, either. Our breakdowns are based on population estimates, which is the denominator that is used to calculate the statistics, so there will always be a slight margin of error. For example, we say in the briefing paper that 100 per cent of over-60s have been vaccinated, but there will be a small margin of error because we know that probably a few over-60s will not have taken vaccine. This is about the population estimates that statisticians use to calculate the figures, in which there can be a small margin of error.

On targeting groups in which uptake has been lower, we say in our paper that the Scottish Government undertook a health inequalities impact assessment of the impacts that the vaccination programme would have on different groups. There are detailed recommendations in that assessment on actions that should be taken.

Has that impact assessment been published yet?

It has not. As you can see in our briefing, we recommend that it should have been published—

Do you know why it has not been published?

You would have to ask the Scottish Government that question.

Back to the action.

The assessment includes details on messaging and how to reach different populations. We have recommended improvement of data collection so that the Government can understand the groups in which there is lower vaccine uptake. We talked about data a lot. The data was not that good, but there have been improvements in understanding why that was the case, and there has been work with various organisations to ensure that the messaging for different populations is right, and on improving the accessibility of information.

NHS Inform now provides information in lots of languages. There is assertive outreach to different communities, including the Gypsy Traveller community, the homeless community and the Polish community, for example. There are also mobile clinics that go to the places where the populations with lower uptake are—churches for the black community, for example—to deliver the vaccine.

The question of how successful the initiatives have been is difficult; I do not think that we will ever have quantitative data to show the difference that they have made. It is difficult for us to know what has changed people’s minds or has tipped the balance to make them decide to take up the vaccine. As I said in one of my earlier responses, Public Health Scotland is conducting on-going surveillance of the data, of the differences that initiatives are making, and of where it needs to take targeted action, when there is lower uptake among a certain population.

Yesterday, I was reading an article from Voluntary Health Scotland, which represents third sector health and social care organisations. It was discussing the fact that NHS Forth Valley and NHS Fife have been able to show that assertive outreach to the homeless population and to the Gypsy Traveller population has succeeded in getting people who have never engaged in any kind of vaccination programme to take the Covid-19 vaccine. The feedback is anecdotal and qualitative, but we have had some successes in encouraging people. We do not know whether we will ever have quantitative data. With better data collection, however, we now have a baseline to work from.

Have any NHS boards developed their own health inequalities impact assessments?

Yes. the Scottish Government has not published the data, so it is not publicly available, but as far as we are aware it shared it with health boards, so that they could develop their own health inequalities impact assessments.

Have they done so?

We have not done detailed work on all NHS boards, but we know that the Scottish Government encouraged them to do their own health inequalities impact assessments.

I am reminded just how important these questions are by the evidence in your briefing paper. Exhibit 2 shows us in very clear terms the difference in outcomes for those who are unvaccinated and those who have received the double dose. For the record, the number of unvaccinated cases recorded is almost two and a half times the number of fully vaccinated cases, and the number of hospitalisations is three times more for the unvaccinated than it is for the fully vaccinated. Sadly, the mortality rate for people who have not been vaccinated is five times higher than the rate among those who have been fully vaccinated. Matters of inequality, ethnicity and deprivation feed into those outcomes. Do you want to comment on that?

Those are incredible statistics on the efficacy of the vaccine, from tracking progress between March and September 2021. One caveat relates to the rationale for the booster programme, which is that we are led to believe that efficacy perhaps wanes.

The point is well made, however. Groups in society that are not accessing the vaccine programme would already be facing health inequalities , which will be exacerbated by their not accessing the vaccine. That makes it all the more important to emphasise the need to extend and continue the push among those groups, so that everybody gets the benefit that the vaccine provides.

11:00  

The committee will reflect on the answers to our questions on the health inequalities impact assessment data and the fact that it has not been published. We will deliberate on whether we can make an intervention on that.

The final area that I want to ask about and which falls within your domain relates to planning and budgeting. How do you plan and budget in a situation in which a third party—essentially the JCVI—is deciding who the priority groups are, and the chronology of who should receive boosters and further access to vaccination programmes? Do you have any reflections on how well the Scottish Government, health boards and so on have responded so far in that environment? What will the future look like and what difficulties and challenges are posed to those who have to budget for and plan those vital services?

This has undoubtedly been an incredibly challenging and complex programme to deliver, and the variables have been endless. Exhibit 1 of the briefing sets out some of the timeline and the major milestones; I stress that those are just the major ones and that many other events have taken place. That full-page exhibit sets out the events that have had to be anticipated and responded to. As you said, some have been oriented around the JCVI’s clinical judgments on the timing, pace and roll-out of the vaccination programme. Clearly it is very difficult to plan and budget for all that. The finances have been dealt with differently to how they would normally have been dealt with, with the full costs of the programme being covered and not left to individual NHS boards.

My answer, I think, would mirror our overall judgment in the briefing: excellent progress has been made in delivering a successful programme, but challenges remain in delivery of the programme in the future, given the extent of the variables, the need for a permanent workforce and the importance of reaching all components and parts of Scottish society to ensure that everybody gets the benefits of the programme. Variables remain; for example, there could be further waves, further booster programmes or more clinical research on the durability and efficacy of vaccines. In the briefing paper we seek to provide an update and offer a snapshot while recognising that more reviews and audit work will be undertaken, beginning in early 2022.

Thank you. The committee will look forward to receiving the outcome of that work, so I am sure that we will have more evidence-taking sessions on it in the months ahead.

I thank the Auditor General and his colleagues very much for coming along and taking part in this morning’s very helpful session.

11:03 Meeting continued in private until 11:43.