Meeting of the Parliament

Meeting date: Tuesday, November 24, 2020

Official Report 1010KB pdf

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Topical Question Time

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Covid-19 (Care Homes)

To ask the Scottish Government for what reason it is allowing the discharge of Covid-19-positive hospital patients to care homes. (S5T-02539)

Covid-19-positive patients are not routinely being discharged to care homes. In a very small number of exceptional cases, only when the clinician has judged that it is in the best interests of their patient’s care, discharge without a negative test can be undertaken when steps including clinical risk assessment are undertaken.

The Scottish Government’s guidance, which was issued in May, states:

“residents being admitted to a care home should have a negative test before admission unless it is in the clinical interests of the person to be moved and then only after a full risk assessment.”

The policy has not changed.

The Public Health Scotland guidance that was issued in October mirrors that, and states:

“The presumption should be that residents being admitted to a care home should have a consented PCR test before or on admission unless it is in the clinical interests of the person to be moved and a risk assessment can support this; local HPTs can advise in more complex situations.”

Last Tuesday, my constituent was admitted to hospital from her care home. She tested positive for Covid on Wednesday and was discharged back to the care home on Thursday. When I raised that at First Minister’s question time and asked whether we were back to discharging Covid-positive patients to care homes, Nicola Sturgeon was emphatic in her answer, saying:

“With ... respect, I do not accept that. There is no such policy and there will not be one.”—[Official Report, 19 November 2020; c 22.]

In a previous parliamentary answer to Miles Briggs about care home discharge, the cabinet secretary said:

“no one should be discharged from hospital who has a positive test for Covid-19. If they are in hospital ..., they should remain there and be treated for the virus.”—[Official Report, Health and Sport Committee, 4 June 2020; c 18.]

That was another emphatic answer, with no caveats.

Since Thursday, I have spoken to families, care staff and a care home manager from another establishment who all told me of Covid-positive hospital discharges to care homes that are not end-of-life cases and for which no, or a very limited, risk assessment has been carried out. I have also been advised by care home staff that they are repeatedly being asked to accept Covid-positive patients, with no negative test, and are being told just to isolate them for 14 days, instead. Did the First Minister mislead Parliament on Thursday, or did she not know what her own Government guidance was?

Neither the First Minister nor I have misled Parliament. The guidance has been clear. I read out the relevant sections from the guidance that was issued in May, and from the Public Health Scotland guidance that was issued in October, both of which include exceptional circumstances that are based on clinical judgment.

As I have said in the chamber before, and will repeat now, it is entirely right in this, as in other instances of medical care, that we allow doctors, on the basis of their clinical knowledge of the patient and their experience, expertise and many years of training, to exercise clinical judgment. It would not be right for this politician, or for any politician of any stripe, to take away the capacity of clinicians to exercise clinical judgment.

The guidance has been clear and includes detailed guidance on exceptional circumstances. It says that clinicians will consult the patient—if possible—and will consult their family and the care home on what is in the patient’s clinical interests. A full risk assessment will be carried out on any transfer, and appropriate mitigation actions and support will be put in place. A 14-day period of isolation must be completed in all circumstances. The risk assessment would consider specifically whether the care home is able to support that 14-day isolation period. A care plan for what happens on completion of the isolation period is also required.

All that is clear in the guidance. We all need to understand that nothing has changed since we introduced the requirement for testing before patients or residents are admitted to care homes, whether from hospital or from the community. It is not the role of ministers—nor should it be—to take individual discharge decisions. That is entirely properly the role of doctors and others in the clinical team.

It appears that across the country the guidelines are being repeatedly flouted.

However, what about the rights of the other care home residents? The guidance says that visiting should take place only when it is established and declared by local health protection teams, 28 days after the last positive test, that a care home is free of Covid cases. The cabinet secretary knows only too well of the anguish of residents who cannot be visited, and of the families who cannot see their loved ones. However, the guidance builds in further isolation and entrenches isolation from family. If someone who is Covid-positive is put back into the home, there is a 28-day period when they can have no visitors. What about the rights of the existing care home residents and their families to have connections and to see each other?

I will make two points in response to that question.

If Mr Findlay has evidence that the guidelines and protocol that I have just read out in summary are being flouted, I want that evidence in order that we can investigate those matters, as we did with the case of the constituent that he raised at First Minister’s questions. He will have had a response from me to explain what happened in that situation.

On the 28-day period, Mr Findlay is correct. Relatives of people in care homes have raised that issue with me, and this morning so, too, did colleagues who are chief officers of health and social care partnerships. I am happy to inform members that our chief medical officer is leading a discussion with clinicians to see whether, given our developing knowledge of the epidemiology of the virus, it is possible to safely reduce the current length of time. Depending on that advice, I will act, but I will not act in defiance of clinical advice.

The cabinet secretary touched on the importance of clinical expertise in her response, but that importance is worth emphasising. Discharge decisions have been made, and must continue to be led, by clinicians who decide on the best care option for each individual. Can the cabinet secretary expand on some of the factors that clinicians have to take into consideration? I remind members that I am a registered nurse.

As Emma Harper said, it is entirely proper that doctors and clinical teams are charged with making those decisions. They make such decisions and judgments every day in many circumstances, and no one should underestimate how difficult that is for them. The type of exceptional circumstances in which they would consider the position that was highlighted in the original question might, for example, involve an individual who cannot take the test because the clinical judgment is that it would be too distressing for them to do so, but it is no longer necessary for them to stay in hospital for clinical care.

Alternatively, an individual might have reached the end of their life and be determined to go where they want to go. It might be their expressed wish or that of their family—we should remember that those conversations have to take place—that they be discharged home, or to a care home, with appropriate palliative care.

We should also remember that, although testing is really important, care homes undertake, and put a great deal of time and effort into, a range of other important infection prevention and control measures to ensure that their residents are cared for as well as they can be, and that everything possible is done to prevent transmission of the virus in the home. That includes staff testing. I hope that members will be relieved and pleased to hear about the additional measures that I will set out tomorrow in my statement on testing.

A few weeks ago, the Scottish Parliament voted for the Scottish Government to hold a public inquiry into care home deaths at once. Rather than delay things further by waiting to hear back from other United Kingdom nations, will the cabinet secretary now respect the will of Parliament and commit the Government to holding its own public inquiry immediately?

I would never disrespect the will of Parliament. As I have explained to individual members, I have sought to find out whether it is possible to have a public inquiry that rests, at least in part, on the four nations, because that would make a great deal of sense. However, I regret that I have not had a response on that, so we will now begin to take steps.

Nonetheless, members should be under no illusion: setting up a public inquiry is not a quick exercise. Significant steps need to be taken that involve the Lord President, the Lord Advocate and others. We will take those steps, as we continue to deliver a vaccine programme and an enhanced testing programme; as we continue to support our national health service and social care; and as we continue to deal with the levels of virus prevalence and cases that threaten our citizens across Scotland every single day.

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Covid-19 (Restrictions over Christmas)

To ask the Scottish Government whether it will provide an update on any relaxation of restrictions over the Christmas period. (S5T-02550)

The Scottish Government has been discussing with counterparts in the United Kingdom Government, the Welsh Government and the Northern Ireland Executive a slight and careful easing of measures for a few days over the festive period. The Scottish Government’s proposed approach is still to be finalised, and the First Minister will take part in discussions on a four-nations basis later this afternoon.

We hope to reach an agreement in principle across the four nations that will allow people to travel to spend time with friends and family for a short period over Christmas. We are considering that because we recognise that isolation and loneliness can hit people particularly hard over the Christmas period. Of course, any relaxation carries with it a level of transmission risk and, when we set out the rules that will apply over the period, we will be asking people to think very carefully about what they can do to limit their social interactions and the opportunity for the virus to spread.

We all agree that, although people are looking forward to celebrating Christmas, we must do so carefully, given that the pandemic is still with us.

Throughout the past eight months, we have had to balance the risk of the virus with the impact of social isolation and loneliness. A report by the British Red Cross found that, sadly, 32 per cent of adults in the United Kingdom

“worry something will happen to them and no one will notice.”

We cannot let that happen over Christmas. Would the Deputy First Minister agree that, over the festive period, that balance is more important than ever, especially for people who have not seen their family in months?

Those are all entirely understandable and significant issues. As we have rehearsed in the chamber consistently over the past eight months, there are many competing pressures and risks in the handling of coronavirus. There is the immediate health risk that is faced by individuals as a consequence of the virus; there are the implications of isolation, which can affect individuals; and there are issues around economic loss, social harm and social wellbeing.

Those issues are all considered by the Government, and that thinking will be brought to bear in the judgments that we make at Christmas time. I wish to be very clear with the Parliament that we are talking about a very limited relaxation of restrictions, to ensure that we do not in any way fuel the spread of the virus. Any amount of human interaction helps to spread the virus—that is the nature of the virus—but we will be trying to minimise that through the advice that we give out, based on the decisions that we take.

To ensure that as many people as possible can see their families, we need a four-nations approach. It is vital that there is a coherent set of rules across the United Kingdom so that people can have the confidence to celebrate Christmas safely. We must ensure that people understand the risks and the trade-offs. Will the Deputy First Minister indicate whether the forthcoming details will include information on any subsequent restrictions in January?

We are trying to operate on a four-nations basis in the Christmas period, as we recognise that families are spread right across the United Kingdom, and we have to have coherent arrangements in place to enable people to interact.

It is important to stress, however, that wherever individuals go during the Christmas period, they will have to follow the rules in that locality. That will certainly be the insistence of the Scottish Government: whatever rules pertain in the area to which people come must be followed. Any subsequent decisions in the aftermath of the Christmas period will be for each part of the United Kingdom to make, as we have done so far.

This Government has taken a set of steps that have resulted in a reduction in the prevalence of coronavirus over recent weeks. We took further significant decisions just last week, and we will continue to monitor the effect of those and to make subsequent judgments with regard to the prevalence of the virus.

The point on which I agree with Rachael Hamilton is that we must be very careful that, in whatever we do at Christmas, we do not fuel the virus.