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Chamber and committees

Meeting date: Tuesday, August 25, 2020

Meeting of the Parliament (Hybrid) 25 August 2020

Agenda: Time for Reflection, Business Motion, Topical Question Time, Ferguson Marine, Business Motion, Children (Scotland) Bill: Stage 3, Children (Scotland) Bill, Parliamentary Bureau Motion, Decision Time


Topical Question Time

Masks (World Health Organization Guidance)

To ask the Scottish Government what its response is to the latest World Health Organization guidance that young people over the age of 12 should wear a mask to help prevent transmission of Covid-19. (S5T-02332)

In the light of the latest scientific and public health advice, including the World Health Organization guidelines, the Scottish Government has, after discussion with the education recovery group, updated the advice on the use of face coverings in secondary schools and on school transport. Unless specific exemptions apply, face coverings should now be worn in secondary schools by adults and pupils in corridors and confined communal areas where physical distancing is difficult to maintain. Face coverings should be worn also by all children aged five and over on dedicated school transport, in line with the guidance for public transport. The guidance on school reopening will be revisited to reflect that latest advice.

I thank the cabinet secretary for that answer and I welcome today’s announcement, although I am unsure why it could not have come before schools reopened, rather than two weeks into term. I accept that, were masks to be worn in class, there are legitimate issues with communication and learning, but the Government’s rationale for not including classrooms in the guidance appears to be that there is greater scope for social distancing there. That is not what pupils and teachers are telling me, which is no surprise, given that classrooms are no bigger than they were in March. What is the cabinet secretary’s message to teachers and pupils who cannot socially distance in their classrooms?

The reason why the guidance has been issued today is that the public health advice has changed. That was not the public health advice that we had when schools returned three weeks ago.

The rationale for our approach to classrooms, for which we are not recommending that face coverings should be utilised, is that, in the World Health Organization guidelines, there is to be a clear balancing of the public health benefits versus the potential for undermining education and learning. In such matters, there is a sensitive balance to be constructed and considered in that respect.

In response to Mr Greer’s question, I say that the guidance from the education recovery group is very clear: in a classroom setting, teachers should be exercising physical distancing of 2m from pupils to minimise the risk of transmission of the virus. However, if individuals wish to wear face coverings, they should be free to do so at any stage in the school day.

The National Deaf Children’s Society, among others, has been calling for the increased use of clear face masks, which will now be particularly important in schools, for not only staff, but other pupils, so that those with hearing impairments and other additional access needs are not socially excluded. Will the Government ensure that clear face coverings will be made available to all schools for staff and pupils, if they require them?

Mr Greer makes a valid point. That is why we have encouraged schools to specifically look at the circumstances of individual children and young people, and make sure that their needs are properly taken into account in the planning for the delivery of education in the very different environment in which we are now having to operate.

I will give the Government the opportunity to clear up any potential confusion around the guidance. The language that is being used by ministers, as reported in the media, is “non-mandatory but obligatory guidance”, or words to that effect. Which is it? Is it guidelines that the Government would like schools to follow or mandatory regulations that schools must follow? There is an important difference between the two. If the guidance is not compulsory, does that mean that schools can choose whether to implement it? If the guidance is mandatory, who will enforce it, and who will provide the personal protective equipment?

Let me try to navigate my way through the issue, because I appreciate its complexity.

The guidance that is being set out today is to be applied in all secondary schools in Scotland without question, and the guidance specifies how it is to be applied. In communal areas and on school transport, the guidelines should be followed. There will be exceptions, for example for health reasons, including those that Mr Greer has just raised. There will also be circumstances in which young people might be concerned about face coverings. We are trying to create an approach that is consistent with the wider approach in Scottish education of encouraging compliance and working with individuals to secure their compliance, rather than having mandatory guidance that has legal force, which, frankly, would be alien to many aspects of the normal working of our schools. That approach is being taken to ensure that individuals can follow the guidance that is being set out by the Government in a fashion that is consistent with the way in which our schools habitually operate.

I hope that my answer gives Mr Greene the clarity that he seeks. We are trying to work with schools to make sure that they are as safe as possible for children, young people and staff.

I thank the cabinet secretary for that answer, as my main concern is the issue of exemptions on health grounds for young people. I was concerned to see photographs from a school in my Motherwell and Wishaw constituency in the press last week. Given the change of direction, what comfort can parents and young people take from the guidance to make them feel safer?

It is important that we consider this move, along with the other mitigations that are part of the guidance that has already been published. In the guidance, we set out the importance of physical distancing in schools, and the importance of hand hygiene, cleaning regimes and following cough etiquette in all circumstances. We are adding an additional layer of protection through the wearing of face coverings in the circumstances that I have set out in my answer to Mr Greer’s question. There will, of course, be exemptions for young people who are unable to comply with the approach. However, the approach is designed to take every measure, based on the available public health advice, to make our schools as safe as they can be.

The WHO’s advice on face coverings in schools has changed, but its advice on testing is long standing. Why can we not complement the use of face coverings in schools with the routine testing of staff, as the GMB trade union has argued?

I announced in Parliament about two weeks ago that it is possible for staff to secure testing when they are concerned about Covid. A direct employer portal enables staff to access the testing, whatever their role happens to be in school.

Last week, I made the case for extending the guidance on face coverings. The Government’s guidance was one step behind, so schools were forced to take the initiative themselves. I am glad that the education secretary has now progressed the issue. Most pupils are already familiar with wearing face coverings in public places. Is the Government advising that face coverings should be worn as soon as possible, even though the guidance will not come into effect until next Monday?

I encourage the wearing of face coverings by young people as soon as practicable. Beatrice Wishart makes the fair point that we are all accustomed to wearing face coverings in a variety of public settings, so there will be familiarity with the practice. I certainly encourage individuals to take that action as soon as possible, and certainly before 31 August.

I welcome this morning’s clarification from the cabinet secretary that children and young people with autism—I highlight my interest as a parent of an autistic child—will be exempt from wearing face coverings. How prescriptive does he expect the list of exemptions to be, given the plethora of conditions that might make it difficult for young people to wear face coverings? What steps will be taken to ensure that there is awareness of the exemptions, so that young people are not singled out for not wearing them and subjected to bullying?

Fundamentally, I think that it is important that schools, which know their pupils well, are able to exercise the judgment that will enable appropriate exemptions to be applied to the pupils who require to have them. That is best served by judgments in school, rather than by a prescriptive list from the Government.

The second question was about how young people with exemptions are treated. That is a sensitive issue. Mark McDonald raises the danger of young people being singled out or targeted because they are not wearing face coverings. We have to work in schools, which our educators are doing at all times, to create an atmosphere of mutual respect for individuals, so that the difference in circumstances that they face can be properly respected in how they participate in schools, because we want our schools to be safe and inclusive places for all children and young people in Scotland.

Delayed Discharge into Care Homes

To ask the Scottish Government whether it will provide an update on delayed discharge into care homes. (S5T-02346)

The latest published information from Public Health Scotland indicates that 357 patients who encountered delay in their discharge were discharged to care homes during June 2020, which is 32 per cent of the total discharges that month. The remaining 68 per cent were discharged back to their own homes. That compares with 33 per cent of delayed discharges going to a care home in June 2019.

Hospitals and care homes are taking three key steps whenever a patient is discharged from hospital. First, a patient should be tested 48 hours before discharge. Secondly, they should be isolated for 14 days on arrival in the care home, regardless of the test result. Finally, at all times a thorough risk assessment should be undertaken prior to discharge, to ensure that the care home is able to provide the care required, including having suitable physical space for isolating individuals and having staff available for the delivery of care and support to the resident.

Last week, as members might recall, I commissioned Public Health Scotland to produce validated statistics on patients who were tested prior to discharge, and on the outcome and date of the test. That information will include how many were discharged while still considered to be infectious and the rationale for that decision.

How does the number of delayed discharges compare to the number prior to the pandemic?

The number of delayed discharges has reduced significantly over the past few months. The June census, which is the latest published, validated census, showed 808 delayed discharges for any reason or duration, compared with 1,627 in February 2020 and 1,442 in June 2019. Nearly a third of all those that were delayed this June were complex cases, including people who lacked capacity and were awaiting a court-appointed guardian.

The cabinet secretary will be well aware that the winter season always sees an increase in hospital admissions, and I know that work is currently being undertaken to strengthen the resilience of our Scottish health service. What forecasting work is being done to balance the transfer of care and mitigate the impact of that on our health and social care sectors?

A number of steps are being undertaken as part of what would be normal winter planning but are this year increased in their significance because we are still in the middle of a pandemic. They include the significant expansion of the flu vaccination programme.

With regard to our health boards’ work, another step is health board mobilisation plans, which the boards were asked to produce to take us through to the end of March 2021. Those plans have to have been developed in consultation with the local health and social care partnerships, which include our local authorities, so that we can also see what additional capacity either needs to continue, particularly in terms of care at home, or needs to be brought in, as we make those estimates. The overall objective is to treat people as close to home as possible, so part of that effort also includes scaling up—where it is clinically safe to do so—the hospital at home initiative, which has been so successfully undertaken by NHS Lanarkshire over many years.

To follow up on the revelations by the Sunday Post and The Courier at the weekend, if the decisions that were made in March and April to discharge all those hundreds of patients who were untested or Covid positive were based on the clinical needs of patients, why were those same patients not discharged in February or December or January, when they were likely to have become delayed discharge cases?

I will make two points in answer to Mr Findlay’s question.

First, the point of commissioning Public Health Scotland to do the work that I have just outlined is to make the data that it produces, which will cover all our health boards, really clear. As Mr Findlay knows, the Sunday Post article was able to deal with only some returns from some of our health boards. Part of the objective of the Public Health Scotland work is to identify not only patients who were discharged who had had a positive Covid test, but the date on which they had that test. That information determines whether they were infectious at the point of discharge. When we have those numbers, which I hope that we will have by the end of next month, that data will of course be published, and then we can have further discussions with colleagues on the issues that they want to raise.

On Mr Findlay’s other point, I remind members that, on 17 March, I said in the chamber:

“We are also working closely with the Convention of Scottish Local Authorities, health and social care partnerships and chief officers to get a rapid reduction in delayed discharges. I have set a goal of reducing those by at least 400 by the end of this month.”—[Official Report, 17 March 2020; c 7.]

That was part of a statement to the Parliament that outlined our understanding and expectation at the time of the number of potential hospital cases that would have to be dealt with because of Covid-19. Our modelling said that we needed to create space in our hospitals and additional intensive care space to deal with the demand. That was all part of that work.

It has long been a policy of the Government to reduce delayed discharges, and colleagues from across the chamber have agreed with that. In the period that we are talking about, the health and social care partnerships, supported by the health boards, put additional focus on working through the obstacles that were in the way of discharge. However, that does not contradict the fact that it is always a clinical decision that determines whether someone is ready to be discharged and that a multidisciplinary risk assessment is carried out to agree where they should be discharged to.

Following the reports on the issue from the Queen’s Nursing Institute, is the cabinet secretary aware of whether there have been issues related to delayed discharge early in the pandemic in other parts of the United Kingdom?

Yes, there have been. In the regular four-nations calls that I take part in with my colleague health ministers in Wales and Northern Ireland and the Secretary of State for Health and Social Care, Matt Hancock, we regularly discuss the common challenges to us all in responding to the pandemic. Those challenges have included ensuring that our NHS was prepared, introducing additional resources—in Scotland, that was done through the NHS Louisa Jordan hospital—the issues around personal protective equipment, which have been rehearsed in the chamber many times, and of course the situation with delayed discharges. We discussed the care and support that were needed to ensure that we had the right care-at-home services, as well as the approach that was taken in care homes. In common with those three other countries, we have developed our understanding as the understanding of the virus has developed, and we have developed our guidance and actions accordingly.

On Sunday, a letter was published from the cabinet secretary and COSLA’s health spokesman to Scotland’s health and social care partnerships. The letter revealed that the director general of health and social care set a target to reduce delayed discharges by 900 by the end of April. Does the cabinet secretary consider that that letter constitutes an intervention by Government in decisions that would otherwise have been taken purely by clinicians in consultation with social work colleagues? What consideration was given to the impact that urging the partnerships to meet the target might have?

No, I do not think that there is any contradiction whatsoever in our approach. I mentioned what I said in the chamber on 17 March. On 1 April, I said that we had

“reduced the numbers of delayed discharges in our hospitals by 500.”

I went on:

“We will continue to work towards a further reduction of 500 over the month of April.”—[Official Report, 1 April 2020; c 85.]

There is no contradiction in the Government or indeed any Opposition party having a policy to reduce delayed discharges on the ground that we all know about and accept—that it is positively harmful for people, particularly older people, to stay in hospital for longer than is clinically required—and saying that the final decision about whether someone is ready to be discharged is a clinical decision that is to be taken patient by patient, as it should be, or that the decision about where they will be discharged to and the care and support that they require involves a multidisciplinary risk assessment that is undertaken by social work, the clinicians and the resident or their family, or both.

There is no contradiction in that at all, so that letter is not some blinding revelation; it is simply the Government enacting a policy decision. The decisions about who is discharged, when, and to where remain clinical and multidisciplinary decisions, as they have always been.

Big questions are still outstanding, on: the advice on asymptomatic transmission; the value of testing all the way through the pandemic; the number of positive patients who were sent or moved to care homes; and the isolation arrangements in care homes. All of those are big questions. Do they not lead the health secretary to the conclusion that we need an early public inquiry?

Mr Rennie is right that all those issues require big decisions and need to be scrutinised thoroughly. As the First Minister and I have said more than once, we know that there will need to be a public inquiry into the entire handling of the pandemic in Scotland—I expect that there will be inquiries elsewhere, too. When the time is right, we will say what we believe the remit of the public inquiry should be, and it will get under way.

Right now, we are still in the middle of a pandemic. We have outbreaks, clusters of cases, testing challenges and a flu vaccine expansion programme, and we still have to remobilise the NHS while it does all that additional work. This is not the point for us to take our focus away from that job—which, at the end of the day, is about saving lives—in order to set up a public inquiry and direct all officials into that area of work.

The work that we do now is important. The public inquiry will also be important. When the time is right, we will have that public inquiry.

It is unfair to let social workers and clinicians take the blame for what happened. We have all seen the letter, so I give the cabinet secretary another opportunity to now admit that it was the Government’s policy that led to so many untested and infectious patients being cleared out of hospitals and placed into Scotland’s care homes. Will she admit that?

Nobody—not me, the First Minister or any other member of the Government—is suggesting that clinicians, care home workers, social workers or even patients themselves are somehow to blame for what happened. [Interruption.] No, I am explaining to Ms Lennon how delayed discharge works in any circumstances, including in a pandemic.

First of all, the lead clinician for a patient—any patient—determines that the patient is ready to be discharged, because they need no more treatment in the hospital setting. A multidisciplinary assessment is then undertaken to determine the best place for the individual to be discharged to. One of the great improvements that we have seen during the pandemic is the widespread adoption across our health and social care partnerships of work on such assessment beginning much earlier than the point at which the clinician decides that a patient should be discharged.

I am not in the business of blaming anyone at all. I have always been clear that I am accountable for the decisions that I have taken. I believe that it is right to hold a public inquiry at the right time. Right now, I am focused on doing the best possible job that I can to ensure that citizens, patients, residents and our staff across the NHS are given the resources that they need and are kept as safe as possible.

I keep hearing the phrase “clinical decision”. The reality is that a clinical decision is about the health of the patient and the patient’s ability to leave hospital; it is not about the impact of Covid on a care home. We heard today that the Care Inspectorate was not involved in the decision-making process, so who was looking after the care homes when the legislation was brought to the Parliament?

The care home looks after the care home in relation to—let me be very clear—deciding whether it wishes to take a person. That is the care home’s decision. Some care homes closed their doors to new admissions, and some still do. We ask them to do so if they have a positive case but, in those early days, care homes did that themselves, because they are independent providers. As Mr Whittle knows, some care homes are run by the private sector, some are run by the third sector and some are run by local authorities.

They make those decisions. However, the work of determining whether the care home in question has the right nursing and physical capacity to keep a new admission isolated from day 1, as the guidance specifies, is undertaken by the multidisciplinary team, which will of course talk to that care home about whether it can meet the resident’s requirements.

I tell Mr Whittle that that is how it works. It is not rocket science—it is really straightforward. I know that he knows that, so I am not quite sure what point he is trying to make. He knows as well as I do the process that is gone through—there are many care homes in the constituency that I represent and which he covers as part of his responsibilities, so he knows exactly how the system works with East Ayrshire Council and the local health and social care partnership.

We know how the system works: it continues to work as it always has done. The idea that there was some secret target is nonsense; I have just read out from the record—twice—what I previously said we were going to do.

Cancer Services

To ask the Scottish Government what action it is taking to ensure that patients have timely access to cancer services, and when cancer surgery will be restored to full capacity across all national health service boards. (S5T-02339)

From the outset of our response to the pandemic, we prioritised emergency and urgent care, including cancer services, which have remained in place throughout the pandemic. Although some treatment plans have changed to minimise individual risk, cancer surgery in Scotland is currently operating close to pre-Covid levels, and the service is looking to increase what it is doing.

The framework for the recovery of cancer surgery, which I published in June, was clear on how cancer surgery would be prioritised across Scotland. Provision is supported through the utilisation of private sector capacity and the NHS Golden Jubilee. Cancer wait time performances for quarter 1 include 96 per cent meeting the 31-day target and 84.7 per cent meeting the 62-day standard. Further management information that we currently hold will be validated and published later in September.

Health boards are now working on local mobilisation plans to ensure timely access to services, including those relating to cancer. Last week, I announced a new national plan for cancer services, to be published in the autumn, which will ensure that patients continue to have swift access to treatment and care.

I thank the cabinet secretary for her response, and I note from today’s update that the Scottish Government has indeed published a refreshed framework for the recovery of cancer surgery. I also note that the reference to 60 per cent capacity has now been removed, which is a welcome change. We are all grateful to those healthcare workers who were able to keep emergency cancer services running.

However, we know that there was a postcode lottery in cancer provision before Covid, and things were not exactly going brilliantly before the pandemic hit. Can I get a guarantee from the cabinet secretary today that cancer surgeries will not be reduced? Can we get a date for when they will be restored to full capacity in all health boards?

Cancer surgeries will not be reduced. With regard to the date that Ms Lennon is—entirely reasonably—seeking, my answer is that when we have the validated management information, that will tell me what percentage of the pre-Covid level our current surgery capacity is at. It is more than 60 per cent—I know that for sure. I will then be able to decide, based on what boards and the cancer teams tell me, how long I think that it will be before we get to 100 per cent capacity. At that point, in September, I will be happy to write to the member and to bring the matter back to the chamber if colleagues wish me to do so.

I welcome the cabinet secretary’s offer of a written update, but I think that the whole chamber would appreciate the opportunity to ask questions and get a fuller statement on the matter.

Today, in response to the statistics published by Public Health Scotland, Macmillan Cancer Support has said that it is “extremely” concerned, and it has reminded us that waiting for a cancer diagnosis, or to hear whether you have a life-threatening illness, is one of the worst experiences that anyone can have in their life. Can the cabinet secretary provide an update on how many people have missed out on cancer screenings as a result of lockdown measures so far? What is the cabinet secretary’s message for anyone who is at home and is worried because their appointment or treatment has been delayed? We all have constituents in that situation. What can the cabinet secretary say to reassure them?

I completely understand what Macmillan Cancer Support is saying. The new national plan for cancer services that is being developed, which I will publish in the autumn, is being worked through with key stakeholders such as Macmillan and Cancer Research UK, which have such a great deal of expertise and of understanding about how patients feel and what they need and want.

I do not have the number of people who missed screening with me. Rather than make an approximation, I am happy to send it to Ms Lennon immediately after these questions. She will know that we have restarted screening services, with cervical screening beginning on the week of 13 July and breast screening having resumed from 3 August. Boards have also resumed bowel screening colonoscopies and appointments.

My advice to individual patients would always be to speak to the clinical lead of their cancer team, who is best able to advise them about their particular situation and how the team is progressing in its work. That failing, individuals can of course write to me, and we can assist them as best we can, but the starting point is those with the expertise and the knowledge of the individual patient and their case. That will be the clinical lead for their team or, in some instances, the specialist nurse.

Can the cabinet secretary provide an update on the framework for recovery from cancer surgery? How will that tie in with the overall objectives of the Scottish Government’s cancer strategy?

It will tie in with our objectives under the cancer strategy. The framework makes it clear that patients are treated and listed for surgery in order of clinical priority in exactly the same way across all of NHS Scotland. The point of that is to ensure that there is equity of access based on that assessment of clinical priority. Our boards are expected to work together to ensure that patients are offered the earliest available appointment. In some instances, that might mean that patients will not be treated in their local board area, or they will perhaps be treated in their board area but not in the nearest hospital setting to where they live. In those circumstances, we will ensure that support is provided to the patient and their family if they have to move any distance from where they would normally expect to receive treatment.

The national cancer treatment response group is overseeing all of that and is ensuring that the framework is being implemented. The framework, the national plan for cancer services and our overall cancer strategy—which Mr Torrance referred to—will be brought together, and we will ensure that they align. The objective here is to restart and increase the delivery of all those services as quickly as we can. As members would expect, and as I know they will agree, treating cancer is one of our most important priorities.

My apologies to the three members who were not called.

On a point of order, Presiding Officer. Have you had a request for the Cabinet Secretary for Health and Sport to make a statement on the issues raised in question 2? What happened in our care homes is a national scandal and we have to get to the bottom of it. We have to hold the Government to account for decisions that it made. Can you advise whether there has been a request for a statement? Has the cabinet secretary advised whether she will come and take more questions on this very important issue?

I thank Mr Findlay for the point of order. That issue was raised at the Parliamentary Bureau earlier today. The business managers agreed to return to the subject following today’s topical questions. Business managers will consult with me later today, and Parliament will be kept informed as to whether the Government will come back with a statement on the matter.