Meeting of the Parliament

Meeting date: Tuesday, January 9, 2018

Official Report 913KB pdf

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National Health Service (Winter Pressures)

The next item of business is a statement by the Cabinet Secretary for Health and Sport, Shona Robison, on the response to exceptional winter pressures. The cabinet secretary will take questions at the end of her statement. If members wish to ask a question, I encourage them to press their request to speak buttons as soon as possible.

14:21  

The staff of the NHS are the beating heart of the service. They have been nothing short of exemplary in the care that they have provided in the face of exceptional winter pressures. They have gone more than the extra mile, they have worked across and beyond boundaries, and above all they have continued to deliver safe and effective patient care in the most challenging of circumstances.

I am sure that I speak for all of us when I give a heartfelt thank you to our NHS, community health and social care staff for their continuing dedication. That thanks is shared by patients and their families, many of whom have contacted me to praise the efforts of staff.

Equally, I want to apologise to patients whose treatment has been delayed. I want to take this opportunity to thank them and their families for their patience and understanding during this extremely busy time.

Each year we try to prepare for the additional pressure that winter can bring. This year that has included working with the service and other partners since the summer to prioritise and invest an extra £22.4 million to meet accident and emergency and winter pressures.

However, our NHS is facing a number of sustained challenges this winter. Emergency departments are seeing the highest level of attendances over the festive period in a number of years. During the two-week festive period, attendances were up 10 per cent compared with the same time the previous year, and in the week leading up to Christmas alone that level rose to 20 per cent. We saw a huge surge in falls and fractures before Christmas, which has undoubtedly impacted on the number of admissions and length of stay in hospitals. Some hospitals reported that the level of demand in one day was the equivalent to average demand for a week. Flu rates in Scotland doubled in December, with the most recent figures from Health Protection Scotland showing that in one week around 46 Scots in every 100,000 were suffering from the virus, compared with 22 in every 100,000 for the same week in 2016.

Over the festive period between 15 December and 2 January, there were more than 73,000 calls to the Scottish Ambulance Service. Indeed, overnight on hogmanay the Ambulance Service saw its control centres take almost 40 per cent more calls than they did during the same time last year. NHS 24 received more than 45,000 calls in the four days over Christmas—almost double the number of calls that it received during the same period last year—and thousands more calls were taken over the new year period. Christmas day was the busiest for NHS 24 since it began in 2002. In short, the demand for emergency care services has been unprecedented over the festive period.

Our NHS has sought to manage the impact of that demand in a number of ways. For example, where necessary for infection control, hospitals have on some occasions closed wards. Such closures mean that those beds can be closed for a number of days.

NHS boards are taking decisions to manage the exceptional demand based on their local plans, and that might include the deferral of some non-urgent elective surgery. Boards are reporting that, over the festive period, the level of cancellations was consistent with that of previous years. It is important to say that, unlike in England, no blanket cancellation of non-urgent elective procedures is planned. In England, it was reported that an estimated 55,000 non-urgent operations could be deferred as a result of the deferral of all non-urgent inpatient elective care to 31 January.

I want to take some time to set out the impact of flu on our health service and our population, and what action has been taken. I have already outlined the increase in the flu rate this year, which is at its highest level in the past six years and is double that of last year. It is right that we take flu seriously, and we should note that Scotland was hit by flu earlier than anywhere else in the United Kingdom.

As we do every year, we put in place preparations ahead of the flu season commencing. We have worked to ensure that flu vaccines are available to those who need them, and that people are aware of that and are encouraged to be vaccinated.

Each year, the World Health Organization reviews evidence from previous years and determines the flu viruses that are most likely to occur and which should therefore be covered by the vaccine programmes in the northern and southern hemispheres for the next influenza season. Those are the only vaccines that are available on the global market. The data tells us that the most commonly found flu types in Scotland so far are well matched to this year’s vaccine, and it is ill informed and alarmist to suggest otherwise.

Sustained exceptional levels of demand or regular peaks in demand, such as during increased flu levels, require different clinical processes from the usual systems that are in place in hospitals. Of course, the vaccine is useful only if we can make sure that as many people as possible receive it. I note that the Conservatives claimed over the weekend that uptake rates in Scotland have dropped. The fact is that our uptake rates are broadly in line with those in previous years. Overall, to the end of the second-last week of 2017, more than 1.4 million people had been vaccinated by the NHS in Scotland, which is 26 per cent of the whole population. At the same point in the previous year, 26 per cent of the population had been vaccinated. Therefore, we are in line with where we were last year. In fact, the uptake has increased among some eligible groups—for example, among pregnant woman with risks the uptake has increased to 57.5 per cent, which is higher than the rate in England.

In Scotland, all primary school children have been offered the vaccine since 2014-15, which has provided improved immunity to the wider population. This year, 71 per cent of the primary school population has been vaccinated, whereas in England only children in the first four years of primary school are offered the vaccine, and uptake in that group is 50 per cent or less for each of those four year groups.

I want to say a word about healthcare staff vaccination. The rate is lower than we would want it to be. I am absolutely grateful to the NHS staff for all the hard work that they do, but in this particular area I think that we can go further. We estimate that, so far, more than 40 per cent of healthcare staff have been vaccinated. That figure covers patient-facing and non-patient-facing staff, whereas the English figure covers only front-line healthcare workers. I caveat that by saying that the figure might be an underestimate, as it will not reflect the proportion of staff who might have been vaccinated through the national programme because of clinical eligibility.

We have made it clear to the NHS that free seasonal influenza immunisation should be offered by NHS organisations, including primary care employers, to all employees who are directly involved in delivering care. I know that NHS boards across Scotland have worked hard to promote uptake through innovative approaches and to provide leadership through senior clinicians and managers. We have supported them with national resources, including the development of a toolkit that helps those who are charged with promoting and delivering planning of their local flu campaign and the provision of campaign posters and leaflets to every health board in Scotland.

Our public campaign this year, which was launched in October, included adverts for the childhood flu programme and the seasonal flu programme for adults that ran on television, radio and digital and social media platforms. In addition, we worked with a wide range of partners, including the British Heart Foundation, the British Red Cross and Scottish businesses that are healthy working lives registered, to distribute promotional materials. In total, that work resulted in 106 organisations supporting the seasonal flu campaign, and 93 organisations supporting the childhood flu campaign.

Campaign materials for the general public for general practice surgeries, nurseries, libraries, community centres and antenatal clinics have also been distributed. Ultimately, the decision about whether to be vaccinated is down to individuals, but I am sure that we would all want to take this opportunity to urge all those eligible to get the flu vaccine as soon as possible, if they have not already done so.

Finally, some rather alarmist commentary on flu mortality rates has been reported that needs to be corrected. Four people have passed away in hospital after being admitted with flu-related symptoms and each one of those deaths is a personal and family tragedy. However, all-cause mortality is not the same thing as flu-related deaths. That data reflects deaths due to any cause, such as accidents, other diseases and old age, and is not just about flu. On that point, timing is important. The three-week period at the end of 2017 was before we really started to see flu infections presenting in our hospitals, so it is too simplistic to say that that excess is explained by flu. Work is under way by public health experts to investigate that aspect urgently so that we can use facts rather than speculation.

As I have said, a number of factors are contributing to the current pressures and they have not been just about flu. Clearly, though, flu will be a key factor over the coming weeks. The winter flu season usually has a duration of eight to 10 weeks, so it is too early to say what the end-season picture will be. However, we must view the current and emerging data in the right context and must allow space for our health service to continue to treat our sick patients with flu-like illnesses or other conditions and allow them to recover from what has been and still is a very challenging time.

NHS and care staff have worked incredibly hard over the past few weeks and have pulled together to cope with winter pressures—I pay tribute to them again for that. They deserve the collective support of this Parliament in their endeavours and I hope that that is what they will get today.

Thank you. A number of members wish to ask questions, starting with Miles Briggs.

I thank the cabinet secretary for the advance copy of her ministerial statement and I associate members on the Conservative benches with what she has said today. All of us in this chamber have been able to see over the past few weeks the tremendous work that those who work in our health service have done for our constituents and our families, and we all pay tribute to those staff and their dedication. Can the cabinet secretary answer this question, though? Is she able to confirm alarming reports that the Scottish Ambulance Service’s national command and co-ordination centre, which is normally reserved for major incidents such as terrorist incidents and emergencies, has been set up and operating for several weeks now because there have simply not been enough call handlers in local call centres and not enough crews out on the road to cope with the current high level of demand? Can she tell Parliament what extra support she will be providing to hard-pressed ambulance staff, paramedics and call centre operators?

I thank Miles Briggs for his comments about the staff. It is important that the messages that we send out are in support of our hard-working staff, because they have pulled together in a way that has been astonishing. In the comments that we make, it is incumbent on each and every one of us to get behind our staff in those efforts.

Miles Briggs talked about the Scottish Ambulance Service, which has escalation procedures that kick in when it is under pressure. With regard to the 40 per cent rise in calls on hogmanay, in such cases the senior management team will escalate procedures to ensure that the command and control processes reflects that level of demand. We would, of course, expect them to do nothing less than that when faced with those demands on the service. Of course we support the Scottish Ambulance Service and all the other parts of the system in responding to those demands. I get updates on a daily basis on what the services, including the Scottish Ambulance Service, are looking like, and we closely monitor that. The Scottish Ambulance Service has done a tremendous job in responding to the unprecedented level of demand and I put on record my particular thanks to it.

We all give our heartfelt thanks to all our amazing NHS staff, who go above and beyond all year round but particularly at Christmas. To be clear, any failures in our NHS are despite the fantastic efforts of the staff, not because of them. However, this is not just a winter issue. The staff have been left overworked, undervalued and underresourced all year round, and that is amplified now in winter.

Yesterday, the First Minister and the health secretary issued an apology for winter failures, but every month cancer patients do not get their treatment on time, every month children are denied mental health support and every month patients are waiting too long. A new analysis has shown that, in 2017, the service failed to meet the four-hour A and E standard for more than 100,000 patients. It is not just one apology in winter that is needed from the First Minister and the health secretary, but more than 100,000 apologies all year round.

“Thank you” alone is not enough, so when will the warm words stop and when will we actually see meaningful action in support of our NHS staff and Scotland’s patients?

The actions that we are taking through the draft budget, which I hope Anas Sarwar will support, are making sure that we will provide record levels of new investment to the NHS. I look forward to his support for that budget. We provide support and resources all year round, but this winter we have provided the biggest injection of resources that we have seen in any winter, with £22.4 million specifically to help the service cope with winter pressures.

On an apology, all health systems across the UK have issued an apology to patients who have had to wait longer, but patients have been hugely praising of the staff. The public have been very understanding. In the face of winter pressures, with an unprecedented level of flu—double the rate of last year—they understand the pressures that are on our system, even if Anas Sarwar does not.

I will say a final word on A and E. Scotland’s A and E departments have been the best performing over two and a half years but, this winter, even our best performing A and E departments have faced pressures. My local A and E department at Ninewells had never fallen below 95 per cent but, over the past two weeks, it has done so because of the pressures of fractures and of flu and unprecedented winter pressures. I think that most reasonable people would understand that.

I thank the cabinet secretary for the early sight of her statement. I also thank the NHS staff.

The cabinet secretary talked about working “across and beyond boundaries”. I heard of a situation where there were frequent falls in an area. The local hospital made inquiries with the local authority and discovered that it no longer gritted the area around pensioners’ houses, so the NHS now pays to grit it. If that is correct, I commend that approach and the other preventative steps that have been taken, which the cabinet secretary alluded to in her statement, including the flu inoculations.

Does the cabinet secretary recognise the benefits to the NHS of additional funding for local authority social care and indeed the gritting operations? Will she ask the Cabinet Secretary for Finance and the Constitution to direct more money to local authorities specifically for those purposes?

One of the main issues before the flu epidemic hit Scotland was the level of fractures. John Finnie makes an important point about the impact of those falls on the NHS, in that we had a wave of mainly frail elderly people, many of whom had to have operations—I know that, at Ninewells hospital, theatres were dedicated only to fixing fractures—and many of those elderly people are still in hospital. At Christmas and new year, bed availability usually increases as people leave hospital, but we have not seen that this year because of that wave of fractures.

About £550 million of resources have now gone through the health budget into social care, and that will be added to by £66 million in the budget for 2018-19. However, more important than that is the joined-up service. When I visited Perth royal infirmary yesterday, I visited the discharge hub, where we have local authority colleagues working side by side with NHS staff, making sure that people get home as quickly as possible and, in many cases, preventing people from coming into hospital in the first place. That is integration working and working well, and we should pay tribute to all the staff involved.

I thank the cabinet secretary for the advance sight of her statement. I absolutely echo the praise that has rightly been delivered by members in all parts of the chamber for our hard-working NHS staff, but does the cabinet secretary expect Parliament to believe that a bout of icy weather and an uplift in flu cases are genuinely all that are to blame for the worst waiting times on record? Is this not just symptomatic of a health service that is on its knees, where those additional pressures are heaped on hard-working staff who are fighting fires in every overstretched shift that they do?

No. They are facing unprecedented winter pressures, the likes of which we have not seen for years. We cannot have a doubling of the flu rate and not expect it to have a severe impact on front-line services.

We have put in additional resources of £22.4 million in anticipation of a colder winter. The doubling of the flu rates has exacerbated the issues. It is not just an issue for Scotland. All health services across the UK are facing the same, if not worse, winter pressures. Because our accident and emergency departments were performing at such a high level going into winter, they had a resilience that many such departments across the rest of the UK did not have. When the figures eventually come out, it will be interesting to see the comparison with the festive season here in Scotland.

How do the attendance rates at accident and emergency departments during the festive period compare with those of the past few years?

As I said in my statement, they have been much higher than they were in previous years. In the week leading up to Christmas, they were 20 per cent higher. We have had approximately 3,000 more attendances than usual, and that was on top of the trauma cases that the service was still trying to deal with in numbers that it had not seen previously. NHS 24 and the Scottish Ambulance Service were also working at unprecedented levels.

Despite all that, the service has rallied round and people have pulled together. The accident and emergency figures of 78 per cent that were published today are challenging because they are too low. However, for the service still to be seeing, treating and discharging eight out of 10 patients in accident and emergency in the face of all those pressures is commendable, and each and every one of the staff involved deserves our praise.

The number of hospital beds in Scotland has fallen by more than 7 per cent in the past four years, which has a particular impact in winter when beds are full, accident and emergency departments are overflowing and delayed discharge is preventing people from going home. Does the cabinet secretary accept that more must be done to improve patient flow throughout the health and social care system, particularly in the busy winter months?

I will deal with acute beds first. Acute bed usage has changed dramatically during the past 10 years, as far more people come in to have day case surgery. I am sure that Brian Whittle is aware of that. The way in which our health service is used has changed dramatically.

Brian Whittle is sitting beside his health spokesperson, who has demanded that we shift the balance of resource away from acute spend into primary care. They cannot sit side by side and ask me to do two different things. I hope that they will support the 2018-19 budget so that we can make the investment in community health services, avoid people going into hospital in the first place, and help those in hospital to get home more quickly.

There has been a 10 per cent reduction in delayed discharge since last year. There is more work to be done, but when he considers that most of the delays are in five or six areas, I hope that Brian Whittle will acknowledge the progress that has been made in tackling delays.

Can the cabinet secretary confirm that there have been no blanket cancellations of elective surgery in Scotland this month?

That is correct. Cancellations of electives are, so far, in line with last year’s rates for the festive period. That is quite astonishing, given that, in England, we have seen a blanket cancellation of elective procedures for the whole of January—to the tune of up to 55,000. We have not done that in Scotland. Although we have seen some limited cancellations of elective procedures, we expect boards to minimise such cancellations on a daily and weekly basis because it causes problems for the service further down the line. We expect boards to keep the position under review.

I should also point out that the latest published figures, from back in November, showed a reduction in cancellations, so we were starting from an improved position. There have been no blanket cancellations and boards will look at the position on a daily and weekly basis to help manage pressures.

Will the cabinet secretary join me in thanking all our hard-pressed and dedicated NHS staff for the work that they do, not just at Christmas but all year round?

Will the cabinet secretary agree to review the eligibility criteria for the flu vaccine, in terms of age and vulnerability? Does she share my view that general practitioners have autonomy to apply clinical judgment to extend the flu vaccine to non-eligible patients if the risk of flu would exacerbate illness?

I will of course join David Stewart in thanking NHS staff, and I thank him for the constructive tone of his questions.

The eligibility criteria are guided by the public health experts. We have seen changes over the years in the groups that have been covered by the eligibility criteria and the criteria are kept under constant review.

On the point about GPs using their clinical judgment, clinicians always have that option, but they would be guided by the priority groups because they need to make sure that the campaign and the vaccine supply are focused on them. However, once we are out of the winter pressure period and we reflect on the winter period, we will certainly look at whether there is further work to be done around the eligibility criteria, guided by what the public health experts tell us.

I think that the cabinet secretary might have covered this in her statement when she spoke about the World Health Organization’s determination of the most likely flu viruses, but can the she reiterate how the current vaccine matches with the prevalent strains this year?

Yes. The vaccine is a good match for the current dominant strains that are in circulation. That is a very important message. To say otherwise risks undermining the confidence that people have in being vaccinated. It is very important that we all use the opportunities in the Parliament and outside it to encourage everybody in those priority groups to get vaccinated. It is never too late and it is a good defence against flu. In particular, we know that the impact of flu on someone under 65 who has an underlying health condition can be very severe indeed, so vaccination is very important.

One of the issues that we may need to address is that, because of the relatively mild winters and low rates of flu that we have seen in recent years, people have perhaps forgotten how difficult and severe flu can be. This winter is a reminder, and I suspect that over the next few weeks, we will see a rise in the vaccination rate as people realise how important to their health it is to get the vaccination.

Figures today have revealed that over the Christmas period, the A and E waiting time target figures reached an all-time low. Between Christmas and the new year, 21.6 per cent of patients across Scotland were forced to wait beyond the target of four hours and, in one health board—NHS Forth Valley—the figure was a shocking 42.7 per cent. In that single week, 272 people had to wait longer than 12 hours, compared with just two people in the same period last year. What action will the Scottish Government take to restore confidence in our emergency departments?

The 78 per cent figure that was published today for the week ending 31 December is disappointing but understandable, in the light of all the pressures that we have seen. It was unlikely that we would be able to maintain the levels of performance in A and E that we have seen over the past two and a half years—levels that are the best in the whole of the UK—in the face of those unprecedented winter pressures. Most reasonable people would understand that.

It is important that we are now focused on helping those A and E departments to recover. The fact that, despite all those winter pressures, nearly eight out of 10 patients were still seen, treated and discharged within the four hours is actually quite remarkable.

I gently point out to Annie Wells that surely the Prime Minister and the Tory health secretary would not have had to apologise if they were not facing some of the same winter pressures in their A and E departments. Therefore, to come here and say that the position in Scotland is somehow different from the position elsewhere in these islands is disingenuous in the extreme. We are all facing winter pressures, and we should be getting behind our hard-working staff rather than talking down their efforts.

What alternative services are available to people who are concerned that they may have flu-like symptoms, short of going to A and E? For instance, are there more appropriate services to try first?

Yes, there are. One of the best first ports of call is NHS inform. I can tell Parliament that the NHS inform website had 60,000 hits on Christmas day, which is unprecedented. NHS inform is a hugely important source of information and has now become a key part of the health advice system. In addition, there is NHS 24, which many patients have used. There are also local GP practices, the out-of-hours service and, importantly, community pharmacies. If someone has flu-like symptoms, we do not want them to wander about, potentially infecting others, so the advice is to stay at home; family and friends will be able to get over-the-counter remedies from a community pharmacy. If people are in any doubt, they should please contact NHS inform, where they can get good advice and information.

The cabinet secretary will be aware that NHS staff in Lanarkshire, as well as doing their day job, have been brought in as volunteers to cover clerical and cleaning roles. They are the heroes that have kept our hospitals in Hairmyres, Wishaw and Monklands running. However, staff and patients in my region are wondering why NHS bosses in Lanarkshire have had to go looking for volunteers when other health boards in Scotland have not. Does the cabinet secretary agree that a properly resourced health board with a strong workforce plan should not have to resort to that kind of approach?

First of all, I pay tribute to the staff in NHS Lanarkshire. No one forced them to do that, but they rallied round and came out in huge numbers to support the front-line staff. I pay tribute to each and every one of them.

NHS Lanarkshire had particular challenges, partly because it has three A and E departments that were hugely under pressure, and because flu has hit NHS Lanarkshire very hard indeed. We have been working with NHS Lanarkshire to support it to ensure that it can keep patients safe and keep services operating. I also pay tribute to the GPs who came out and worked last Saturday morning. It is a real credit to them that they did so, and it helped to relieve some of the pressure on hospital services. We do not see that sort of thing very often, and we would not expect staff to have to do it very often, but it says a lot about our staff that, when push comes to shove and the service is under pressure, people roll up their sleeves and get on with the job. They are to be commended for that.

I think that we all welcome the extra £22.4 million to support boards to meet A and E and winter pressures. In addition to that extra investment, can the cabinet secretary confirm that the Scottish Government will continue to work with health boards and will be available to assist them with the pressures that they are under not just at this time but in the future?

We monitor what is happening across our system every day, and I get a report on that every day. I should pay tribute to our civil servants and senior officials who have been out and about in the service providing really important support to the front line and to senior management teams.

It is important that we are all focused on getting through the winter period, because flu will be around for another few weeks, with all the impact that that will bring, so we are not out of the woods yet. However, once we are through this winter period, we will do a proper analysis, as we do after every winter.

If there are lessons to be learned about changes that we need to make or other things that we need to do, we will do that for next winter. That is part of the normal course of winter planning and preparation in advance of the following winter.

That concludes the statement.