Meeting of the Parliament (Hybrid)

Meeting date: Wednesday, October 28, 2020

Official Report 1038KB pdf

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NHS (Winter Preparedness)

The next item of business is a statement by Jeane Freeman on winter preparedness in the national health service. The cabinet secretary will take questions at the end of her statement.

15:24  

The rise in positive tests for Covid-19 confirms not only that the pandemic is still with us but that the virus will seize any opportunity to spread. Today, I will set out the steps that we are taking to prepare our NHS to respond to that and to wider winter pressures.

Earlier this year, I put our NHS on an emergency footing, and that emergency remains. The plan published today is directly linked to the social care plan that I will publish next week. They are interconnected and interdependent. I will return to Parliament next week to set that out in more detail.

Scientific evidence indicates that, prior to a vaccine, further waves of infection are probable. Previously, the incredible commitment of our health and social care staff, as well as the unstinting support and perseverance of the Scottish people, prevented the NHS from being overwhelmed.? Our overriding priority at this time is to ensure that that continues to be the case.? Not only is that vital to saving lives and providing care to those with Covid-19, it is vital if we are to ensure, as far as we can, that care can be provided safely for the other health needs of our nation.

We need to make every effort to prepare the NHS for the pressures that it will face in the coming months, as we do every winter. However, we do that this year with additional demands because of a significant resurgence of Covid-19 and the uncertainty of Brexit, given that the threat of there being no deal at the end of the transition period remains.

A few weeks ago, I set out the key pressures that are on our NHS. Those are: the critical public health measures of test and protect and flu vaccination, to deal with Covid-19; the demands of dealing with rising Covid cases and holding capacity for any surge in case numbers; and the need to restart and maintain critical healthcare services in the community and in hospital to deal with those who have been waiting as a result of the earlier lockdown and to do what we can to prevent that number from significantly increasing. That all needs to be done while putting in place the necessary Covid-safe measures of increased personal protective equipment, physical distancing and enhanced cleaning, all of which inevitably decrease the volume of patients that can be seen in any one clinical or theatre session.

All those demands are here now, and are faced by a workforce who have already had a very tough year. Therefore, it is inevitable that difficult decisions will have to be taken to prioritise NHS capacity and resilience to address those demands. That is why I am publishing our NHS winter preparedness plan today. I am doing so to set out those challenges and to capture the range of actions that we are taking and the resources that are being made available to support what has to be a multifaceted response.

Last month, I announced £1.1 billion of funding for NHS health boards and integration authorities to meet the costs of responding to the pandemic. Today, I am announcing an additional £37 million to ensure that our health and care services are in the best position to respond to those unprecedented winter challenges. Those resources will support our key priorities for the next phase: our vaccination programmes, test and protect and sustaining our essential services.

Our objectives on vaccinations are twofold: to vaccinate nearly 2.5 million people for flu—an increase of 50 per cent over last year—and to be ready to deliver a safe and effective vaccine against Covid-19 as soon as one is available. The first of those is under way using a range of delivery routes, with health boards aiming to deliver vaccinations to all high-risk groups by 31 December. Many are operating seven days a week to do that.

Alongside that, work is under way on a national plan with local delivery for the Covid-19 vaccine, learning the lessons from the flu programme. As soon as a Covid-19 vaccine becomes validated and available, our initial focus will be on protecting the most vulnerable from harm. As that work crystallises, I intend to return to the chamber to provide more detail to members.

Our test and protect strategy is a vital element in the battle to disrupt the spread of the virus. We are increasing overall Scottish testing capacity from the current position of around 27,000 tests per day to at least 65,000 by the winter, drawing on NHS Scotland and UK-wide Lighthouse laboratory capacities. Three new NHS regional testing hubs will be fully operational by early December, contributing an additional 22,000 daily tests to the 65,000 number.

We are also working through what additional capacity new processing technologies can offer and what new test routes can bring to our plan to increase the cohorts of individuals who are offered regular asymptomatic testing. That is in line with the clinical review that was published last Friday.

Our contact tracing record remains strong. Over the four-week period of 21 September to 18 October—weeks when case numbers were rising—91 per cent of positive cases were successfully completed within 48 hours, and 75 per cent of that number were completed within 24 hours. It is a vital service—our second line of defence—so we continue to actively ensure that health boards use the resources that are provided so that we have the necessary capacity, as well as back-up resilience through the national contact tracing centre.

Members will recall the planning that we put in place to deal with hospital and intensive care unit Covid cases in the early months. The need to repurpose approximately 3,000 acute beds nationwide for Covid-19 patients remains. Our health boards retain the ability to double ICU capacity within one week, treble it in two weeks and quadruple it to over 700, should circumstances demand. Today, in some of our acute settings, we can see the importance of retaining that capacity as hospital and ICU cases rise.

Those beds need staff—trained, skilled staff—so an increase in Covid cases will inevitably limit capacity for other services. We need to be ready for that and plan for the possibility that resumed non-Covid services might have to be limited or paused so that we can direct capacity to accommodate Covid or winter pressures.

Those pressures will impact differently across the country—we can see that today. However, although that is the case, we need to have an approach that strives for as much equity of access for patients as we can and, unlike in the early response, strive to maintain as much non-Covid healthcare as possible.

We are putting in place a national framework to ensure a consistent approach to prioritisation for planned and unplanned care across the country, alongside actions to mitigate the impact in local areas if we face the situation in which services need to be suspended for any length of time. The pressure on acute capacity and the patient-centred approach of our NHS, which works to make sure that people receive the right care in the right place, make the work that is under way to redesign urgent care all the more important. That redesign work, which is being undertaken with the full involvement of clinical colleagues and boards and is overseen by the mobilisation recovery group, which I chair, aims to help patients know where to go for urgent care when they need it.

It is a significant programme of work, and it will not be completed in six months or even a year. It will be undertaken carefully and in stages. In order to test it and make sure that it works and is safe and accessible, the first phase of the redesign programme will be implemented at a pathfinder site over November, from which we will learn lessons, from patients as well as from the service. We then aim for a national roll-out in December, which will be supported by £20 million of investment and a major information campaign to ensure that people know how to access the right care in the right place.

Although our response to Covid-19 is fundamentally important, so too is our ability to continue to provide care and treatment for other health needs, both urgent and routine. As we have done throughout the pandemic, we will continue to provide treatment for cancer and other life-threatening conditions. Recently, health boards have begun to safely restart a number of diagnostic and screening services and elective procedures. Last month, we wrote to health boards and their integration authority partners to confirm the provision of more than £78 million to ensure that NHS boards continue to restore as much of their elective activity as circumstances allow. That funding will support additional activity, with more than 70,000 out-patient appointments, more than 13,800 elective procedures and more than 98,000 diagnostic tests.

The NHS Golden Jubilee hospital continues to play an important role, with an additional 1,600 urgent and cancer patients seen between March and September, and a plan to treat a further 13,000 across all relevant surgical specialties before the end of March next year. It is operating as a Covid-light site.

Since July, more than 4,000 out-patients have been seen in the NHS Louisa Jordan hospital, with numbers continuing to grow. The facility offers us crucial additional capacity in orthopaedics, dermatology, oral medicine and imaging, as well as remaining ready to stand up to care for Covid patients if we need it to.

The curtailment of many services for patients in the early stage of the pandemic has meant that many people who need care are waiting longer than any of us would want them to. I am truly grateful to them for bearing with us as far as they have, and I assure them that we are doing all that we can to get the care to them as quickly as possible. The place to start is with clinical judgment so that we prioritise planned and unplanned care based on clinical need and those with the greatest need are treated first. That should be done in a consistent way across the country.

I said at the outset that addressing all those demands raises perhaps the most significant demand of all: the demand on NHS staff, who have already had such a tough year. We have asked much of them, and we are asking that again. There are not words to express how truly grateful I am to them. However, more than words, we need to ensure that they have the support that they need. I intend that all the practical on-the-ground support that we saw in the early phase remains and that the significant additional support for mental health and wellbeing stays in place, and I intend to ensure that staff hubs and rest areas are maintained and to establish a mental health network, backed initially by £5 million of funding.

We know that, like the year so far, the next few months will not be easy. They will once again require difficult judgments and difficult choices to be made. I am all too aware of the sacrifices that our response will entail, from the amazing but weary front-line workers to people across our communities who may need to wait longer for treatment than I would want. I am absolutely determined that we will do everything in our power to be ready for those challenges. We have learned a great deal from the first wave of the pandemic, and we are better prepared.

Our “Winter Preparedness Plan for NHS Scotland—2020/21”, which was published today, sets out the range of actions that we are taking to support our incredible healthcare services and to work with them to manage the next phase. That is nothing more than they and the people of Scotland deserve.

We will move to questions, the first of which is from Donald Cameron, who is joining us remotely.

I thank the cabinet secretary for advance sight of her statement and the publication of the plan.

As we move into winter, it is more critical than ever that we ensure that the most vulnerable people in our society receive their flu vaccinations. However, as we have seen over the past few weeks, the roll-out of that vaccination programme has been chaotic and confusing, with issues in NHS Ayrshire and Arran due to unprecedented demand, problems with booking appointments in NHS Tayside and NHS Fife, and NHS Greater Glasgow and Clyde having to apologise for notifying people about their appointments after they had taken place. Ministers need to get a grip on that because, if the Scottish Government is struggling to organise a vaccination programme for flu, people will rightly worry about it being able to organise an effective Covid vaccination programme when the time comes.

In that regard, can the cabinet secretary explain why the Covid vaccination programme appears to be using the same model as the flu vaccine programme—that is, a national plan with health board delivery?

On the cabinet secretary’s comment that there is a possibility that non-Covid services may have to be limited or paused this winter, will she set out in exactly what circumstances that will happen, given the existing NHS backlog and the fact that we all know about the incredible damage that can result from cancelling planned operations?

I do not believe that the flu vaccination programme has been shambolic across the country. Let me be clear: there have undoubtedly been problems in a number of areas, some of which boards have acted quickly to resolve and some of which boards are still trying to resolve. I am acutely aware of that. However, in other parts of the country, the vaccination programme has worked relatively smoothly. I have received almost an equal number of complaints from individuals and comments from individuals who have told me that the programme worked well for them. However, there are undoubtedly lessons to be learned.

Mr Cameron is wrong. The Covid vaccination delivery programme will not follow the same model as the flu programme, because lessons need to be learned. There are a number of ways in which it will be different. The plan will be a truly national one, with the delivery models that boards will use determined nationally in consultation with them, so that all boards will make maximum use of all the routes that are available—not only hubs and walk-in and drive-through centres, but community pharmacies, general practitioner practices and local mobile delivery units for vaccinations, particularly for remote and island communities.

As I said earlier, as soon as that final plan is crystallised and we have all the details in place, including the milestones and delivery timetables, I will come back to the Parliament to make sure that members are informed and can ask me questions about that.

On the member’s second question about where we might have to pause or slow down the delivery of non-Covid healthcare services, I need to say two things. The delivery of non-Covid healthcare services has slowed down already, because use of PPE, making sites Covid-safe and physical distancing inevitably reduce the volume of services that can be delivered. NHS Louisa Jordan and NHS Golden Jubilee are a significant help to us in trying to address some of those mitigating measures. In addition, our boards are now operating a mutual-aid arrangement, in which nearby boards help each other. Some of that is happening between NHS Forth Valley and NHS Lanarkshire, which, as I am sure members will appreciate, is under particular pressure with Covid cases. That mutual-aid arrangement will be formally in place across all our boards where it is practical and feasible.

If we have to significantly pause any services for any length of time, those decisions will not be taken lightly, and they will be taken with the medical directors and others in affected boards. Where we can, we will prioritise on the basis of clinical need, so that the patients who most urgently need non-Covid healthcare—not urgent care—will be seen first. We will work our way through that and will look to deploy as many additional resources as we can to ensure that people do not wait longer than they have to.

I thank the cabinet secretary for advance sight of her statement and record Scottish Labour’s gratitude to all healthcare workers who are working incredibly hard to keep our NHS going.

The additional financial support is welcome, but there are already serious signs that our NHS is struggling to cope with Covid-19, never mind winter pressures and normal business. The cabinet secretary knows that, in the summer, health boards raised fears about resilience and their ability to deliver the expanded flu vaccination programme. It is fair to say that that programme is not going smoothly in every part of Scotland. There are real concerns. Donald Cameron mentioned NHS Ayrshire and Arran, where staff were told that their flu jabs had been suspended, and other boards have apologised for putting our older citizens at the back of the queue.

As well as confirming when the flu vaccination programme will get back on track in all parts of Scotland, can the cabinet secretary confirm how many wards are currently closed due to Covid-19 outbreaks? Can she give further assurance that our hospitals are properly equipped with PPE and access to testing, because not only have wards closed, we are also aware of tragic cases in which patients have died after getting Covid in hospital. Could the cabinet secretary give an update on that? People are worried about going into hospital, and that is no good at all. I would appreciate further reassurance on that.

I need to be clear that I am not saying that the flu vaccination programme across Scotland has gone smoothly. There are some boards where it has gone very well, but there are others where it has not, either because they have been overwhelmed by telephone enquiries and were not staffed up to deal with that, or where they have used the Scottish immunisation and recall system—SIRS—which is used to plan appointments for childhood vaccinations. As we all know, and as Ms Lennon knows, because she is nodding away, the SIRS programme is about childhood vaccination and, rightly for that group, puts the youngest first. However, that is not appropriate for flu, where we need to prioritise the oldest and most-at-risk patients first. We will most certainly not be using that programme for the Covid vaccination programme.

The board that is most high profile in that regard is Greater Glasgow and Clyde. Absolutely rightly, it has apologised. To my mind, it has taken a wee bit too long to do that, but it has done it. It has apologised and offered reassurance that everyone who is over the age of 65 who has not received an appointment letter so far will receive one this week, and that it will run parallel programs, make every effort to give people as much local accessibility as it can and will staff up to do that.

Ms Lennon has my personal assurance that where individual boards, including Greater Glasgow and Clyde, have encountered issues, I look every single day to see whether they are making the improvements that I need them to make. In Fife, for example, the board has made those improvements. In Grampian, I am assured today that there is no call waiting on the health board’s phone lines, because it has staffed up to answer them.

We learn as we go. That is no great comfort to patients who are anxious and so on, but we learn as we go and we will apply what we learn to the Covid vaccination programme. Members will be able to scrutinise and check that we have applied all those lessons.

I do not have an accurate number for closed wards and I would not want to estimate it, but I am happy to ensure that Miss Lennon gets that number later today, if it is possible for my officials to get it to her, or first thing tomorrow.

With regard to resilience, we published a PPE plan today that I hope gives members assurance about the forward planning for PPE. As Ms Lennon knows, thanks to the efforts of my colleague Ivan McKee, if rubber gloves are excluded, 90 per cent of our needed PPE is now sourced in Scotland through Scottish companies. That includes not just the demand from the health service, but the demand that we met in the first phase across social care, primary care, pharmacy and dentistry. We watch PPE constantly, but I am confident that we have the right infrastructure and the right forward ordering in place, and that the resilience of our domestic supply of PPE will enable us to provide what is needed. The modelling that has been done has been based on the demand in the early phases.

Ms Lennon is right to point to the issue of hospital-acquired infections. The most recently published statistics indicate an increase in the number of “probable”—that is how they are described—Covid infections that were acquired in hospital. The nosocomial group, which, as members know, identified those NHS staff who should be subject to regular testing—which is under way—is looking actively at how we extend testing of NHS staff in acute and primary care, to ensure that we are protecting not just the staff but the most vulnerable people.

I am happy to pick up later any areas that I have not touched on.

I highlight the fact that we have taken 10 minutes on the first two questions. I allow extra time for questions from front-bench members, but 11 members are waiting and we now have two minutes and 20 seconds to get through the remaining questions. I will allow some more time, but it will not be possible to get through all the questions. I recently wrote to all members and ministers to ask them to be brief and succinct, and for such sessions to proceed at pace, and I again make that appeal.

The cabinet secretary has already referenced Fife in her remarks. As the member for the Cowdenbeath constituency, I was well aware of the initial problems with the roll-out of the flu vaccine for over-65s. I agree that quite a lot of progress appears to have been made since then.

Looking to the next phases of the roll-out, will health boards be encouraged to facilitate greater take-up at community pharmacies, from the point of view not just of the quantity of vaccine that will be made available to them, but the number of community pharmacies that can be included in the process?

The simple answer is yes—we certainly will encourage health boards to do that. We wrote to boards on 25 September to encourage the increased use of community pharmacies, and we will continue to encourage that. We cannot make community pharmacies take part, but many of them are keen to be part of the programme. Their participation will require us to look at the scheduling of the supply of vaccine to the various routes through which the flu jab is delivered.

I know that the cabinet secretary is aware that the application of Covid restrictions to so many non-Covid conditions has significant health implications. What long-term planning is the Scottish Government doing to ensure that the backlog can be addressed once we are on the other side of the Covid pandemic?

That is a really important question. We are doing two things. First, we are trying to maintain non-Covid healthcare services as we deal with Covid cases, as I have outlined, which is different from what we did with the steps that we took during the lockdown earlier in the year. We are doing that in order to deal with the backlog and to ensure that it does not grow any further. There was a decline in the backlog of non-Covid cases between the end of the lockdown and the beginning of September, and we want to maintain that using NHS Louisa Jordan and the Golden Jubilee, as I have described.

In addition, clinical prioritisation will let patients across the country know what to expect, and I am very keen that that happens. The prioritisation numbers go from P1 to P4. We will set that out in more detail. Individual cases will then be clinically assessed so that people know which they are. P1 and P2 are considered to be urgent cases and will be dealt with within that timeframe. P3 will be dealt with within three months, and the timeframe for P4 will be over three months. That work will apply the numbers to clinical prioritisation and will allow us to demonstrate, in different scenarios, how well we can work through the backlog of cases.

The winter months can place additional pressure on primary and community care services. How are health boards working to ensure that my constituents can access those services closer to home throughout the winter period?

I am sure that Ms Maguire will remember that one of the things that I have said repeatedly in the board mobilisation plans is that we need to focus as much on primary and community care as we do on acute care. That includes making best use of the pharmacy first programme, which was launched some time ago, and making best use of the entirety of our primary and community care practitioners—not just general practitioners, but practice nurses, allied health professionals and so on. Some of that has been picked up in the plans that we have published on, for example, rehabilitation and work to deal with long Covid, so that we direct people to the right care in the right place. That has also been picked up in the redesign of urgent care programme. Again, I will be happy to provide members with more detail on that, as it is finalised. As the pathfinder site works its way through during November, we will see whether we can roll it out further from December onwards.

Given that planned operations are still at only half the level that they were at last year, will the cabinet secretary publish information on how long patients with different conditions will have to wait for elective surgery and treatment so that we can feed that information back to those patients who have written to us? Will that be impacted by staffing shortages as NHS staff get Covid and have to self-isolate or opt for early retirement?

As I said to Mr Whittle, as the work is undertaken across the boards to apply the clinical prioritisation framework to individual cases, the most important people who will need to know what the situation is will be patients themselves. I am determined that each of them will be written to in clear and understandable language that tells them the decision that has been made on their case and what they should expect. We will make the overall situation across Scotland—broken down, as far as is possible, into individual boards—available to members so that they know what the situation is in the area that they represent.

The plans describe a new urgent care pathway that encourages people who might not require emergency treatment to seek a clinical assessment by phone prior to travelling to accident and emergency. The statement confirms that the redesign of urgent care will be tested out. Will any corresponding impact that the redesign will have on primary care, which is already under significant strain, also be highlighted? The cabinet secretary will be aware of the concerns that the British Medical Association has raised in that regard.

The modelling that underlies the redesign of urgent care—which is independent modelling that clinicians undertook for us—shows that, for approximately 20 per cent of the people who go to accident and emergency, that is not the right place for the care that they need.

The intention is to ensure that we can help patients to determine where they should go. Obviously, if someone feels that their situation is life-threatening and very urgent, they should go straight to A and E, but for many people, GP surgeries, out-of-hours services, the pharmacy first service and, in some cases, the Scottish Ambulance Service, which has highly trained and qualified paramedics, will be the right and the best place to go and will be more local.

Primary care and the BMA have been actively involved in the redesign work, and they will be involved in the pathfinder project and its evaluation, which will include consideration of its impact on them. That evaluation work will be overseen by Sir Lewis Ritchie, who is a general practitioner with particular expertise in remote and rural general practice. That is important, because we need to ensure that the redesign works for all of Scotland, not just our urban centres.

The dramatic increase in the number of people from high-risk groups who qualify for the flu vaccine has led to chaos in its distribution. That programme will continue until the turn of the year. At the same time, there are strong indications that a viable Covid-19 vaccine could be approved for use within weeks. Given that the same high-risk groups will, I presume, be first in line for that vaccine, how does the Scottish Government intend to manage any overlap between those two distribution programmes?

The overlap for those vaccinations will be determined by what the clinicians and the Joint Committee on Vaccination and Immunisation tell us about how a Covid vaccine should be used and what its interaction should be with the flu vaccine. They will say whether there should be any period of time between people getting the flu vaccine and their getting the Covid vaccine, and whether they will need one shot of the Covid vaccine or two. All that is still to be determined; in part, it will be determined by the nature and volume of the vaccine that is approved as being clinically safe for use that comes first.

The broad answer to Mr Cole-Hamilton’s question is that we will not know until we get that clinical advice, which will be fed into the overall delivery programme.

I want to ask the cabinet secretary about capacity. The roll-out of flu vaccinations in the Grampian area has been slightly problematic, and staff capacity seems to be an issue in dealing with that, the pandemic and everything else. With that in mind, what consideration has the Scottish Government given to the very real possibility of a no-deal Brexit on 31 December? What impact will that have on our NHS, which will be in the middle of what we already know will be a very difficult winter?

I have a couple points to make. NHS Grampian has recruited additional staff and, as I said earlier, this morning it gave us an assurance that there is currently no call queue on the appointment booking line, which was one of its big pinchpoints. We have asked NHS Grampian and all boards to make sure that their call-handling facilities are adequately resourced, as well as the locations where vaccination takes place.

In the health service, we have been planning for Brexit for some time. The concerns that remain around its impact on the supply of medicines and other consumables now apply to the vaccine. If the vaccine requires to go to Europe and back before it is finished and ready for use, which is a strong possibility, the impact of Brexit could make that a slower process than we would either want or need. However, that is not yet clear, because it will depend on which vaccine comes first and on our continuing work with the UK Government.

There is undoubtedly uncertainty around all that, depending on the impact of Brexit. Even those of us who are least worried about Brexit would say that there is a risk of some impact. Whether the impact on some of those programmes will be small or great is yet to be determined, but we are planning in order to mitigate it as best we can.

I apologise to Maurice Corry, Joan McAlpine, Lewis Macdonald and Fulton MacGregor; we have run out of time and have no room for any further questions.