- 24 Jun 2021
Attendees and apologies
- John Burns, NHS Board Chief Executives’ Group representative
- Donna Bell, Director of Mental Health and Social Care
- Sandra Campbell, Convenor, Scottish Social Services Council
- Dave Caesar, Interim Deputy Chief Medical Officer, Scottish Government
- John Connaghan CBE, Chief Operating Officer, NHS Scotland
- Iona Colvin, Chief Social Work Adviser
- Amanda Croft, Chief Nursing Officer, Scottish Government
- George Crooks, Chief Executive, Digital Health & Care Institute
- Cllr Stuart Currie, Health & Social Care Spokesperson, COSLA
- Amy Dalrymple, Royal College of Nursing Scotland (deputising for Theresa Fyffe)
- Nicola Dickie, COSLA
- Graeme Eunson, BMA Scotland (deputising for Lewis Morrison)
- Tom Ferris, Chief Dental Officer
- Jeane Freeman MSP, Cabinet Secretary for Health & Sport (Chair)
- David Garbutt, NHS Board Chairs’ Group representative
- Mairi Gougeon MSP, Minister for Public Health, Sport & Wellbeing
- Cllr Kieron Green, Vice Chair, IJB Chairs & Vice Chairs Group
- Philip Grigor, Scotland Director, British Dental Association
- Annie Gunner-Logan, Coalition of Care and Support Providers
- Clare Haughey MSP, Minister for Mental Health
- Pauline Howie, NHS National Boards’ representative
- Caroline Lamb, DG Health & Social Care and Chief Executive, NHS Scotland
- Angela Leitch, Chief Executive, Public Health Scotland
- Dave Caesar, Interim Deputy Chief Medical Officer, Scottish Government
- Donald MacAskill , Chief Executive, Scottish Care
- Miles Mack, Chair, Academy of Medical Royal Colleges and Faculties
- Peter Macleod, Chief Executive, Care Inspectorate
- Kathryn McDermott, UNISON National Staff Side representative
- Harry McQuillan, Chief Executive, Community Pharmacy Scotland
- Patricia Moultrie , Deputy Chair of BMA SGPC
- Peter Murray, Chair IJB, Chairs & Vice Chairs Group
- James O’Connell, National Staff Side representative, UNITE
- David Quigley, Chair, Optometry Scotland
- Sir Lewis Ritchie, Mackenzie Professor of General Practice
- Claire Ronald, National Staff Side representative, Chartered Society of Physiotherapy
- David Shackles, Joint Chair, RCGP Scotland
- Cleland Sneddon, Health and Social Care Spokesperson, SOLACE
- Alison Strath, Interim Chief Pharmaceutical Officer, Scottish Government
- Ian Welsh, Chief Executive, Healthcare & Social Care Alliance Scotland
- Carole Wilkinson, Chair, Healthcare Improvement Scotland
- Andrea Wilson, Convener, Allied Health Professions Federation Scotland
- Jane Anderson, UNISON representative
- Marion Bain , Deputy Chief Medical Officer
- Andrew Buist, Chair, GP Committee, British Medical Association
- Joanna Macdonald, Chair, Adult Social Care Standing Committee, Social Work Scotland
- Lewis Morrison, Chair of Scottish Council, British Medical Association
- John Thomson, Vice President Scotland, Royal College of Emergency Medicine
- Linda Walker, National Staff Side representative, GMB
- Gregor Smith, Chief Medical Officer
- Cleland Sneddon, Health and Social Care Spokesperson, SOLACE
- Jason Leitch, National Clinical Director
- Nicola Barnstaple, Programme Director, Cancer Access
- Derek Bell , Special Advisor, Scottish Government
- Jan Beattie, AHP Professional Advisor, Scottish Government
- Heather Campbell, Interim Deputy Director, Primary Care, Scottish Government
- Michael Chalmers, Director of Children and Families, Scottish Government
- Mairi Cameron, Strategic Reform Unit, Scottish Government
- Catherine Calderwood, Clinical Director, Centre for Sustainable Delivery (Golden Jubilee)
- Derek Grieve, Interim Head of Vaccinations Division, Scottish Government
- Aidan Grisewood, Interim Director, Primary Care, Scottish Government
- Helena Jackson, Health Performance & Delivery, Scottish Government
- Michael Kellet, Director of Population Health, Scottish Government
- Helen Maitland, Director of Unscheduled Care
- Jennie Marshall, Health Operational Planning, Scottish Government
- Richard McCallum, Interim Director of Health Finance & Governance, Scottish Government
- Christine McLaughlin, Director, Test & Protect, Scottish Government
- Jessica Milne, Health Performance & Delivery, Scottish Government
- Diane Murray , Deputy Chief Nursing Officer
- Sean Neill, Deputy Director, Health Workforce
- Gillian Russell, Director of Health Workforce, Leadership and Service Reform, SG
- Colin Sinclair, Director of Vaccination Delivery, Scottish Government
- Malcolm Summers, Head of Strategic Reform Unit, Scottish Government
- Yvonne Summers, Head of Operational Planning, Scottish Government
- Richard Foggo, Director of Covid 19 Public Health
- Stephen Gallagher, Director for Local Government and Communities (Vaccination Policy)
- Christine Gilmour, Director of Pharmacy, NHS Lanarkshire
- Jack Downie, PS/Cabinet Secretary for Health & Sport
- Andrew Fleming, Health Performance & Delivery, Scottish Government
- Angela Gibson, Health Performance & Delivery, Scottish Government
- Dan House, Health Performance & Delivery, Scottish Government
- Jake Macdonald, Health Performance & Delivery, Scottish Government
- Sean More , Health Performance & Delivery, Scottish Government
- Charlotte Jack , Health Performance & Delivery, Scottish Government
Items and actions
Item 1: Welcome
1. The Cabinet Secretary opened the thirteenth meeting of the Group by welcoming attendees. Ms Freeman noted some new appointments and welcomed them to the group: Susan Aitkenhead has recently taken up the role of Director at Royal College of Nursing (RCN) Scotland and Colin Sinclair is the new Director of Vaccination Delivery for the Scottish Government. She also welcomed Dr Catherine Calderwood to the meeting who has been appointed as Clinical Director, Centre for Sustainable Delivery, at NHS Golden Jubilee.
2. The Chair noted a number of developments since the last meeting, including the recently updated Strategic Framework; the gradual return of schools, which will see all young people back in school after the Easter break if we continue to make progress against COVID-19; the continued success of the vaccination programme; and the significant developments underway to protect the health and wellbeing of our workforce.
Item 2: Note of Previous Meeting Held on 22 January 2021, Action Log & Matters Arising
3. No amendments had been received from Group members and there were no outstanding items (other than the standing action that encourages members to approach the secretariat with any suggestions for future agenda items); nor matters arising noted. As such, the note of the meeting on 12 February was agreed and will be published on the Group’s page on the Scottish Government website.
4. John Connaghan introduced this item and outlined the general content of the presentation: pertinent data to note, the strategic framework, and NHS remobilisation plans. He noted that the Scottish Government issued guidance in November to NHS Boards on the Annual Operating Plan (AOP) process for 2021/22. First iterations of the plans had been received and are being discussed with NHS Boards; to be agreed in the coming weeks. In terms of the COVID-19 context within which these AOP’s have been developed, we continue to see a slow and steady decline of patients in hospitals, as well as admissions. That said, significant pressure and volatility remains, notably in terms of intensive care.
5. Andrew Fleming took the group through the Strategic Framework which was published on 23 February and sets out how the Government plans to restore, in a phased way, greater normality to our everyday lives. It focuses on a number of areas, notably the suppression of COVID-19 to low levels, providing care for those who need it, and allowing the economy to recover. Actions associated with this work include: the continued rollout of the vaccination programme, effective testing and contact tracing, applying proportionate protective measures, and managed isolation for international travellers to reduce the risk of importation of the virus from high prevalence countries. As we move towards fully remobilising health and social care we will progress through a number of stages. We expect to see all children return to school after the Easter holidays, though the country in general will remain at Level 4. We are then likely to return to the geographically variable levels system; predicated on the country being able to meet several gateway conditions based on indicators set out by the World Health Organisation (WHO), in conjunction with the successful vaccination of all the JCVI priority groups. Depending on the prevalence of the virus, we will continue to move towards a future where COVID-19 is viewed as less of a public health threat than at present. The first six months of NHS Board AOP’s/remobilisation plans will focus mainly on recovery and re-establishing activity, whilst the second six months are expected to move Boards closer towards some form of normality.
6. Yvonne Summers spoke to the slides on remobilisation and drew upon the principles and objectives as outlined in Remobilise, Recover, Re-design, published in May 2020. These principles and objectives remain the basis upon which the Scottish Government has asked NHS Boards to safely and incrementally remobilise health and social care services. They have continued to be relevant throughout the pandemic and were reflected both in our Winter Preparedness Plan as well as within the commissioning documents for AOPs. Since the publication of Remobilise, Recover, Re-design, we have worked closely with planners to understand the experience of NHS Boards and the assumptions underpinning their planning process. Key themes emerged from those conversations: that the planning context is volatile, uncertain, complex and ambiguous; that there is a continuing need for agility and flexibility to respond to developing situations; that there is a need for comprehensive ongoing support for mental health and wellbeing, with workforce stability crucial; and that there are opportunities to build on the innovations undertaken during the pandemic as we move forward.
7. In terms of the review of initial NHS Board plans for 2021/22, Scottish Government officials have been very impressed: despite the enormous pressures NHS staff have been working under, there is comprehensive coverage of the priorities set out in the commissioning letter. This is very much envisioned as a whole system approach which encompasses acute, primary, community, and social care and has fed right through across a range of services, from mental health to urgent care.
8. The importance of staff decompression and recovery has been emphasised in every plan submitted so far. Other key themes include: the expanded role of public health – i.e. testing and vaccination infrastructure – and the need for that to continue and grow; and workforce sustainability (i.e. untaken leave and the potential higher rate of retirals this year), recruitment and training. Infection prevention and control will also impact the way in which services are provided and the speed at which services can remobilise.
9. It is also clear from remobilisation plans that NHS Boards are hearing, through their own staff and stakeholder engagement, similar messages as those demonstrated in the ALLIANCE report on the lived experience of COVID-19. These include the importance of having people at the centre of service design, and the need to build on and be flexible in relation to digital innovations. It is equally evident from some of the graphics provided within the plans that there is a huge appetite to do things differently, in a way in which the public are most meaningfully engaged in the process of service redesign.
10. John Connaghan spoke to the data slides, noting that this helps to orientate colleagues on some of the factors that will be key to effective remobilisation. He outlined some key performance statistics including cancer activity, A&E, CAMHS and psychological therapies, noting that we have significantly fewer outpatients coming into the system; how we recover must therefore take into consideration this backlog, in conjunction with the need to allow staff time to decompress; noting that this lost activity also poses questions about the potential impact on primary care. The NHS will continue to prioritise those with the highest clinical need. There are currently six Centre for Sustainable Delivery pathway programmes being worked on; these are clinically led and have a significant potential impact in terms of outpatient appointment efficiency. As already mentioned, we are working in a volatile, complex, and ambiguous landscape so we need to balance strategic objectives against our emerging short-medium term objectives in our planning. We are therefore asking NHS Boards to review and resubmit their plans in September. Planning will also inevitably be affected by the incoming Government and Ministerial priorities.
11. John Burns welcomed the presentation and noted that it demonstrates the level of detail going into remobilisation planning. He reiterated the importance of whole system working: linking all aspects of the health and social care system and identifying where pressures exist. Embedding reform is an important part of remobilising and NHS Board Chief Executives welcome that planning will be revisited mid-year, as that is crucial to allow learning and reflection to take place. We will also likely need to consider winter planning earlier than usual this year. We must strengthen and build on the social care reform agenda. In terms of the restarting of elective activity, we do need to take into account the workforce element and provide staff with the space to recover so that they can move forward: local systems will therefore need to be agile to achieve the right balance as NHS Boards have had different experiences. We should also be mindful of infection prevention and control and the impact this will continue to have. Clinical prioritisation is key but we need to take our communities with us as there will be a desire to return things to normal and patients will reasonably want to know when they might expect their appointments. In terms of future COVID-19 vaccination programmes, we are currently relying on volunteers so we need to think of a more sustainable model.
12. The Cabinet Secretary noted the importance of looking ahead as far as possible and that, following the election in May, any new Government will want to carefully consider a comprehensive multi-year plan for health and social care. Planning for 2021/22 will help the public to understand the steps and stages required to remobilise, and will allow us to take our communities with us. Testing and vaccinations will continue and so we should use the significant infrastructure built for this to consider how we can add value beyond the pandemic.
13. Catherine Calderwood thanked everyone for their comments and highlighted that staff are central to our recovery. We need to re-design to ensure we recover properly. There were clinical concerns raised, rightly, about digital innovations, but this has proved to make a significant contribution so we now have a confident workforce who have embraced this approach, as have large numbers of patients. There are many opportunities if we focus on the principles of realistic medicine, offering individualised care and shared decision making. We also need to ensure these principles and objectives feed into social care, in light of the Feeley Report recommendations.
14. Stuart Currie suggested that turning the vision into reality is difficult and that sustaining community resilience is equally challenging. We must also ensure that the infrastructure we have built continues to innovate and provide for communities. Stakeholder engagement actually demonstrates that people understand issues better than we might expect; if you ask people what they want, they often tell us something different to what we are prepared to provide. Capacity, and the ability to respond as a whole system, is critical. In terms of infection prevention and control, we do need to challenge the misnomer that issues happen by way of course. We should not accept the orthodoxy that winter is inextricably linked to more extreme pressures.
15. Donald Macaskill further noted the necessity for whole system working and cautioned against any drift back to previous priorities. If we are to follow through on re-design, we need more engagement with social care. There are critical issues with recruitment and retention. As such, we have a real transition challenge, even before we can get to a national care service. There should not be a presumption of continuation or an ability to simply re-mobilise. A recent study by Napier University found that there has been a 38% increase in deaths of individuals in their own homes; only 2% of which were attributed to COVID-19. This is potentially a positive finding as we want people to die in a non-institutional setting. However, we need to consider the impact: for example, what has been the mental health impact on carers, and what is the resource required for this reorientation of care? Adult social care is critical to the recovery and so we need to integrate that work with the rest of the system more fully.
16. The Cabinet Secretary noted that NHS Boards have worked really hard, in a situation of significant pressure, to ensure their AOPs are as whole system focused as possible. However, further work is required including engaging stakeholders in adult social care, recognising that we need to think about adult social care as a whole, rather than just care homes. Most people want to remain at home and so we should provide the care and support to allow them to do that.
17. Graeme Eunson emphasised the importance of staff to recovery and noted that the British Medical Association still has concerns about wellbeing. There is a short term issue of untaken leave, people still absent from ill health, and the impact of the generally traumatic experience of the last year. In the medium term, there is the issue of how we resource moving back to pre-pandemic levels of activity given there is such a backlog. This leads to the longer term issue of staff retention. At the moment, around 20% of consultants retire in their 50s and 46% plan to retire in next five years, before their retirement age. We therefore need to retain workforce at top end, given that it takes 15 years to train a member of staff at the bottom end. There has been some work undertaken to address staff retention under the Scottish Access Collaborative but we need to bring that work back to the forefront of discussions.
18. James O’Connell noted from a trade union perspective that we should talk about the health and social care sector as a whole rather than one, or the other. Remobilisation is crucial; however, we do need to recognise that staff decompression will have a direct impact on how such remobilisation looks due to untaken annual leave, the need for people to have a break, and the impact on mental health. Staff are doing wonderful jobs because they know it needs to be done, but that is not sustainable forever, so we need to plan for that potential impact on remobilisation. Consideration should be given to how we utilise and retain the staff who have been brought into the system to deal with the pandemic: the workforce strategy currently in place means we have a lot of knowledge and experience, and now that we are looking to ease off restrictions, we shouldn’t lose that. On remobilisation plans, partnership working is really important and trade unions must be fully involved. In light of the Feeley report, it is clear that things need to change and there is an opportunity to realise that change.
19. The Cabinet Secretary thanked James for his contribution, agreed with the importance of retaining staff, and asked that a substantive item on workforce planning be considered in conjunction with strengthening public health at the next meeting of the Group. On the Feeley report, there are some questions on governance and architecture which are not straightforward, but a future Government can work those through with colleagues in COSLA and elsewhere so that progress is not impeded.
20. David Shackles noted that the data slides were informative but that we need to think about whole system working, recognising that primary care is relatively data poor. As the NHS re-designs and remobilises, we need to know what is happening in primary care so that we can understand whether, when and how this feeds into secondary care. Without good data collection systems we are working in the dark: this is an opportunity to develop better data systems within primary care so that we undertake more robust workforce planning and assess the impact on the wider system from primary care.
21. The Cabinet Secretary agreed that this was a very important issue and suggested there is consensus here around the opportunity to bridge any data gap in primary care. To do this, the Scottish Government will need primary care colleagues to be as engaged as possible.
22. Patricia Moultrie echoed David Shackles’ views on data and noted that messaging to the public would be key in terms of encouraging digital access to services. She also noted concern about the overall number of GPs and the intention of a significant number of these to retire in the coming years.
23. The Cabinet Secretary reflected feedback that many were in favour of digital consultations. Nonetheless, this is not always desirable or appropriate and should continue to ensure there is sufficient in-person provision.
24. Harry McQuillan emphasised that we need to focus on realistic care, but noted that this will require all delivery partners to change the use of language around this so that the public don’t think we are returning to the traditional way of working.
25. David Quigley agreed with colleagues on data and noted that the role of optometry is often to relieve some of the pressure on other primary and secondary care colleagues, especially given the likely increased outpatients. However, data is still something optometry does not have access to and ongoing support for remote consultation is critical. Given the wider implications of sensory impairment, it would be beneficial to make more direct links between social care and community eye care.
26. Derek Bell noted that the more the Government and delivery partners can integrate data in real time across the system, then the more nimble we can become. Whilst we do have the foundations for this, there is still a degree of urgency around filling data gaps which persist.
27. The Cabinet Secretary agreed, noting that integrating data has traditionally been viewed as an obstacle, but there is now a recognition that we cannot do many of the important things we need to do without getting the data right.
28. Caroline Lamb suggested that the conversation has been really helpful and agreed that we need to re-design as we remobilise, whilst taking cognisance of staff wellbeing. In addition, we have an opportunity to think about what we want out future system to look and feel like; some of the key principles at the heart of the Feeley report apply just as much to health as they do to social care. As we progress out of the pandemic, we need to hang on to some of the innovative ways of working. Tackling COVID-19 has been the single purpose that has united everyone over the past year, and so we should look to carry that ethos into future reform. Partnership working has been really important and enabled us to move on a whole system basis, so it is important that is maintained. Much of this will be down to leadership, and culture: a huge amount of infrastructure has been built during the pandemic, and we need to look at how we can harness this going forward. People want to see their services enabled by digital technology; for example, people are going to want to see data about their vaccination and we need a way to do that without placing the burden on our primary care systems, so this should be the starting point for making data more accessible.
29. Amy Dalrymple highlighted, for a Royal College of Nursing (RCN) perspective, continued workforce issues, including the retention of senior staff. RCN anticipates a significant amount of retirals and so we need support for students and newly qualified staff; otherwise we will end up with shortages across the system. We need to look at how we support students both in terms of their placements, as well as when they are qualified; to ensure that they are supported in their new careers and can provide the workforce for the future.
30. The Cabinet Secretary agreed that we do not want to lose people early who might be coming to the end of their career, and that we need to look at alternatives to ensure we not only enhance peoples’ skills but also ensure they continue to be confident in their roles.
31. John Connaghan brought the discussion to a close and noted four main reflections: the concept of realistic care is enormously powerful; achieving a balance across the whole system is of critical importance; effective integration of data is key; and we must engage, support and nurture our workforce.
Item 4: Overall Health and Social Care SitRep
32. Dave Caesar provided an update on the state of the pandemic and reminded the Group that, although we are heading in the right direction, we need to be aware of how quickly things can change. On COVID-19 bed occupancy, we are following the better track in terms of modelling which suggests the measures in place are working. For intensive care, we continue to see some instances of extreme pressure, though the reduction in occupancy does continue to follow the better modelling track. Recently published Scottish data on the effect of the vaccines demonstrates that people are less likely to be hospitalised with COVID following vaccination. There is, nevertheless, around a 21-day lag between receiving the first dose and the clinical effect, and so this must continue to inform any decisions on easing restrictions.
33. Andrew Fleming provided an update on acute hospital pressures, noting the three headline areas: COVID-19 acute beds occupancy, overall ICU occupancy, and A&E performance against the 4 hour target. COVID acute capacity has reduced significantly, whilst ICU pressure is relatively stable at a high level, and A&E performance has slightly improved. On primary care, Aidan Grisewood provided a brief update, highlighting that there is an improving position overall, although NHS 24 continues to experience challenges. Service levels for the Scottish Ambulance Service remain very high, whilst activity in optometry and dentistry continues to be subdued, though increasing. On workforce, Sean Neill noted that the system is marginally improving overall, though there are a couple of specific areas still experiencing pressure. Donna Bell noted that adult social care recently published guidance on indoor visiting and this has received generally positive feedback. In terms of absence, there has been a slight increase in care at home absences which is being monitored, though is believed to be due to increased testing. Christine McLaughlin provided an update on testing pathways and highlighted the considerable progress made to increase access: there are a number of asymptomatic units as well as different institutional settings which now offer testing. A refreshed testing strategy will be published soon to reflect the increased number of pathways. On the vaccination programme rollout, Stephen Gallagher provided an update and outlined the most recent statistics. Targets are expected to be exceeded due to improved supply in the coming weeks. As we move towards offering a vaccination to all of the adult population, we will continue to follow the JCVI priority list.
34. The Cabinet Secretary thanked everyone for their updates and noted that this work is essential to realising many of the ambitions discussed under the previous agenda item before offering colleagues the chance to respond.
35. Graeme Eunson queried the situation with particular Health Boards under pressure and sought information on what is being done to support these. John Connaghan confirmed that the Government continue to actively work with NHS Boards on a daily basis, identifying and agreeing specific actions and support where this is required, including wide ranging improvement plans and mutual aid. Dave Caesar provided an update on localised issues in relation to prevalence of the virus for different areas. Regular conversations are held with particular NHS Boards: some have particular demographics to content with such as relatively high percentages of key workers, meaning there may be continued COVID-19 pressures whilst other areas may have much reduced prevalence.
36. Graeme Eunson also asked about the vaccination programme rollout and whether this would be extended to children. Dave Caesar suggested that substantial evidence on the impact of the vaccination on children does not currently exist though it is likely to emerge in the next few months.
Item 5: Any Other Business and Future Meetings
37. There was no other business. The next meeting of the Group is scheduled for Friday 26 March 2021 between 09:00 and 11:00.
38. The Cabinet Secretary thanked everyone for their invaluable contributions and noted that the chat function will be shared with the Group in recognition of the issues experienced today by some members. The next meeting will consider the strengthening of public health and workforce planning.