Coronavirus (COVID-19): Scotland's Route Map - supporting evidence - 20 August 2020 review

WHO criterion 3: Outbreak risks are minimized in high vulnerability settings, such as long-term care facilities (i.e. nursing homes, rehabilitative and mental health centres) and congregate settings.

Hospital Associated Infections (HAI)

On 1 July 2020, National Services Scotland (NSS) published the results of the intensive work to validate data on the source of infections in hospitals. Previously, unvalidated cluster data was self-reported by NHS boards ('health boards'). Scotland was the first part of the UK to publish both unvalidated cluster data and validated data, and hopes that the data helps other countries across the world in their fight against COVID-19.

In spite of the limitations of the unvalidated cluster data, it brought benefits to Scotland's response to this virus by helping health boards to put in appropriate measures to minimise COVID-19 outbreaks, limit the impact to other care services and provide feedback to inform infection prevention and control measures.

Data published more recently is more robust as it looks at each positive case in hospitals and identifies a likely source. This is the most detailed picture of hospital associated infections in the UK to date. Data is now published weekly on the HPS website, and can be found on the NSS website. This data will support our ambition to detect, test, trace, isolate and treat every case of COVID-19.

Publication of validated data adds to steps already being taken in NHS Scotland facilities to minimise risks of virus transmission. These steps were further supplemented on 23 June 2020, and again revised on 11 August 2020, with a number of additional precautionary steps:

• Extending the use of surgical masks to be worn by all health and social care staff who work in a clinical area of an acute adult (incl. mental health, maternity, neonatal and paediatrics), community hospital, primary care, care at home (community care), or in a care home for the elderly at all times throughout their shift;
• Physical distancing of 2 metres is considered standard practice in all health and care settings;
• Use of face coverings by all outpatients (if tolerated) and visitors when entering a hospital or GP/dental surgery;
• Use of a surgical facemask by all inpatients/residents in the medium and high-risk pathways if this can be tolerated and does not compromise their clinical care; and
• Asymptomatic healthcare staff testing for COVID-19 has been expanded from testing all staff working in an area where there is an outbreak of COVID-19 in a non-COVID ward, to include healthcare staff working in specialist oncology wards, long term care of the elderly wards, and long term care wards in mental health facilities.

These steps were informed by the work of the Scottish COVID-19 Nosocomial Advisory Group, which was established at the start of May to focus primarily on analysing and interpreting the existing nosocomial data in Scotland in order to identify additional interventions to reduce in-hospital transmission of COVID-19 and identify what other data are needed.

NHS Boards will also integrate infection prevention and control into their remobilisation plans so that paused services are better able to be resumed in a safe and clinically prioritised manner. The Scottish Government has emphasised the importance of continually reviewing infection prevention and control measures, and has asked health boards to ensure the effectiveness of their remobilisation plans regarding additional cleaning, the built environment (water), good hand hygiene, physical distancing, COVID/non-COVID areas for patients, and staff movement and rostering. Effective action in these areas will help to minimise the risk of outbreaks of hospital associated infections.

Additionally, Healthcare Improvement Scotland were able to resume inspections of Scottish hospitals in the week commencing 6 July 2020. The safety of patients, staff and inspectors has been paramount in the resumption of inspections.

Prisons

The Scottish Prison Service (SPS) published its COVID-19 route map and related physical distancing guidance on 25 June here. The plan sets out a series of indicative steps through 3 phases that will be taken to ensure the prison service can move forward while acknowledging the measures that will have to be taken due to the unique environment of prison settings. This remains essential to protect the health and well-being of those who live and work in our prisons and to prevent the spread of the virus. It is likely that individual prisons will move between the phases at different rates due to the local guidance and different accommodation types. More guidance on key dates will be published by SPS in due course. In-person visits have resumed in all prisons with the exception of HMP Grampian which suspended in person visits from 5 August due to the current lockdown restrictions in the Aberdeen City Council area. This will be kept under review and those in HMP Grampian care have access to virtual visits.

New powers have been put in place through the Coronavirus (Scotland) Act 2020 for the early release of a specific class of prisoners held in Scottish prisons. A controlled early release scheme was then undertaken in order to provide the Scottish Prison Service with additional operational capacity. This allowed for a greater use of single cell occupancy, keeping prison staff and the people in their care safe. The early release process has now been completed. 348 prisoners were released under the scheme between 4 May and 1 June.

Operational measures taken by prison and health staff in Scotland continue to be effective in reducing the spread of COVID-19 across the prison estate. As of 12 August, there are currently 13 individuals self-isolating across 8 establishments and being monitored accordingly. In addition, there are currently 125 persons in custody being held under Rule 40a (Non Symptomatic - Precautionary) in Low Moss, due to possible contact with a member of staff who returned a positive test. A rapid and responsive set of measures was put in place at HMP Low Moss following confirmation of the positive test of a prison officer for COVID-19 to mitigate any potential spread of the virus. The prison continues to operate safely and effectively.

Care Homes

Since the beginning of March, we have taken regular and firm action to support care homes across Scotland and to protect the wellbeing of those who work and live there. Clinical and practical guidance for care homes was first published on 13 March and has been kept updated, most recently on 15 May, to reflect developing circumstances. We have established a Care Homes Clinical and Professional Advisory Group led by the Chief Medical Officer (CMO) and Chief Nursing Officer (CNO) to provide up-to-date advice on the response to COVID-19 in the care home sector.

We have tasked Directors of Public Health with providing enhanced clinical leadership to care homes. To supplement this, we have asked all health boards and local authorities to establish multidisciplinary clinical and professional oversight teams – including Medical Directors, Nurse Directors and Chief Social Work Officers – to provide scrutiny of care home provision in their areas.

A Care Homes Rapid Action Group has been established with representatives from across the sector to receive regular updates and activate local action where it is required. As well as providing advice and oversight, we have ensured care homes have the means, resources, and capacity to implement the guidance.

We have established a Care Homes oversight board and developed a safety huddle tool that enables care homes to identify residents' care needs and associated staffing requirements. The information is shared with local care home support and oversight teams to allow them to plan coordinated support for local care homes. Work is underway to automate the tool and support universal adoption.

From 25 May, we started to offer testing to all care home staff, regardless of whether they have symptoms or if there is an ongoing outbreak in their care home. This is being achieved through a range of methods including the UK Government Social Care Testing portal, mobile test units, self-test kits and the employer referral process. Health Boards have been asked to oversee the implementation of this policy. From 10 June, we began to publish data on the number of tests being carried out in each health board. We asked all health boards to finalise their testing plans and these were made publicly available on 10 July.

Since 8 June, the UK Social Care Portal has been available for Scottish staff and care homes. We have access to a weekly maximum of 67,900 tests and this is the primary method by which care homes are testing staff. Staff agencies have also been notified that all staff should be tested proper to deployment into a care home and advised that the UK Government Employer referral portal should be used.

We are introducing visiting in care homes in a staged way. This is in response to lower levels of community transmission of the virus and a reduction in deaths and cases in care homes. Our four staged plan, first published on 25 June and updated on 8 August, permitted outdoor visiting of one visitor from 3 July in adult care homes that have been declared COVID free (28 days from the last positive test or symptoms). Since 10 August care homes have been able to support weekly outdoor visits of up to 3 visitors from no more than 2 households. This is in addition to essential visits in exceptional circumstances which have operated throughout the pandemic. The introduction of one indoor visitor will take place following approval of care home plans to support safe indoor visiting by 24 August. Further visiting options will be introduced incrementally and subject to scientific advice. We will publish a staged plan for the return of services who contribute to the wellbeing of residents in care homes.

Other Vulnerable Settings

The package of measures to minimise infection applies to all adult care homes as above. We will strengthen information on other residential settings including adult mental health, learning disability, and forensic services. In addition, we are putting in place comprehensive and location-specific measures across the mental health inpatient estate to minimise the risk of infection. Patient safety is an absolute priority in mental health inpatient settings.

In terms of secure mental health services, as part of the NHS they are following all Scottish Government and Public Health Scotland guidance. This includes measures relating to staff and patients as well as the wider community. In addition, the Minister for Mental Health wrote to NHS Chief Executives to set out the presumption that all patients being admitted to a secure hospital should have a negative test before admission, unless the patient does not consent to a test, lacks the capacity to consent or it is in the clinical interests of the person to be moved urgently and then only after a full risk assessment. We continue to liaise with practitioners across the secure mental health estate on a regular basis and are of the view that the measures being taken by secure forensic mental health services are minimising the risks of an outbreak in these settings.

The COVID-19 Children & Families Collective Leadership Group brings senior leaders together to review data on children, young people and families with vulnerabilities, and to identify issues requiring action as we move through and out of the crisis. The Leadership Group is supported by a range of organisations to ensure that the experiences of children, young people, and families inform this work. A children's residential care group, supported by SG officials including clinical advisors, considers necessary advice to that sector. Alongside continuing liaison with Social Work Scotland and the third sector, this ensures appropriate guidance for social work and social care services for children and families.

There are a wide variety of approaches to social care which pose different levels of risk for different individuals, for example buildings-based services working with multiple people – day care and residential respite – pose greater risk than support at home, working 1:1.

We are working with the Office of the Chief Social Work Adviser (OCSWA) and other stakeholders to agree a route map guiding the safe continuation, resumption and response to changing needs for people in the community in receipt of social care services. This includes carers and personal assistants employed by directly by people who require support. The route map will be driven by a set of overarching and principles, based on human rights and support the moving through different stages of recovery from the pandemic.

Respite and day care support covers a multitude of user groups and settings including building-based services, family-based care, support at home, group activities, community activities, individual support and overnight support. There is nothing to prevent respite support at home, outdoor activities or children's day care from continuing in line with existing infection prevention and control guidance. Respite services remain open for emergencies such as a carer being admitted to hospital or where there are other serious breakdowns in care arrangements. Some modified day care support for adults has remained in place with appropriate physical distancing and hygiene measures.

Guidance on adult day care and dedicated overnight respite is under development to issue as soon as possible. Ministers wrote to the sector on 3 August to confirm that, in the interim, these types of building-based services can reopen, subject to risk assessment in line with existing guidance and agreement with the Care Inspectorate and local Health Protection Team.

Regarding children's services at the community level, agreement has been reached with stakeholders on when incremental steps for targeted and general support might commence, inside and outdoors, and with groups and households.

The route map for social care services is particularly complex and, as a result, services will look different when they reopen; for example, changed staff to service users ratios in day service provision, which will impact on the unit cost of these services.

Personal Protective Equipment (PPE)

COVID-19 has presented many complex challenges including the provision of PPE at a time when the global supply of PPE has been, and remains, challenging. The Scottish Government, in partnership with the NHS/NSS, Scottish Enterprise, the National Manufacturing Institute Scotland and private companies, has increased both the volume of PPE being manufactured in Scotland and the amount being imported to provide PPE for both immediate and future needs. We are working with partners within Scotland, across the four UK nations and globally to ensure continued supply and distribution.

Adding to well-established arrangements in hospitals, all health boards now have a Single Point of Contact (SPOC) to manage local PPE supply and distribution for health and social care. For social care, in both the private and public sectors, the supply of PPE is primarily the responsibility of social care providers themselves. However given the pressure on normal supply chains due to COVID-19, we have committed to providing top-up and emergency provision to ensure staff have what they need. As of 11 August we have, since 1 March, distributed 256 million items of PPE to hospitals, 32 million to community care and 105 million to social care.

Other public services, such as the police and fire services, have their own routes of supply, but they are joined up with the Scottish Government Procurement Directorate and, via policy leads, with the PPE Division. We have also established a process with a third party supplier, making PPE available to purchase for organisations providing essential public services if they have difficulty accessing supplies through other means.

Organisations that routinely use PPE, particularly those in health and social care, are generally well placed in terms of demand prediction and supply and guidance has been produced to ensure that all sectors are aware of the appropriate use of PPE and are using it when required by risk assessment alongside other measures to ensure the safety of staff. The Scottish Government will continue to work with all sectors to achieve this, including supporting the development of any further required guidance and helping to address PPE demand and supply problems where they arise. The PPE division has developed a PPE Sustainability strategy to ensure the supply of PPE for Phase 3 and longer-term resilience.

Workforce

Steps have been taken to bolster and support the social care workforce. NHS Education Scotland and Scottish Social Services Council (SSSC) have developed a national online recruitment portal to support local efforts to enable those with relevant skills and experience to re-join the workforce and support health and social care services. The national online recruitment portal went live on 29 March and as of 11 August, 159 individuals have been matched with employers with a further 801 people available to employers, should they need them. This complements extensive work on the ground to deploy local health and social care staff to support care homes.

A national recruitment campaign encouraging people to consider a career in adult social care ran from 27 January until 20 March. We are currently considering a second phase of the campaign.

The Social Care Staff Support Fund became operational on 25 June. This provides support social care staff who, due to the nature of their work or work environment, may be expected to self-isolate on more than one occasion as part of infection prevention and control but whose terms and conditions of employment provide only for Statutory Sick Pay. Its purpose is to ensure that social care workers do not experience financial hardship if they are off work ill or self-isolating due to coronavirus.

Emergency Legislation

As we move through the phases of the Route Map through and out of lockdown and public services begin to re-open we have acted quickly to introduce interventions which will protect the progress that we have made so far. We have amended The Health Protection (Coronavirus) (Restrictions) (Scotland) Regulations 2020 to expand the mandatory use of face coverings to include certain indoor public places, including museums, galleries, community centres and places of worship. The Regulations have also been amended to exclude face shields as a definition of a face covering, as the emerging scientific and clinical advice indicates that they do not provide adequate protection against aerosol transmission. The use of face shields is still permitted, however you must be worn with a face covering underneath. These amendments were laid on Friday 7 August and came into force at 12:01 on Saturday 8 August.

We have brought in new legislative powers to ensure the swiftest intervention if individuals in a care home are being put at risk. The Coronavirus (Scotland) (No. 2) Act 2020 contains powers allowing directions to be made of care home providers; ministers to apply for an emergency intervention order in a care home; and powers to voluntarily purchase a care home or care at home service. These powers can be used where there is an anticipated risk to residents' health, life or wellbeing and allow the highest risk cases to be addressed urgently. These additional measures reflect our commitment to working with all stakeholders to take action, adapt and improve the system as new information comes to light.

Care Homes Data

Over the week commencing 7^th August:

36,410 staff were tested. This included 414 in homes with confirmed COVID-19 and 35,920 in homes without confirmed COVID-19. In addition, 48 staff were tested in Forth Valley in homes where no information on confirmed COVID-19 status was supplied, and 28 staff were tested in Grampian that could not be allocated to any individual care home.

As at 19 August, 52 (5%) adult care homes had a current case of suspected COVID-19. This number relates to care homes who notified the Care Inspectorate of at least one suspected case of COVID-19 in the previous 28 days.

There were 0 new positive COVID-19 cases among care homes residents for week 10 – 16 August.

There has been a consistent decrease in both the number of care home deaths and the number of homes with an active case of COVID-19.

National Records of Scotland are the official source of COVID-19 deaths. The most recent publication on 19 August continues to shows a steady decrease in the weekly number of deaths in care homes, falling from a peak of 341 at the end of April to 1 death from 10 to 16 August.

Cases of infection in hospitals, prisons and care homes have consistently declined since late April.

Robust monitoring and reporting mechanisms, together with enhanced funding, provision of PPE and bolstering of the workforce in care settings will ensure that any new cases are quickly identified and isolated and the risk of future outbreaks is minimised.

Application of robust testing measures will ensure that infections are contained, and that staff are routinely tested to ensure their health and wellbeing. We will take further action to address nosocomial infection in healthcare settings that is comprehensive and system wide and that delivers sustainably and at pace; and ensure for care homes full compliance with the testing policy in place.

Funding

We have confirmed funding of up to £100 million to address immediate sustainability and financial challenges across social care. We are carrying out a detailed review of actual expenditure incurred by Health Boards and Integration Authorities during the first quarter of 2020 and, following that, we will make a funding allocation to further recognise cost implications. We have provided assurance across the sector that the necessary funding will be made available for health and care services in recognition of costs incurred to date in responding to COVID-19, to support remobilisation of services, and to ensure that patient safety remains the top priority at all times.

In conclusion:

• Cases of infection in hospitals, prisons, care homes and other vulnerable settings have consistently declined since late April;
• Additional, stringent infection prevention and control measures and guidance to safeguard patients and staff in these settings have been established;
• NHS Boards remobilisation plans core aim is to restart paused services in a safe and clinically prioritised manner;
• Well-managed and established plans are in place to meet demand for PPE;
• Application of robust testing measures will ensure that infections are not being moved around the care system, and that staff are routinely tested to ensure their health and wellbeing;
• Early action to address nosocomial infection in healthcare settings that is comprehensive and system wide is being taken; and
• Significant national and local funding is in place to strengthen resilience.

On the basis of the evidence summarised above the assessment is that this Phase 3 criterion continues to be met at this review point.