Coronavirus (COVID-19): Scotland's route map - supporting evidence for the 30 July 2020 Review

WHO criterion 3: Outbreak risks are minimized in high vulnerability settings

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 is 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, with a number of additional precautionary steps:

• Extending the use of surgical masks to be worn by all healthcare staff who work within a healthcare setting and may be unable to physically distance from either patients or staff;
• Out-patients, day case attendances and visitors will be asked to wear a facial covering; and,
• Asymptomatic healthcare staff testing for COVID-19 will be 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.

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 asked them to ensure the effectiveness of their remobilisation plans regarding additional cleaning, the built environment (water), 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.

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, however SPS is planning that physical visits will be available in all establishments by Monday 3 August.

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 at week ending 24 July, there were no confirmed positive cases of COVID-19 in Scottish prisons and just 2 individuals self-isolating across 2 establishments.

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 have asked all health boards to finalise their testing plans and these were made publicly available on 10 July.

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 published on 25 June 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). Further visiting options, including indoor visiting, will be introduced incrementally.

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 recently 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.

The Scientific Advisory Committee recently delivered advice on the wider issue of reopening day care and respite supports, bearing in mind the broad spectrum of ages and user groups that this covers. This is a complex issue given the wide variety of supports, services and user groups involved.

We have used that scientific advice to inform a submission on national actions to support local decisions on re-opening of day care and services, highlighted in Phase 1 of the route map. This includes proposals to develop appropriate guidance with stakeholders and work has begun to develop this. In the interim, the Scottish Government has provided a clear statement for regulators and Health and Social Care Partnerships that building-based support for those with critical needs may be re-opened where support has been adapted with risk assessments in line with the relevant Health Protection Scotland guidance on IPC and PPE as well as physical distancing; and their approach agreed with the local Health Protection team and the Care Inspectorate.

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 30 July we have, since 1 March, distributed 236 million items of PPE to hospitals, 26 million to community care and 98 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 23 July, 177 individuals have been matched with employers with a further 790 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.

Testing

Our approach to testing is focussed on saving lives and protecting the vulnerable, rolling out Test and Protect to interrupt chains of transmission in the community, and continuing the vital surveillance work to support our understanding of the disease in Scotland.

Test and Protect – our direct response to Criterion 2 – launched on 28 May. Anyone with symptoms of COVID-19 should contact the NHS online or by calling 0800 028 2816 to arrange a test.

Since the start of the outbreak we have significantly increased our testing capacity – the original capacity was 350 tests a day. We now have active weekday NHS lab capacity of around 10,000 tests a day (around 8,000 on weekend days) and around 20,000 tests a day from the Glasgow Lighthouse Laboratory, providing overall normal weekday capacity of circa 30,000. The Glasgow Lighthouse Laboratory may process tests taken from across the UK.

This increased testing capacity has enabled us to continually expand eligibility for testing, and ensure the necessary capacity exists to support Test and Protect. Testing of symptomatic individuals was expanded to include children under 5 years of age on 22 July.

Health Boards and NHS National Services Scotland (NSS) are working hard to manage demand across different geographies and maximise daily capacity. This includes using real time data to allow variances in capacity and demand to be managed.

NSS are continuing to develop lab partnerships with all sectors of Scottish society to further build Scotland's testing capacity.

We are working with NHS Boards and health care partners on restarting health care services and will ensure there is sufficient capacity to manage additional testing. To enable the remobilisation of the NHS, we will regularly test staff working in specialist cancer units, in long-term care of the elderly and in long-stay mental health wards.

Since 8 June the UK Social Care Testing Portal has been available in Scotland to help staff to access testing in the care home where they work. Guidance has been provided and updated on use of the Portal, and capacity has been expanded to 67,900 per week, which is more than sufficient for all staff to be offered testing weekly through this route.

We are also testing any health care staff connected to a nosocomial outbreak regardless of symptoms. This testing began on 8 July.

Discussions are under way between health boards and clinical teams about testing patients before surgery, alongside all staff involved in a patient's treatment.

We are continuing to work closely with health board Chief Executives and Directors of Public Health to ensure access to resources to increase testing capacity including Mobile Testing Units MTU & UKG Social Care Testing Portal.

All health boards are using the digital tools to support contact tracing. We continue to enhance and develop these tools - adding more sophisticated management tools - for use solely by our contact tracing staff. We are also separately developing public-facing versions of these simple tools and users will be involved in the design of these.

We continue to work with the UK Government and independently to explore how proximity tracking via a mobile app may assist the Test and Protect system – but Test and Protect will not be reliant on the use of an app.

Data valid as of 19 July:

953 individuals (1,699 cases) were recorded in the contact tracing software and 2,573 contacts have been traced.

The initial data shows that the average number of contacts per positive case is 1.49; this is what we should expect to see during Phase 1 and 2 of lockdown restrictions. For the most recent week of data, the average number of contacts per individual is 2.54. This newly-published figure gives us a more accurate reflection of the number of contacts that people have had in the most recent week.

Scottish Government are working with PHS to understand what data breakdowns are available to identify more local outbreaks.

Emergency Legislation

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 10 July:

• At least 1,620 individual care home staff, and 417 residents were tested in care homes with a confirmed case of COVID-19.
• At least 32,829 individual care home staff, and 2,019 residents were tested in care homes with no confirmed cases of COVID-19.

Note: this is based on new data reported by NHS Boards and includes staff and residents tested across all routes. Please also note that we are no longer collecting data from Public Health Scotland regarding testing via NHS labs.

As at 22 July, 81 (8%) 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.

Over the last few weeks, there has a 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 22 July continues to shows a steady decrease in the weekly number of deaths in care homes, falling from a peak of 340 at the end of April to 3 deaths from 6 to 12 July.

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 allocated initial funding of almost £60 million to health boards to route to integration authorities to strengthen resilience. We have also assured local authorities that additional costs arising from COVID-19 will be met by the Scottish Government, aligned to local plans already in place.

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.
• 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.