Coronavirus (COVID-19) initial health and social care response: lessons identified

4. Lessons identified by Theme with Supporting Scottish and Global Case Studies

Governments around the world have followed similar paths as the pandemic evolves, seeing eight pandemic management phases – from international travel restrictions, through vast closures and to the gradual easing of restrictions. These phases correlate and influence the rate of rise and decline of the pandemic. Health systems around the globe have responded to the immediate challenges of Covid-19, began to recover services, but are now back into a period of disruption and uncertainty with the second wave and rising infection rates.

Since the onset of Covid-19, a number of trends have been observed both within Scotland and internationally. Using the framework below, these trends have been mapped to the pandemic's health conditions, healthcare recovery phases and wider economic circumstances. This framework has been used to ensure those lessons identified within the documentation provided by Scottish organisations are appropriately grounded in similar lessons being identified worldwide. The ten key categories as referenced in Section 1 of this report are covered by the fifteen items below, and therefore are satisfied that the lessons identified are sufficiently comprehensive. The one category not covered within the scope of this report relates to cashflow management, and no lessons were identified by Scottish organisations given the nature of funding provided centrally for the pandemic response.

For each of the 10 themes we have in the following pages summarised:

• The challenge facing Scotland;
• What has worked well in Scottish organisations so far (based on outputs from this exercise);
• Opportunities for further resilience in Scotland where they have been found;
• The key takeaways for leaders; and
• Case studies across Scotland and international organisations that provide some additional insight into how organisations are dealing within specific problems as part of the Covid-19 response. Contact details are not publicly published here but are available for international case studies if desired.

Diagnoses and Contact Tracing

1. Testing

What is the challenge?

The implementation of an effective, nation-wide testing strategy involved a wide range of functions within Public Health. The purpose of testing itself has also evolved throughout the pandemic response, from supporting patient care through positive tests, testing key workers to prevent further transmission, and to wider population testing to understand transmission patterns.

Frequency and impact of lessons identified

Through the review of documentation provided from previous lessons identified sessions, very few organisations discussed the impact of Covid-19 testing either on their staff or their priorities. While testing remains a key issue in the Scottish Government's response to Covid-19, the lessons will not be relevant to all organisations in scope equally given the involvement of national bodies and Public Health teams.

What has worked well in Scotland?

• Public Health Scotland noted that links with colleagues across England, Wales and Northern Island were vital in terms of supporting learning, sharing best practices and receiving notifications on early warnings around issues.
• Stakeholders talked about clear public engagement when setting up testing sites to ensure optimum uptake within communities. This was felt to be particularly strong when engagement was led in conjunction with local Public Health teams: with examples cited including engaging early with international students and older people to determine where testing sites may cause concerns due to lack of public transport or proximity to other high risk areas.
• The role of digital in reporting test results has evolved throughout the pandemic, with a completely new system being implemented by the National Notification System to support this, working across Boards and with DHI. The Data Intelligence Network has also been cited as a lasting legacy for the Public Health response.

Opportunity for further resilience

• The impact of 'Test and Protect' will need to continue to be monitored as staff who have contributed to that work are brought back into their normal workplaces. UK testing centres have reported staff as a key 'bottleneck' as scientists return to academia for example. Organisations will have to ensure an appropriate balance between restarting existing laboratory work processes over the winter months, and increasing testing capacity through the regional testing hubs.
• Considering the attention drawn to contradictory guidance, one organisation highlighted the need for Scotland-specific solutions, including a clear strategic framework for Test and Protect that aligned with wider, UK government approaches. A specific example cited was weekly testing in care homes. More clarity on where the responsibility lies for testing both within Scottish Government teams and in the relationship between Scottish Government and the UK Government would allow for more tailored, local responses.
• A recent clinical review by Scottish Government has highlighted the importance of faster turnaround times for test results and increased capacity. A highlighted priority in this report is increasing routine testing to mitigate the risk of asymptomatic transmission (for example in care homes).

Key takeaways for leaders

• Resourcing remains a challenge. Despite the considerable work done to identify teams, increasing testing requirements will increase the need for specialist skills. Closer working with non-healthcare organisations could support this.
• Clarity of roles and responsibilities between Scottish Government and other UK bodies both in communications and decision-making will continue to support a more tailored, Scottish response for issue such as rurality and engagement with the islands to provide rapid testing and results.

Capacity and Demand Modelling

2. Capacity and Demand Modelling

What is the challenge?

The Covid-19 pandemic has highlighted the importance of modelling capacity and demand, both with regards the transmission and extent of the virus, but also the impact on hospitals and Social Care for increasing demand for patients and service users, staff, and PPE among others. This will continue to play a key role as elective work is restored across the country.

Frequency and impact of lessons identified

Limited modelling information covering initial Covid-19 demand capacity assessment or for PPE supply chain analysis was found in the documentation. Through follow-up consultations, interviewees have referenced the significant work done on demand and capacity and PPE modelling through the early months of the pandemic, particularly from a virus transmission perspective.

What has worked well in Scotland?

• As noted above, few outputs from lessons identified exercises discussed the impact of modelling on the first wave response to the pandemic. Where multiple interviewees felt that the Scottish approach worked well however was a reflection on how quickly the infrastructure supporting modelling was stood up during the first few months of the pandemic. This significant investment in infrastructure provides decision makers with clear evidence for short-term decision making.
• One interviewee also referenced some initial work towards integrated modelling within NHS Boards. Ayrshire and Arran was cited as having made good progress to date by engaging with wider organisations within the region as part of their modelling.

Opportunity for further resilience

• A key area for improvement relates to the connections between demand and capacity modelling outputs at the national or board level, and its translations into 'on the ground' decisions across health and Social Care. A reported lack of integration between health and Social Care meant that the impacts of the modelling could not be easily cascaded through Boards into individual organisations. Further integration will continue to improve the efficiency of this process.
• A second area for further resilience identified was the involvement of team members on the modelling process. Few individuals within the Scottish Government have the required experience and expertise to be able to design, use and interpret the outputs from the models, meaning increasing demands on their time and bottlenecks around decision-making. Where further resource is deployed to support these individuals, there is not always the requisite experience to be able to support appropriately, and key individuals as a result continue to act across a number of roles. This presents a short-term risk to capacity and a longer-term risk to sustainability in post. To mitigate this, identification of individuals either with suitable existing skills, or a process by which these people can be upskilled, will support increased resilience.
• We also found evidence that while considerable work has been done on demand modelling scenarios, the unpredictability of the virus means wide ranges of potential outcomes are provided for any scenarios modelled, and no predictions can be made beyond six weeks with any great certainty. This can lead to reactive decision-making and inefficiencies. Organisations will either have to continue to work with available data and make decisions in the context of heightened uncertainty, or continue to focus resource on the modelling approach to provide longer-term data sets. We note here these comments do not reflect the considerable uncertainty inherent to the novel Covid-19 virus and therefore further certainty may not be possible.

Key takeaways for leaders

• Significant progress was made standing up the infrastructure and teams to model the impacts of Covid-19 on NHS Boards and the public, and this should be recognised and commended.
• Further operationalisation of modelling outputs remain challenging due to uncertainty inherent to the data and a lack of integration across organisations. Dealing with many individual bodies to translate modelling figures into decision-making presents a challenge.
• Skills and experience in modelling remain quite specialist, with limited support available to understand assumptions in the data. Leaders should ensure adequate support remains available to modelling teams to support wellbeing over the coming months and a pipeline of future resource is appropriately identified and monitored to cope with on-going demand.

What is the challenge?

Adapting existing physical facilities to enable the practice of social distancing and the functioning of green/blue (or hot and cold) sites, whilst maintaining non-Covid service provision, was challenging for organisations. There have also been reflections on the increased provision of critical care and how hospitals have adapted to this.

Frequency and impact of lessons identified

Through our review of documentation, few organisations talked about the physical adaptions made across and within sites to treat Covid-19 patients separately to non-Covid patients in detail. As organisations seek to restore elective work while ensuring staff and patient safety, this will continue to present an opportunity for further review based on the findings of this report.

What has worked well in Scotland?

• NHS Grampian noted that considerable time had been invested into safeguarding GP practice staff as layout changes were implemented to maintain social distancing. This was complemented by other safeguards including using alternative buildings and staggered hours to support effective distancing.
• The estates team of NHS Highland have been working closely with Acute and community clinical teams to physically return space to the 'new normal' working environment. In addition to this, buildings and departments have been reconfigured to more effective service delivery by taking into consideration lessons identified from wave one.
• NHS GGC has created a 'social distancing and workplace risk assessment' to be reviewed every 6 months that identifies key considerations for teams, and where estates may be able to support safe distancing within wards.

Opportunity for further resilience

• In outputs shared through this exercise, a small number of organisations have noted that through the work done by Boards in conjunction with Estates and Clinical teams, there is a sense that those working on non-Covid work were being deprioritised. With high priority non-Covid procedures only being performed during the height of the first wave, it will be important to provide sufficient operational and clinical focus on non-Covid work in subsequent waves. While no specific comments were made in the documentation provided, the case study below identified staff feedback around the process through which staff were selected to be part of hot or cold sites to ensure this is transparent and equitable.
• As outlined in further detail in the case study below, considerations around zoning of hospitals or sites must be assessed with both staff and patients. Regular feedback on the accessibility of sites, effectiveness of Infection Prevention Control (IPC) procedures and feelings of safety for staff and patients will be important aspects of maintaining elective care over the winter months. Increasing audit procedures around IPC may become more important to maintain the distinction between hot and cold sites.

Key takeaways for leaders

• Where physical adaptations are made to existing or new sites, consultation with patients, staff and trade unions remains crucial to ensure both buy-in and all feedback given can be considered to provide the best possible care.
• Communication with staff and patients about the process of zoning is important, particularly where redeployment is required across sites.
• On-going reviews of the 'new normal' will be needed to embed aspects of redesigned services that can be maintained and embedded going forward.

Creating Extra Capacity

3. Primary Care

What is the challenge?

The response to Covid-19 has led to a rapid change in how general practice operates. A significant acceleration of the use of remote consultations has meant that while continuity of care was possible, the way in which the public interact with the service has fundamentally changed for most patients. Combined with the backlog of unmanaged conditions that has built up over the first response, primary care continues to face significant challenges.

Impact and Frequency of Lessons identified

Many references were made to the expanded role of primary care as part of the outputs provided to date. As with the findings for social and community care in the following section, these predominantly focused around the importance of a coordinated, wider response to the pandemic beyond hospital-based care.

What has worked well in Scotland?

• As outlined above, the key focus of what worked well for primary care in Scotland is the acceleration in the use of remote consultations. Many organisations reported significant uptake of digital tools, with the national Near Me TEC leading on work related to 'ihub' which was used to provide a standardised process for rolling out Near Me across 652 practices with 100% engagement. A series of 'Primary Care Resilience' Webex sessions have been recorded and remain available through 'ihub' for colleagues across health and Social Care as response continues over the winter months.
• A smaller number of organisations also referenced an increased offer of services to the public through primary care as part of the response to the pandemic. Examples provided during this exercise included the use of primary care teams to talk to patients about shielding or having Key Information Summaries (KIS) prepared proactively (increase of 4% to 17% of Scottish population with a KIS now prepared). Other Boards also noted an increased access by primary care teams to diagnostic services, which supported urgent cancer referral decisions into secondary care.

Opportunity for further resilience

• Research published towards the end of 2020 suggests that the pandemic response has exposed a significant gap between Public Health and primary care, and between local government and primary care teams. While we found evidence of some expanded services being provided above, other organisations noted that the strengthening of this relationship (and therefore the range of services that could be offered through primary care) would be important in the future.
• Organisations also noted that while the uptake of remote consultations has been significant, one Board in particular noted that there was a preference for telephone consultations amongst GPs which lead to a lower than expected take-up of Near Me. Further follow-up on this would provide insights into potential barriers to the use of digital in primary care, but we suggest (in line with other findings in this report) that access to digital tools and limited infrastructure may continue to impact full digital roll-out across primary care.
• When reflecting on the lessons from the first wave of this response, a number of organisations noted that an increasing focus on scheduled care through general practice provides the opportunity to minimise existing pressures on secondary and tertiary care. A key area for focus was around how existing contractual and funding arrangements are no longer appropriate for this expanded role, and that new arrangements could improve resilience in the future.

Key takeaways for leaders

• Central source of guidance, tools and case studies available through Healthcare Improvement Scotland.
• A wider range of services can support more effective primary care but needs close alignment with local government and Public Health teams to ensure consistent provision of care.
• Continued uptake of digital consultations will be important but recognise there may be barriers around access and infrastructure in the community.

Creating Extra Capacity

4. Community and Social Care

What is the challenge?

The impact of the pandemic on people using Social Care services and staff has been significant. Both a Kings Fund report (focused on England) and the Independent review of social care in Scotland indicated that Covid-19 effectively highlighted and intensified existing challenges facing the sector including workforce issues, a lack of integration with other services pre-existing inequalities especially for older people.

Impact and Frequency

Many of the documents reviewed referenced the important role of non-hospital care in the response to the pandemic to date. We also found regular references in interviews on other topics (including digital and modelling discussions) of the role of community and Social Care as part of the wider response to the pandemic.

What has worked well in Scotland?

• A number of organisations have referenced the good work of the Health and Social Care Partnerships across Scotland, with a particular focus on the redeployment of staff to share lived experiences across organisations to identify lessons. More integrated leadership and decision-making has been referenced as being successful where it takes place. These developments have been mirrored in social care organisations who had to adapt quickly to new and difficult circumstances – the Independent Review of Social Care reported that some people who work in social care support felt they have been able to make decisions more quickly, to good effect.
• Building on the work of HSCPs, the collective mobilisation of local multidisciplinary teams from NHS health boards and local authorities to provide enhanced oversight for local care homes and wider social care services has been a key development during the pandemic. These arrangements have made a significant contribution to the development of protective arrangements for ensuring mutual aid and support for social care services who provide care to some the most vulnerable of citizens and the workforces supporting their care needs.
• The development and implementation of a safety huddle TURAS care management tool within the care home sector has been a valuable introduction. The key elements of this were that it enabled a consistent approach to data collection, report staffing decisions, and permitted early escalation and warning to allow for timely support and interventions for care homes.
• NHS GGC's six health and Social Care partnerships have been collaborating throughout the Covid-19 pandemic, which has been described as instrumental in delivering a GGC-wide response which involved a rapid and wholescale review of service provision; redesign of service delivery and access pathways; and significant changes to working practices.

Opportunity for further resilience

• A number of organisations within the scope of this work called for an increased focus on non-hospital care. These concerns firstly discussed funding and contractual arrangements, specifically requesting that social and community care colleagues are present when agreeing new funding arrangements to ensure there is sufficient focus on the full patient pathway. Clarity over funding for additional Social Care costs incurred, as echoed elsewhere in this report, has also been cited here.
• A second opportunity for further resilience raised by organisations was around a perceived disparity between social and healthcare staff. Examples cited here, which were confined to the early weeks in the pandemic, include the ability to access testing and PPE within Social Care settings. While these issues have been resolved, there were concerns raised at the time around whether social care was prioritised sufficiently in the early phase of the pandemic.
• In wider discussions around workforce planning and modelling, there was a sense that limited information was available from the perspective of non-healthcare organisations. Limited integration and information was felt to impact the effectiveness of planning.
• The range of organisations contributing to the community care response has also been highlighted as a potential opportunity for resilience. NHS Boards reported having to deal with hundreds of individual organisations separately, which impacts their ability to coordinate activities and make decisions at pace. An effective structure for coordination and governance could improve alignment across the health and Social Care sectors in the future.

Key takeaways for leaders

• Cross-organisation and specialty working to respond to the pandemic has highlighted the importance of whole system understanding to understand as many elements of the response as possible. Continued close working relationships and involvement in decision-making and in providing integrated flexible support and mutual aid to support social care organisations will be crucial during remobilisation and recovery.
• It will be important to continue to support equal access across health and social care services particularly with regards access to PPE, testing for staff members and access to wellbeing resources and support.

Creating Extra Capacity

5. Private provider and military partnership

What is the challenge?

As part of the national response to the pandemic, the Scottish Government drew on the support of military partnerships to fill identified resource and/or skills gaps. While this worked to address the immediate challenge, it also raises the risk of a reliance on this into the longer term. Organisations should consider the extent to which this external relationship is appropriate as part of remobilisation and recovery, or whether internal solutions are to be sought to decrease on-going reliance on wider system partners over time.

Impact and Frequency

Few organisations referenced the role of military or other providers in their lessons identified outputs to date. We noted from follow-up consultations that colleagues referenced the important role the military in particular in response to the first wave, but that the availability of military input and private support was not uniform across Scotland.

What has worked well in Scotland?

• Where involved, organisations referenced the specialised input of military colleagues into disaster response plans as particularly valuable as it provided a skillset and mindset not always available within health and Social Care. Tabletop exercises, when conducted with military liaison officers, provided a greater understanding of how an organisation may have responded differently to the first wave.
• One organisation also recognised in their lessons identified that they do not have the capacity or the capability to deliver Covid-19 programmes alone. They reflected on the close relationships with partners to bring in external project and programme management as something that worked well, particularly highlighting that military colleagues brought a focus on quick decision making and pace throughout the initial stages of the crisis.
• Partnerships have also been strengthened through in-housing new resource using secondments and partnering arrangements with Higher Education. These temporary solutions could provide lasting benefits in terms of building working relationships and providing exposure to new skills.

Opportunity for further resilience

• Organisations recognised that the response to the pandemic evidenced a level of reliance on a range of private and independent sector providers across care homes, care package providers, supply chain resilience and testing. These organisations will need to consider whether or not this is desired over future waves and into the 'new normal'. If so, then private and independent providers should be involved more closely in future decision-making and governance. If not, arrangements must be made to reduce this reliance through increased in-sourcing and capacity.
• Health Education England have also agreed to register private providers as recognised training sites during the response to the pandemic. This means that on-going training can be provided for NHS workers to develop appropriate skills for the future as backlogs are addressed through private providers. We have not been made aware of similar arrangements in Scotland through this work.
• Discussions with Boards revealed that not all regions have similar access to private or independent provision. If central decisions are made around how best to increase capacity using other organisations, regional availability and differences must be considered.

Key takeaways for leaders

• Assess the strength of existing networks to private/military partners to identify gaps over the coming months, particularly where Boards have less access to private providers if this will be considered across the Central Belt.
• Recognise capability gaps within Boards and develop plans to address where appropriate through joint arrangements or recruitment.
• Consider the impact of non-NHS involvement on addressing backlogs of care and how this impacts training provision where staff may not be registered with independent providers.

Public Engagement and Education

6. Public engagement and education

What is the challenge?

A key element of the health and social care response was managing public awareness through engagement and education. Through this exercise, we have found evidence that organisations feel lessons identified from the engagement approach to date could be used to support provision in the future. Increasing demand for services will continue to impact organisations, particularly as underlying issues resurface in the coming months, and engaging with the public to manage expectations and increase awareness of how best to engage with services will remain crucial during recovery and remobilisation.

Impact and Frequency

Where documentation referenced public engagement, these referred to concerns about the limited timescales available to hold meaningful engagement with patients and service users prior to changes being made that impacted them. There were otherwise limited references to how the public could be engaged.

What has worked well in Scotland?

• Many organisations recognised the importance of engagement with public and patients across a number of mediums, including coordinated social media and television campaigns, to deliver key messages consistently to all relevant groups. According to respondents from Health and Social Care Scotland, there was a feeling that communications being shared from those in senior leadership positions have been more impactful with the public, particularly where more emphasis and impact is needed.
• Most of these organisations also recognised that specific work had been done to better reflect diversity across population groups, recognising challenges around specific conditions and digital inclusion. A number of interviewees referenced the on-going work of the Health and Social Care Alliance (ALLIANCE) in this space, and the outputs of this work should continue to be reviewed as more insights become available.
• Two interviewees noted that updated guidance on patient inclusion was issued for NHS Boards during the pandemic to reflect the challenges around engagement during the pandemic. This updated guidance should allow Boards to make best use of heightened interest of the public in their engagement with the health and care service.

Opportunity for further resilience

• Many outputs reviewed drew attention to a premise that a culture change would be required to shift attention from 'on-demand' health and Social Care to a service provided based on need. In light of this, suggestions have been made to better educate patients on how they can take greater responsibility of their health and well-being (e.g. improved signposting to sources of self-help). Likewise, bodies highlighted that messaging must be consistent. Opportunities arise when the messaging of promoting self-care, community self-support and of using the NHS and Social Care appropriately is aligned. The prioritisation of 'need' and support for the health system to deprioritise 'wants' will be critical.
• Some organisations suggested that education and communication should be co-designed with the public if not already done so. Fully inclusive co-design will ensure sufficient focus on the patient and include patient-centred care at the heart of remobilisation plans.
• The necessity of command and control-type governance during the pandemic has limited opportunities for public engagement. A key example cited has been the limits imposed on visiting practices without involving the public, and meaningful inclusion of the public in the shape of new services and approaches to responding to the pandemic is strongly recommended. Working with Healthcare Improvement Scotland to access citizen panels for example may support this.

Key takeaways for leaders

• Leaders should consider how communication and engagement can drive more of a preventative, self-care and community health emphasis. This would look to reduce strain on NHS services and adopting more of an educational approach.
• Organisations are reminded of their statutory responsibilities for public consultation on service changes, even during the pandemic. If lasting changes are made to services, prompt consultations will be required.

Supply Chain

7. Supply of PPE

What is the challenge?

The effective management of supply chain, particularly for PPE, was a crucial determinant of the early effectiveness of the pandemic response. Considerable work has been done by NHS NSS to model demand and provide PPE supplies to individual boards, primary and social care organisations. Reliance on global supply chains and challenges around the rurality of Scottish regions will have brought the provision of PPE into sharp focus for organisations and now informs future PPE planning for Scotland.

Impact and Frequency of Lessons Identified

While PPE remained at the forefront of many discussions during the first wave of the pandemic, our review of documentation provided did not find many references to how this has been managed within individual organisations. Where referenced, organisation reflected on the importance of appropriate PPE to continue to safely treat Covid-19 positive patients.

What has worked well in Scotland?

• Participants highlighted the effective supply management of PPE to be a key contributor to a successful response to date. NHS Western Isles said that even with increasing outpatient activity, they had managed the supply chain and application of PPE well during the first wave. Specifically, to allow for any Covid-19 surges, a buffer stock of two weeks' supply has been set aside by working closely with the local authority providing supplies of some PPE when critical supplies not delivered.
• Similarly, NHS Orkney set up a virtual hub arrangement to show the services that each partner would be responsible for in terms of the supply of PPE. This reduces the risk of inefficient stockpiling and aligns priorities across organisations to ensure available equipment can be identified and shared where required.
• NSS drew on its existing National Procurement team to work with Scottish Government, health and Social Care providers and local authorities to extend supply and sourcing efforts to centralise provision where possible. This has been facilitated through an online portal which provides real-time data, deliveries to Social Care hubs across the country and the creation of the NSS Warehouse Management System to provide extra capacity.

Opportunity for further resilience

• Despite some local initiatives being reported as successful, many Boards expressed "anxiety" around the availability of PPE, ventilators and national stockpiles. They have also expressed the fact that there should be clear and consistent messaging regarding the availability and management of PPE, and specialist equipment shortages.
• As outlined in the sections of this report on primary and Social Care, organisations regularly drew attention to the availability of PPE in non-hospital settings. Involvement of wider groups in decision making will continue to raise awareness of any discrepancies between health, social and independent sector colleagues. This aligns with wider comments around the perception of equality between health and Social Care staff.
• Availability of real-time, accurate data is crucial for effective supply chain management. Closer working with digital and BI teams, as well as organisations within each region to capture accurate data, will improve the ability to manage PPE effectively.

Key takeaways for leaders

• The ability to rely on stockpiles of PPE has been critical to the success of some organisations but can also negatively impact on the wider response if stockpiles are used inefficiently. Collaborative working across sectors and organisations should mitigate this risk.
• Consideration into clear messaging so that less anxiety is felt by organisations in the delivery of services.
• Access to accurate, real-time data across organisations will provide a basis for more effective decision-making.

Digital Front Door

8. Tools, Infrastructure and ways of working

What is the challenge?

Organisations all recognised the significant challenge of integrating digital tools and infrastructure into existing pathways and ways of working. With a requirement to move towards more remote working, newly adapted tools were made available to facilitate services, with the majority of organisations highlighting Microsoft Teams and Near Me as key examples.

Impact and Frequency

Many organisations referenced the significant impact of digital tools on how they have responded to the pandemic to date. As part of the findings from our review of documentation, organisations regularly referenced digital as a key enabler for the response and an area for lasting change within organisations.

What has worked well in Scotland?

• Many organisations noted that Microsoft Teams has been the key digital tool to enable staff and services to work remotely during the pandemic. NHS Dumfries and Galloway drew particular attention to the benefits for staff living in rural areas, who have been able to participate in work activities they previously had difficulty attending, providing more opportunities for inclusion.
• Near Me was found to be a key tool to mitigate the loss of face-to-face provision. NHS GGC, among others, recognised that the rapid and widespread implementation of Near Me enabled the effective prioritisation of patients remotely and management of patients presenting at hospitals for unscheduled care.
• In terms of digital ways of working, NHS Orkney mentioned clinical services had fully embraced digital and aligned the rapid rollout of digital with the planning of future service delivery. Orkney also reflected in terms of digital being available to deliver a wider range of services, such as "digital training packages" that can be given to carers to help them understand and support a patient's clinical care.
• A rapid information governance process was put into place to ensure private hospitals (among others) were able to share data for using new digital tools through Digital Health and Care Scotland.

Opportunity for further resilience

• With an increase in demand for digital services, organisations have identified the need to consider assessing their existing IT infrastructure and additional capacity to ensure that clinical services and other enabling services can continue to function effectively.
• National organisations regularly recognised increasing expectations and demand for data as a potential barrier moving forwards. From the start of the pandemic, there was a significant ask for real-time data which continues into the vaccination programme. As organisations scale up to provide this data, there is an opportunity for a new data strategy across health and Social Care to make best use of this infrastructure as part of remobilisation plans. The role of NHS Inform will be important here as a potential 'front door' for health and Social Care data in Scotland.
• A final area of focus on building the capacity for health and Social Care staff to use these tools. It was felt that there is an expectation staff will already have these skills, but new tools will require additional training and support.

Key takeaways for leaders

• Recognise that the rollout of digital tools will strain services if supporting infrastructure is not appropriately scaled up, particularly around integration of systems. In addition, service redesign, culture, leadership and skills are all important areas to evaluate alongside the integration of digital tools.
• Data has become central to the pandemic response. Leveraging this as part of the 'new normal' will provide opportunities to work more effectively and more closely with non-healthcare organisations.

Digital Front Door

9. Access

What is the challenge?

It is important to understand that as digital tools become more integrated into patient pathways and ways of working, stakeholders will be impacted differently. From a staff perspective, the ability to make best use of digital tools may be hindered if the required resources and infrastructure are missing. From a patient perspective, an inclusive approach needs to be adopted so that all stakeholders are considered.

Impact and Frequency

In the same way that digital tools were regularly referenced through outputs provided, organisations also recognised the impact of these tools on their stakeholders. There has been significant work done around increasing access as discussed below and organisations regularly referenced the importance of maintaing this throughout the response and recovery phases.

What has worked well in Scotland?

• The 'Connecting Scotland' programme (delivered in partnership with the Scottish Council of Voluntary Organisations) invested £5 million in providing 9,000 technology packages (hardware and support) to those at risk of digital exclusion. This programme has been extended as the response continues with the training of 'Digital Champions' to support users.
• SMS messaging services were developed alongside UK Government to support those shielding with food packages.
• Digital was highlighted as a key enabler for maintaining training and CPD during the first wave of the pandemic; NHS Borders specifically referenced the use of the LearnPro Competency Assessment tool here. Wider advantages cited using digital tools included: supporting cross sector learning with wider groups; improving attendance rates by enabling remote access; and the ability to record sessions. As a result (particularly of the ability to record), a repository of learning material has now been created, further improving access to training on-demand for the future.
• Participants have drawn attention to innovation in teaching being a steep but valuable learning curve, and the fact that this has paved the way to a new channel of learning, informing how teaching is carried out across the board.

Opportunity for further resilience

• To support the continued and increasing use of digital, organisations have noted that more consideration needs to be made in terms of access where stakeholder groups may be located rurally. Areas with less connectivity may not be able to access all services remotely, with organisations emphasising the need to review bandwidth and public Wi-Fi.
• We also note specific work is being done through the third sector to consult on the impact of digital adoption on patients with different conditions; this should be reviewed and shared across the country as digital adoption continues. The ALLIANCE continue to work with identified groups of service users to understand how they have been impacted by Covid-19 and organisations should ensure the outputs of this work are considered during remobilisation and recovery.
• Equality impact assessments have been suggested to ensure that digital works for all stakeholders going forward. Recognising the extent to which digital exclusion exists will primarily inform the exercises that need to follow to address challenges in providing everyone access. We note through conversations with other stakeholders that these are being rolled out already, so ensuring all services and organisations are covered in a timely manner will be important here.

Key takeaways for leaders

• Recognise that digital will not come naturally to all and leaders must consider access issues, whether it be educationally or having the appropriate infrastructure, for certain stakeholder groups.
• Digital is a key enabler for access in many respects and leaders must consider how to roll this out more widely beyond Covid-19 response.

Programme Management

10. Internal and external communication

What is the challenge?

A number of organisations recognised the importance of clear communications as another "key enabler" for the response to Covid-19, with particular attention made to internal communications to stakeholders within health and social care. Barriers were identified around ensuring any guidance being received/shared within organisations was coordinated appropriately, whereas external communication was felt to have worked well by building public resilience through a planned and proactive approach.

Impact and Frequency

Regular feedback was provided by organisations on the lessons identified from internal and external communications during the first wave of the pandemic. Feedback was generally positive however, with limited areas for improvement based on the documents provided for this phase of work.

What has worked well in Scotland?

• Due to the volume of necessary communications from leaders, many organisations felt those that worked best were those focussed on actions and decisions, providing regular updates and clarity within organisations. Short, regular communications were felt to be the most effective way of keeping staff updated despite a rapidly changing landscape. Lessons from NHS Chief Executives in particular have suggested the need to build on this for the future under a dynamic blended model of remote and office working, for example where electronic communications cannot be supplemented by visual reminders within hospitals or practices.
• NHS Inform have produced a regularly updated Communications Toolkit which specifically provides guidance on engaging with those with communication differences (such as British Sign Language). This will remain important as guidance changes.
• Some organisations talked about the importance of tailored messages for staff and their families. NHS Fife talked about animations being made available for the young families of staff to deliver specific messages for them where uncertainty may have caused distress at home.

Opportunity for further resilience

• Possible improvements around the clarity of communications from Scottish Government into various organisations have been reflected upon by several organisations. "Constant changing guidance" was described as problematic with partnerships having to "continually flex" to short timescales, leaving little planning time going with a depleted workforce. We note from follow-up conversations that this has been recognised as inevitable, but a focus on regular engagement with Boards is planned as a mitigation for rapidly changing guidance.
• Suggestions have been made by bodies to implement a coordinated approach to communication, making messaging clearer for whole organisations. Coordination and timing of communications will need to allow adequate time to develop high quality information and drive decision-making. As part of this, organisations referenced that specific guidance was targeted at different executives (i.e. clinical workforce guidance to medical directors rather than HR teams). This creates a risk of silos being created within teams with delays in guidance being shared. Joined-up, coordinated guidance would mitigate this.
• External communications to the public and other stakeholders remain crucial over the coming months, but feelings of uncertainty also impact staff within organisations. Interviewees referenced teams working to different versions of guidance within one organisation, and organisations should continue to ensure guidance and FAQs are regularly updated for staff as well as patients and service users.

Key takeaways for leaders

• Guidance to organisations needs to be coordinated and consistent. Constant changing guidance has been problematic to some organisations with particular concerns around version control.
• Consideration into keeping staff updated regularly throughout a changing landscape where staff are working flexibly across different organisations and at home. Consistency of message across digital and physical communications (i.e. in wards) will continue to be crucial.

Programme Management

11. Shared Vision

1. What is the challenge?

Alignment both within and across health and Social Care organisations provides the opportunity to work collaboratively and efficiently, but competing organisational priorities or a lack of clarity about aims and objectives can impact this. As found through this exercise, a number of organisations across the system noted that clarity of purpose in the short term provided a focus for decision-making, and the challenge facing organisations now is to ensure that shared aims and objectives continue to provide a targeted focus for staff and other stakeholders.

Impact and Frequency of Lessons Identified

While few organisations referenced how effectively responding to 'one objective' facilitated quick decision-making and breakdowns of silo working, those that did suggested this was a crucial learning from the first wave and may have a significant impact on future ways of working.

What has worked well in Scotland?

• Across a number of organisations, the importance of a clear mandate was noted as being important in the response to the pandemic. Participants regularly made references to clear mandates, well-defined purposes, and therefore the authority to act based on this common vision as allowing progress at pace and limiting conversations about competing priorities and focus for individual teams or organisations. This led to new innovations including NHS GGC's 'Give and Go' service for the public to share supplies with patients and staff on wards by engaging with voluntary organisations and staff networks.
• Many organisations also emphasised that the high levels of trust and support between colleagues as the common purpose or vision encouraged teams to move away from traditional, 'bureaucratic' environments. The rapid response to the pandemic was therefore facilitated by teams working towards an agreed, stated aim in a less hierarchical manner.
• We also found a clear recognition of this at a wider level by the Scottish Government itself, where document outputs directly referenced the fact that a clear and common purpose 'underpinned' the achievements made across health and Social Care during the first wave of the pandemic. Examples cited through interviews included the rollout of Near Me, where interviewees praised the ability to divert significant resources to one, prioritised and agreed challenge to deliver at pace.

Opportunity for further resilience

• Challenges highlighted in lessons identified exercises held to date talked about how existing priorities were not well aligned with the newly agreed 'common purpose'. Organisations felt that additional targets being set in addition to responding to the pandemic felt 'unnecessary' and 'added additional pressure' at a time of already heightened pressure. A specific example cited here was given around managing discharge times from hospitals. Staff felt the reason for targets at a time of pandemic were not well understood and they then could feel demoralised by criticism of performance.
• To mitigate this, opportunities for further resilience are available by ensuring that common purposes or visions are designed to encompass existing requirements where possible. Organisations could also engage with stakeholders about existing priorities while responding to significant events such as pandemics to determine whether or not priorities remain relevant or appropriate.

Key takeaways for leaders

• Ensure that there is an alignment between the new purpose and continuing with the core requirements/provision.
• A clear mandate and well-defined vision can work effectively, especially in rapid-response environments.

Workforce

12. Workforce Supply and Flexibility

What is the challenge?

Even before the pandemic, Health and Social Care organisations have been facing significant challenges around workforce supply, with an excess of demand over supply of staff. With increasing new demand presenting during the pandemic, as well as a growing backlog of work postponed in the immediate response, the supply and flexibility of the workforce presents a key challenge to Scotland over the coming months.

Impact and Frequency

Workforce was highlighted as an area for reflection across a large number of the documents reviewed as well as in the follow-up consultations held. Identifying a sufficient supply of appropriately skilled staff remains a key focus for Health and Social Care organisations, and this will have a significant impact on the on-going response to the pandemic as well as recovery.

What has worked well in Scotland?

• Few organisations have referenced additional supply of temporary/voluntary workforce during the response to the pandemic in the documents reviewed. Where this has been referenced, organisations noted that these staff will have clear insights and lessons from their experiences. We note none of these insights were referenced at this stage but will be an available area for feedback.
• A small number of organisations noted that rapid recruitment processes have provided an alternative way to manage the recruitment of large numbers of applicants over a short period of time. A key example of this at a national level is the work with NHS Education for Scotland to identify c. 20,000 additional staff within a month.
• With a need to flex resources in many places during the pandemic, many organisations praised the ability of staff to adapt and take on new roles where there was requirement to do so. Considerations were made in terms of skill/capability and whether staff where comfortable when taking up a new role when required.
• Efforts were made at national level to anticipate demand for staffing and clinical skills (at whole service level), with emergency guidance in place for staffing ratios in critical care and ICU which assisted in the deployment of student nurses during the first peak. Learnings from this allowed for more accurate predictions and enhanced decision making for future deployment in subsequent waves.
• Whole new workforces were created as part of the pandemic response with the speed and design, assessment and delivery highlighted as areas that have worked well, alongside the recognised value of mutual aid. One key example that was highlighted as working well was within Contact Tracing, regarding having a hybrid model of service delivery in place, with local capacity supplemented at national level with both directly employed and commercial resource. This has proven to be very flexible but offers lessons to be learned about the need to take an 'insurance-based' approach to building capacity in the pandemic and emergency services.

Opportunity for further resilience

• Whilst bodies reflected on the need to meet initial demand with deployment of staff and/or recruitment of additional staff, the transition back to the 'new normal' presents a risk to the capacity of staff with specific skillsets. A key example cited within the documents provided is clinical skills, where clinical supervisors for non-clinical staff remain in short supply. Organisations also suggested that future planning could consider developing a matrix or system where skills and capability are considered and mapped across potential redeployments in advance, to facilitate the pace at which organisations can respond to changing requirements. Closer work with Higher Education Institutions or education practices might support this.
• Having the time to upskill staff during the onset of the Covid-19 pandemic was clearly a limiting factor. Documents provided noted the fact that certain staff groups were especially impacted in terms of learning and development, for example, with the pausing of clinical placements for AHPs in the first wave. This was exacerbated by the practical challenges of reintroducing placements whilst maintaining social distancing, as well as a lack of patient numbers to support a quality learning experience for students.
• Respondents suggested that the workforce planning exercise was heavily supply-led. The NES and SSSC Recruitment Portals were developed and implemented rapidly through partnerships working across the health and social care sector, which on reflection worked well. Boards, however, did not feel that there was enough focus on aligning efforts to seek temporary or emergency staffing to service needs. At the start of the pandemic, NHS Boards, Health and Social Care Partnerships and Social Care organisations did not know which parts of the workforce would experience the most demand and pressure and consequently, the Portals issued a general invitation to workers across the health and social care sector. This has led to an excess of available staff in the NES and SSSC Portals, for a number of reasons (for example, some of the vacancies were not in required geographical areas or services that Portal registrants wanted to work in and some registrants did not have the required skills that Boards or Social Care organisations needed). Another factor was that as a number of services had temporarily stopped, Health and Social Care Partnerships effectively redeployed staff locally, providing mutual aide to respond to workforce pressures. Going forward, more focus on integrated, flexible, demand modelling will improve efficiency of supply sourcing.

Key takeaways for leaders

• Recognise the value of volunteer staff in freeing up clinical staff to focus on my value-added activities.
• Consider the governance around rapid recruitment when trying to meet peaks in demand.
• Increasing digital provision of care impacts of role automation in workforce plans. Scottish organisations should review workforce requirements over the next 5-10 years considering how the pandemic response may have accelerated this process.
• We can take learnings from the initial waves of Covid-19 around how we can rapidly reconfigure the workforce to direct more staff in service to frontline and emergency response, making use of retirees and returners to provide 'business as usual' services such as ward rounds, which would create additional capacity. Overall, future resilience in relation to workforce requires a holistic view on capacity, rather than filling specific gaps or roles with skills that are temporarily in short supply.
• Recognition is required that total clinical workforce capacity is predetermined and finite, it is therefore important to identify that limited additional productivity and/ outputs can be offered by the current workforce, without running risks related to workforce wellbeing, effectiveness and service recovery.

Workforce

13. Wellbeing

What is the challenge?

With the demand for service provision increasing throughout the pandemic, the wellbeing of staff should be prioritised to ensure the sustainability of the health and Social Care response over the coming months. Organisations should also consider the challenge of making resources available to all stakeholders with a consistent offering, aligned with a recognition that staff wellbeing should be a part of business as usual process, not just a temporary service in rapid response environments.

Impact and Frequency

The wellbeing of staff was recognised both during the first response and on an on-going basis as a key priority in a large number of the documents reviewed. As the response continues, organisations also noted that staff resilience should continue to remain a key focus for NHS boards through response, recovery and remobilisation.

What has worked well in Scotland?

• Teams reported an overwhelming sense of camaraderie which was supported by a number of purpose-built resources. As an example, NHS Grampian introduced a Psychosocial Resilience Hub to support the National Wellbeing Hub. The Board's Director of Psychology has led a multi-disciplinary team to create a 'matrix' of resources available to staff for easy access.
• Many organisations clearly identified the requirement to prioritise psychological support for staff early in the on-set of Covid-19 pandemic. This was delivered through a range of dedicated support streams, working groups and wellbeing facilities. Organisations stated that they had reviewed the offer they had made available to staff during the pandemic to ensure that this was still relevant. Several organisations created new staff wellbeing groups to align with the ever-increasing demand for services.
• A national integrated digital wellbeing hub was developed for health and social care staff, carers, volunteers and their families to access relevant support. The hub is supported by a range of organisations and provides a range of self-care and wellbeing resources designed to aid resilience as the whole workforce responds to the impact of Covid-19.
• Digital mental health services were rolled out by Scottish Government for staff including internet-enabled CBT and psychological first aid. This built on considerable pilots already rolled out in Scotland for the public, for example in NHS Western Isles where a pilot saw a 500% increase in referrals to this service.

Opportunity for further resilience

• Despite numerous organisations highlighting that they felt services provided were sufficient for maintaining staff wellbeing, there were gaps identified in terms of access and range of available tools. Not all bodies had the use of all tools, with a key example being referenced by one organisation as not having, but wanting access to, Listening Services.
• Some organisations also recognised the fact that these resources must be considered as more than just a temporary measure. As the impacts of the pandemic continue to be felt, there is therefore a requirement to embed such services into ways of working going forward. The need for support is likely to increase over subsequent waves and some bodies noted that line managers required additional guidance on supporting staff remotely in rapid response events.
• In line with wider findings around the integration between health and Social Care, Scottish Government will need to ensure that, where new tools are rolled out or services provided, there continues to be equal access for all relevant stakeholder groups.

Key takeaways for leaders

• Recognise that wellbeing response to the pandemic will be needed in the long-term. Leaders must consider how to transition this into business as usual and continue to support the physical and psychological wellbeing of staff.
• Line managers continue to be a source of support to staff. Leaders should consider how to equip managers with the necessary training/resources on how to support staff remotely.

Governance and Risk Management

14. Governance and Leadership

What is the challenge?

The challenge, particularly in rapid response environments, is maintaining a level of governance whilst allowing scope for quick decision making. Organisations have drawn attention to the fact that this new way of adopting an agile governance approach could be cascaded into business-as-usual processes to reap the benefits of quicker decision making and increased collaboration.

Impact and Frequency

Many organisations took the opportunity to reflect on changes to existing governance and leadership mechanisms during their lessons identified exercises. As part of this, key comments reflected a desire to embed some aspects of what worked well rather than highlighting significant opportunities for improved resilience.

What has worked well in Scotland?

• There is a collective sense that 'command and control' provided strong leadership across organisations at a time where it was needed. Health and Social care Scotland reflected on this further by describing leadership to be compassionate within partnerships and providing the "backbone" for staff to feel confident about change.
• A key statement referenced by a large number of organisations was the 'authority to act'. Aligning closely with findings throughout this report on governance, organisations noted that leaders at all levels felt empowered to act.
• Several bodies noted that during the pandemic, a change to 'lighter' governance has improved the pace of decision-making. Health and Social Care Scotland highlighted that there has been an increased autonomy within the organisation and teams felt empowered to make change. The organisation also recognised that thresholds to sharing information across organisational boundaries had been lowered thus contributing to the pace of decision-making.
• Participants also reflected on the effectiveness of Covid-19 hubs that provide streamlined care. Health Improvement Scotland commented that the removal of red tape and bureaucracy enabled a rapid response and unprecedented collaboration. Interviewees also noted that Covid-19 had 'forced the agenda' of joined-up working in their local authority and challenged siloes.
• Based on the newly implemented governance at NHS Louisa Jordan, the team involved recommended that daily update meetings should be held in any future rapid response events to ensure all stakeholders are kept fully informed.

Opportunity for further resilience

• Opportunities for improved resilience around the new agile landscape has required a different approach from a management and leadership perspective, namely through the delivery of the leadership development programme. NHS Orkney have stressed that there is an enhanced requirement to equip management with the skills to have coaching and wellbeing conversations with staff during a period of increased self-isolation for some.
• There is also a concern around the recognition that the prevalence of 'command and control' culture setting has involved negative behaviours. The balance between command and control and inclusive, compassionate decision-making will remain crucial over the remaining response to the pandemic.
• The importance of balancing quick decision making with assessing impacts and scrutiny has been referenced by a number of organisations. Having a wider range of decision-makers present (covering operations and clinical teams for example) has been suggested as one way of both speeding up decisions and mitigating unintended consequences.
• Many organisations also noted that responding to the pandemic has required multiple changes to structure, partnerships and delivery groups for both themselves and their partners. As a result, there has been numerous rounds of iterations with multiple new strands of governance groups and committees. Organisations should be sure that any transitions back to previously used structures are appropriately justified and explained to staff members.

Key takeaways for leaders

• It is important for leaders to understand has there always been existing strong leadership skills and approaches within organisations prior to the Covid-19 response.
• Lessons identified around command and control highlights the ability of flexible governance structures that can prove pivotal in a rapid response environment.

Ensure there is enough representation to counteract unintended consequences of decisions could be considered going forward, for example increased clinical representation in operational decision-making.

Developing New Care Model

15. Service redesign

What is the challenge?

With a pressure for bodies to deliver Covid-19 and non-Covid-19 services, challenges arise around the finite availability of resource. In response to that pressure, we are seeing from the literature review that organisations are utilising innovative solutions to better make use of existing capacity. However, it is important to be aware of the environment in which innovation can be fully harnessed, and that this is aligned with pressures experienced.

Impact and Frequency

Many organisations referenced new pathways or innovative approaches to treating patients as part of their lessons identified from the first wave response. Reflecting on these new approaches will form a fundamental part of recovery and remobilisation plans and identifying lessons and good practice from across Scotland will be crucial over the coming months.

What has worked well in Scotland?

• Multiple organisations referenced the national 24/7 pathway with patients being directed through the 111 service as a key area of success. This provided consistent triage for all organisations by NHS 24 and allowed a seamless pathway to local hubs for further clinical consultation and consistent onward referral for self-management and to other services in the community or Acute setting as required.
• Health and social care organisations also noted that even though they were now commonplace, discharge hubs offered added value during the first few months of the pandemic to support planning for discharge from the point of admission. This was highlighted as being crucial when patients were directed to the hubs early on in their care journey.
• Practitioners have drawn attention to redesign around making better use of resources and patient time, with greater clarity in triaging patients. Navigation was preferred rather than redirection, taking a more patient-centred approach and drawing from the patient's own resources for self-care.
• NHS Ayrshire and Arran felt that the work being done through the new urgent care pathway (to provide the right care at the right place to maintain the lower level of A&E presentations found during the pandemic) as a pilot scheme is working well.

Opportunity for further resilience

• Organisations regularly referenced staff only being able to work jointly across Covid-19 and 'standard' pathways due to the pause on most core activity. This leads to an anticipated tension caused within the system while the Covid-19 and non-Covid-19 clinical work both need to be offered from within the same clinical capacity.
• One organisation has also reported that although the turn towards telephone conversations has reduced pressure for face-to-face contact, conversations have taken longer, therefore reducing overall capacity. Concerns regarding the suspension of non-essential services were also raised, recognising that despite the fact face-to-face had to be reduced, there are elements of patient care that cannot be delivered virtually. Note we have not vouched for the accuracy of this statement but recognise one organisation has suggested this may be the case.
• The new urgent care pathway in Ayrshire and Arran has not been supported by a wide-spread patient marketing programme as this risks misleading non-Ayrshire patients. When the pilot extends to the rest of the country, a wider community awareness campaign will support uptake and encourage patients to interact with the system in the desired way.

Key takeaways for leaders

• Service redesign requires statutory consultation with the public and patients, and any organisations looking to embed changes from the Covid-19 response will need to ensure this is managed appropriately.
• Consistent themes across new models of care should be identified and kept in mind as services continue to transform. Regional hubs, targeted patient navigation and the use of digital will remain central to service provision going forward.