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

5. Follow Up Phase

This section of the report provides a more detailed consideration of three of the chapters included in the previous section. As outlined in the executive summary, these chapters were selected for further work by Health and Social Care Management Board. In each of the chapters below, lead directors and identified stakeholders have shaped the content and approach to the review. The content for these chapters was collated over April and May 2021, still with a focus on the first six months of the pandemic, and should be considered as complementary to, not in place of, the relevant chapters in Section 4.

1. Public Health

Introduction

This chapter focuses on the first six months of the Covid-19 pandemic response from a Public Health perspective. To inform the content of this chapter, key stakeholders across Public Health Scotland and Scottish Government, as well as Directors of Public Health from territorial boards, have been consulted on their reflections on what went well and where areas for increased resilience might be. This chapter summarises conversations held with these stakeholders and distills and identifies key findings from this engagement and further reviews of documentation. The findings below have been shaped predominantly through engagement with stakeholders outside Scottish Government to provide an external view on Government's response, although stakeholders from within Government have been included in all consultations to provide context and input where appropriate.

What is the challenge?

Public Health teams have taken on a pivotal role in tackling the Covid-19 pandemic by helping areas to understand and address the economic, social and psychological impacts of the pandemic and the health inequalities that have been highlighted and deepened. Across all four of the Harms identified by Scottish Government (being direct health impacts, indirect health impacts, societal impacts and economic impacts), there is a central role for Public Health teams at national and local levels to drive the country's on-going response to, and recovery from, the pandemic. The impacts of Covid-19 will therefore need to be continually assessed, including strengthening of mitigations and contingencies through this lessons identified exercise and identification of any further work that may be needed to reinforce Scotland's response to the pandemic.

What has worked well in Scottish Organisations so far?

Key themes:

Finding A: Collaborative working across organisations

Collaborative working across organisations has been highlighted consistently by the public health stakeholders we spoke to as as a crucial enabler during the first six months of the pandemic response. Key examples referenced by stakeholders included:

1. The National Incident Management Team: The rapid stand up of a National Incident Management team provided a useful forum for local feedback and intelligence when it came to suppressing the virus. This team provided a forum for shared learning and future foresight as a collective group. To further drive collaborative working, the group made the challenges faced by individual territorial boards more widely visible both to other boards as well as colleagues in government. A key reflection from our conversations with both Scottish Directors of Public Health (SDPH) and Public Health Scotland colleagues was around the evolving structure of this team over the course of the pandemic and that on reflection, stronger connections with DPHs and SG should have been encouraged from earlier on in the pandemic.

2. Joint daily huddles: The creation of joint daily huddles between Covid-19 Public Health Directorate Senior Management Team and Scottish Directors of Public Health was referred to as a valuable asset as a source of cross-functional working which provided not only rapid information sharing and helpful insight into political decision making but also genuine emotional support for individuals. The joint huddles acted as an access point where other Scottish Government Directorates could go to for advice and support of the SDPHs, as well as a means for further input to be provided by relevant Public Health colleagues as necessary. Joint daily huddles have proven to be extremely valuable and it has been suggested that they should be re-introduced at emerging stages of future global health threats and into business as usual.

3. The use of Local Resilience Partnerships: Colleagues discussed examples where these structures worked particularly well, as such in the Dumfries and Galloway area where the Local Resilience Partnership brought together local partners to exchange data, share best practice and coordinate the local response. Through this group, communications were coordinated and agreed in advance between Local Authorities, Police Scotland, Fire and Rescue and the territorial board to ensure a joined-up response. The Partnership also supported local universities and businesses through the deployment of local Environmental Health and Resilience Officers to support testing and provide guidance. In contrast, in areas such as the Highlands and islands, this approach was not so successful, however a workshop was held to help identify and mitigate some of the issues faced in these areas during the pandemic.

Two other wider messages were captured under this theme. The first of these was the importance of the integration of Public Health professionals into many elements of the pandemic response. A key example cited was the role of Public Health professionals being integral to the pandemic response in care homes through the close working of the SDPH group with the Care Inspectorate and within NHS. This went beyond traditional roles and responsibilities in this area and should be considered as the sector moves towards the 'new normal'. Ensuring that Public Health professionals are in the right decision-making conversations will continue to draw on their relevant experience and expertise in any future incidents or pandemics, as well as other expert advice sources. Public Health experts bring viewpoints and expertise not readily available in other teams, and involving them in early conversations and steering groups mitigates the risk of unintended consequences as well as inefficient decision-making.

The final point highlighted under the theme of collaborative working was strong engagement with the Chief Medical Officer. We heard of significant engagement from the interim CMO and deputies with SDPH through many of the above case studies such as the joint daily huddles and National IMT. This was extremely valuable and provided opportunity for the SDPH group to influence and understand the developing response to the pandemic.

Finding B: Test and Protect

The design and deployment of Test and Protect was also cited as a key theme and a case study in itself by stakeholders. Within Scotland, a comprehensive network of testing sites was rapidly established, which now includes eight Regional Testing Sites, 45 Local Testing Sites, and a fleet of over 40 Mobile Testing Units on rolling deployment. This network is now supporting the roll-out of asymptomatic testing and more targeted community testing to finding cases in identified higher prevalence areas and support targeted local interventions. Public Health teams felt that the work around Test and Protect exemplified what worked well for the Public Health response.

In particular, stakeholders reflected on SDPH and Public Health Consultants and Specialists making a huge contribution in taking on key roles in advising on response to the pandemic including co-development of Test and Protect as a local/ national partnership. This was a clear example of how to benefit from collaborative relationships between teams at local and national level. Specific reference was given to the role of local outbreak control teams as well as local resilience partnerships, who have been able to quickly respond to identified local issues with much more flexibility and pace that might have been possible through a solely national response.

To highlight the importance of local knowledge and insights, stakeholders fed back that the UK Government-wide testing model was challenging at times in contrast to what was being done locally in Scotland. Local Public Health teams reported struggling to navigate a system that they felt was not amendable to adjustment when system failures were clearly evident, e.g. allocation of nearest testing location, national switch off and divergence of testing capacity with little or no warning. This further supports the benefits of the approach taken by teams in Scotland to balance the best of local and national responses.

Finding C: Collective mobilisation

Collective mobilisation was also referenced throughout discussions, making a clear distinction between collective working across organisations and the mobilisation effort within Public Health teams as they currently existed to work in innovative and reactive ways.

1. The first finding was the importance of appropriate deployment of staff within Public Health Directorates both across Scottish Government and more widely across NHS Boards.As a result of the enormity of the Covid-19 response, practical decisions were made to free-up resource to sustain the response, including the deployment of staff within Public Health directorates who did not have primary health protection roles including health improvement, research and evaluation staff, and specialists from other Public Health fields (dental Public Health, pharmaceutical Public Health and administrative staff) to name a few.

2. Secondly, the unprecedented and rapid mobilisation of staff was crucial to what worked well from the response and has resulted in the formation of a large system wide approach to tackling Public Health. This approach has been primarily driven forward through emergency planning structures to mobilise staff across the NHS, Health and social partnerships, Local authority, Police, Fire Service, Scottish Ambulance service and the third sector. This has led to the development of strong collaborative relationships at local level meaning that in the event of future pandemics the relational foundations to plan, prevent and respond are already in place.

3. Another key finding related to the collaboration between Local and National Public Health. The Covid-19 pandemic has emphasised the importance of a strong working relationship between local Public Health teams and national Public Health organisations. Public Health Scotland was cited as being critical to many areas, in particular the role of Health Protection Scotland (now Public Health Scotland) in supporting the pandemic response in local boards. This included publication of guidance to support local teams, advice and support on complex situations and attendance at incident management teams which has enabled shared learning. One specific example of local and national collaboration was the co-design and co-delivery of the Scottish Test and Protect Response, which has enabled Scotland to utilise both the benefits of a local response and translate into practice leveraging national co-ordination, surge capacity and supporting infrastructure as referenced above. Stakeholders here noticed a key point of comparison to the English response to the pandemic through the previous abolishment of regional Public Health teams and observatories, which was felt to impact the English response to the pandemic by losing the local knowledge that local teams within Scottish Boards have been able to draw upon throughout the pandemic.

4. Colleagues referenced that the Preparing Scotland for Emergency prepardeness guidance set out a clear process for responding to emergencies, with the central role of SGORR and the creation of a Strategic Coordinating Group, as well as Scientific and Technical Advisory Structures to provide clarity of advice to that group.

5. The final element was the clear commitment of staff. Overwhelming willingness, flexibility, and commitment within Public Health teams to design and deliver the response around the clock. Within the SDPH group, position statements were produced to inform key policy areas of the pandemic response, providing weekend cover and informal support for one another. A workbook approach was established which has been further built on and developed, enabled by ScotPHN team. This overall commitment does however raise potential concerns around the sustainability of this response.

Finding D: How data was used to inform the Public Health response

The final theme that came through strongly in our consultations on the Public Health response was how data was used to inform the Public Health response, particularly to drive decision-making and provide an evidence base for specific interventions. Three key examples were cited to show how data was used, which we have outlined in more detail below:

1. Directors of Public Health referenced the importance of the National Data Intelligence Network as a lasting legacy of the pandemic response. This draws on expertise across local authorities, public health and health boards to try build capability in using real-time data to inform decision-making and policy decisions. Interviewees also referenced the importance placed by the network on ethical concerns about the use of data as being central to its on-going work.

2. Patient data was used to measure impacts of Public Health interventions including EAVE-II study which through data linkage of general practice, hospital, testing, prescribing, and death data allowed demographic description of cases and ultimately real life effectiveness of vaccination on hospitalisation, deaths and transmission. The emphasis on impact measurement of Public Health interventions provides an objective basis upon which future interventions can be measured as Scottish Government reflects on potential easing of restrictions and responses to any future incidents.

3. Another example of a data-led approach to Public Health interventions was through the use of Whole Genomic Sequencing (WGS). The Thomson paper has been cited as a key example here, but also evidence through WGS to show the impact of events such as the Nike conference in the lead-up to the pandemic. While colleagues specifically within PHS highlighted how crucial this approach was for the on-going response, limitations were identified around sequencing capacity and scalability. This was reported to have led to significant challenges in the interpretation of the impact of novel strains and the role of domestic cases versus international travel during the first wave of the pandemic.

4. The final example referenced within the use of data through the Public Health response was the effective use of publicly accessible dashboards which allowed descriptions by LA, NHS board and All Scotland for tests, cases and hospitalisations.

Opportunities for further resilience in Scotland from the Public Health Perspective:

As with the reflections on what went well above, the engagement exercises held with Public Health teams (predominantly Directors of Public Health and Public Health Scotland, but also within Scottish Government) identified opportunities for further resilience. These examples have been grouped by high level themes, which have been agreed with stakeholders as part of these engagmeent sessions. Key examples have been included within each section to highlight specific areas for future reflection.

Finding A: Pandemic Preparedness

Pandemic Preparedness has been highlighted as a key area of interest to keep under review for future incidents. Specific examples of what might be done differently have been outlined below based on our engagement with identified stakeholders:

1. Levels of resource availability across Public Health in Scotland prior to March 2020 impacted both the initial and on-going response to the pandemic by requiring significant staff overtime. In addition, plans were submitted to enhance the Public Health workforce in June 2020 and the funding letter was not received until November 2020. This caused delays in decision making which created additional pressures on the existing workforce. There needs to be reflection on how Public Health is prioritised as part of a 'whole system' approach going forward. Future workforce planning for Health Protection and Public Health needs to be urgently actioned to allow recovery as if left unaddressed this may threaten the aims and objectives of the evolution/development of public health work in Scotland.

2. Whilst threats such as pandemic influenza and emerging infectious diseases were identified as major resilience threats to the United Kingdom, there was a perceived lack of preparedness from a Public Health perspective, particularly in terms of PPE provision. During our discussions with stakeholders, there were concerns raised regarding the absence of pragmatic checks such as checking if PPE was in date and confirming workforce staff levels It is important to note that there was a national stockpile of PPE in place however demand for this was unprecedented, something which could not have been anticipated in previous planning exercises or expert guidance. We note also here that some stakeholders reported that shelf-life monitoring and shelf-life extension through re-testing were planned activities for existing stockpiles.

3. Neither Health Protection Scotland nor Public Health Scotland had formal Category 1 responder status which should be addressed in the future to recognise their key role in responding to emergencies/Public Health incidents of concerns. Stakeholders have noted that individual public health teams are hosted by NHS Boards which are category 1 responders, which ensures there is local public health input into incident response. This status has not been extended to Public Health Scotland however, although stakeholders noted that a review of roles and responsibilities for category 1 responders could determine the need for this going forward.

Finding B: Challenges faced when communicating

A second key area for increased resilience related to challenges faced when communicating within and outside Scottish Government and Public Health organisations.

The first of these related to the timing of communication. Colleagues felt that there were occasions when Scottish Government guidance was issued which either contradicted or did not align with Health Protection Scotland guidance, and that this caused significant stress and confusion to local teams on the ground. This was exacerbated when several aspects of guidance were felt to be 'piecemeal' in collections of letters, often sent out late in the evening or over the weekend with immediate implementation required. The risk that much of this got lost was significant given the workload already facing local teams. There is a recognition from colleagues that there are other demands that led to the publication of guidance at these times, but further, early engagement across organisations could mitigate this

Secondly, colleagues referenced a perceived duplication of efforts internally within Scottish Government. For those working outside Scottish Government, there was a sense of multiple SG teams working on the same topic with little internal communication, leading to multiple similar demands being made to boards which were perceived to be of little added value. Subsequent engagement with Scottish Government highlighted that structures may have been later clarified and communicated, and therefore a key learning from this first phase of the response will be to formalise and more widely communicate this structure to reduce any further duplication.

Stakeholders referenced a lack of alignment between organisations involved in the pandemic response when issuing communications. Specific findings that were felt to evidence this lack of alignment include:

1. SDPH and both local and national Health Protection teams were reported on occassions to not be aware of policy announcements before they happened which led to teams both nationally in Health Protection Scotland and in local boards being on the back foot. However, SG colleagues highlighted the challenges with pace of decision-making and role of government to respond to the unique circumstances of the pandemic.

2. Stakeholders felt that a lack of opportunity to be engaged or work through challenges in conjunction with partners risked unintended consequences or implementation challenges where public health insight was not provided at an early stage.

3. It was reflected by colleagues that SDPH felt they were generally not encouraged to support the national communication effort, giving rise to the view that Scottish Government wished to control communications. This has been viewed as a missed opportunity to allow the voices of trusted local leaders to support the effort. Stakeholders however did recognise that there are benefits to having a single, clear national voice, and that this could be supported by trusted local leaders within their local areas.

4. Stakeholders noted one result of the perceived lack of alignement and delay in commuications was felt to be a delay to confirmed funding for public health teams on Test and Protect. Teams reported that this delay led to significant pressure on the existing workforce and a prolonged period of catch up to train and recruit new staff.

The final element of communications reflected on throughout our engagement has been commentary on the perceived tone of communications issued during the pandemic. During our conversations with colleagues, it was raised that whilst unintentional, the tone of communications and conversations with local teams was at times overly directive and was too heavily influenced by a command and control approach to communications. Stakeholders recognised that this is a delicate balance given the clear need for direct, national communications during incident responses. This resulted in expressions of gratitude and appreciation given at other times being felt as insincere.

Finding C: Centralisation of decision-making and levels of governance

Another key finding raised throughout this engagement with Public Health colleagues, which echoed findings from the first phase of work, was around the risks associated with the centralisation of decision-making and levels of governance. Specific examples within this that were highlighted to us during this work included:

1. Levels of document sign-off for new guidance was seen to impact the pace of delivery and dissemination. The obligation of a requirement for guidance document sign off by Scottish Government, although critical, often led to clinical risk as this was a slow process. Regardless of agreed streamlining of requirements, this process has continued be challenging for the delivery of updates and issue of new guidance for the NHS. We note here that the role of SG is clearly defined in response to major incidents, particularly with reference to the 2017 incident guidance, but it is important that this is considered against the pace at which changes can be made.

2. Siloed ways of working: There were a number of programme boards created at national levels. This was felt to lead to overlap and also inadvertently promote 'siloed ways of working' across key themes (i.e. separation of test and protect and self-isolation support). This then was reported to give rise to slow decision making and lack of clear communication for those areas by virtue of a perceived over-centralisation of governance away from local organisations. In addition, the SG Covid-19 Advisory Group was reported to have not included representation from those working at the Territorial Board front line of the Public Health response. This was seen by colleagues as a crucial perspective that was missing from this important advisory group, although it is accepted that the group was established to consider scientific, and not operational, factors.

3. In addition to this siloed working, colleagues also felt that there were attempts to over-centralise decision making and delivery models without consultation with local SDPHs. It will continue to be important in the future to recognise the crucial insights that SDPHs can bring from their local geography and population needs, with examples cited as vaccination in Island Boards and imposition of Service Now when local delivery models were working well. As with sign-off and communications points previously raised however, it is importance to recognise that Scottish Government is mandated by incident management guidance to make key decisions here which limits the extent to which significant consultation could be undertaken.

4. This reported over-centralisation and lack of formal engagement with Public Health led to a feeling that roles and responsibilities could have been allocated to Public Health directors, recognising they could offer a valuable perspective across the range of the 4 Covid-19 harms. A key example cited here was the fact DPH advice was channeled into Harm 1 (direct health impacts), meaning that input into other areas of harm such as inequalities and determinants of health were not sought.

Finding D: Consistency of systems across organisations

The final area for potential increased resilience highlighted was the consistency of systems across organisations. This is in line with some of the findings from the first phase of work where consistency of digital support across different teams has been highlighted as a challenge, and Public Health colleagues were able to provide additional examples of this below:

1. Stakeholders highlighted that the lack of a common incident management system impacted the effectiveness of the early pandemic response. Stakeholders noted that while NHS Boards had used one system prior to the pandemic (HP Zone), Public Health Scotland only had a 'summary view' to this system due to restricted control by the thrid party provider. This limited the extent to which national management and analysis could be carried out and NHS Boards were not in control of access to important data due to this external licencing arrangement. Future prepardness would be supported by ensuring that commissioning arrangements for IT projects include appropriate governance arrangements to ensure NHS Boards have unrestricted access to clinical data held on their populations which could be accessed as and when required especially in an emergency situation.

2. Standardisation and use of a single technology system across public sector teams to facilitate home working was seen through the implementation of MS Teams, this has been viewed by colleagues as a real strength that has been accelerated as a result of the pandemic. There was an important point around improvements needed in broadband width across Scotland and for colleagues working in Scottish Government to allow use of cameras on Teams as connecting with faces would help to build relationships and trust with individuals meeting for the first time in highly stressful circumstances.

Key Takeaways:

• Workforce planning: A key element of any future pandemic response is felt to be a well-resourced Public Health system with the right level of skills and expertise nationally and locally. This would include the ability to have a robust contact tracing service at both local and national level, an area which was highlighted that had not been addressed following previous pandemic exercises in the recent Audit Scotland report. In addition, a workforce plan for Public Health is felt to be urgently needed. Health Protection Scotland felt under-resourced to mount a sustained response to the pandemic even with suspension of as much business as usual and temporary deployment of staff from within NSS and secondment from Universities and limited NHS board secondment. As the pandemic response continues and future incidents are reviewed, an understanding of current gaps, and a pipeline for how to mitigate these gaps should improve pandemic preparedness.
• Agile ways of working: Public Health is a complex and adaptive system, relying very heavily on local relationships built up over time. The importance of this cannot be overestimated and whilst unwarranted variation is not helpful, the ability to adapt to local situations and circumstances is vital. There must therefore be a recognition that Scotland-wide approaches can be helpful but not for everything. Development of better systems to collect feedback from and engaging with sectors and communities in relation to impact of restrictions applied is something that warrants further consideration.
• Value of Public Health: The response to the pandemic reaffirms the critical importance of Public Health expertise both locally and nationally and the need to use a system wide approach to address not only future pandemics, but to improve the key determinates of health that fuel inequality, long term health conditions and premature death. Local and national systems are energised by way they have managed to respond to the pandemic and bring this learning to other areas which threaten population health.
• Future preparedness: Whole systems approaches are required to tackle both this pandemic and any future incidents. Public Health Scotland has already begun several pilots looking at the Public Health Priority areas using a whole systems approach. There will be an opportunity to refresh these pilots considering the Covid-19 learning rather than directly picking these back up where they left off. It is critical that SDPH and local Public Health teams work together with PHS and key partners to co-create and design these whole systems approaches, just as they have done for the Covid-19 pandemic. Further evaluation and development of a unified incident management system for PHS will be important in the short and medium term. In addition, regular modelling of plans for managing of novel viruses with learning should be implemented with all aspects of the system involved to plan for future major incidents.
• Governance for a future pandemic response: Governance for a future pandemic response must be considered and reviewed considering the lessons identified from this wave of the pandemic. This could include implementation of a National Incident Management Team with strong connection to local DPHs and SG much earlier in the face of a pandemic. Government, PHS and Local DPHs, and Health Protection colleagues must have involvement in this with clear decision making and communication channels established and communicated to national and local Public Health systems, with a forewarning approach were possible to allow for implementation to happen efficiently.

2. Acute response

1. Introduction

This chapter specifically focuses on the first six months of the Covid-19 pandemic from an Acute response. Findings have been informed by engagement with key representatives from NHS Scotland and Scottish Government including the Chief Executive, DPAD Senior Team members, Deputy Chief Medical Officer, Chief Pharmaceutical Officer, Chief Nursing Officer, Head of Scheduled Care and leads from Territorial and Special Health Boards. In holding one-to-one interviews, group sessions and reviewing provided documentation, this chapter seeks to gather reflections on lessons identified with the view to facilitate planning for future waves or incidents, as well as broader recovery.

The scope of this chapter has been agreed with these key stakeholders as providing an illustrative answer to the three questions below. This is not seeking to be a definitive answer given the methodology taken and the time constraints facing those consulted during the process.

1. How was the NHS Acute sector set up to respond to the initial wave?

2. How well were services stood back up through the remobilisation of the NHS?

3. How well were services adapted/changed due to the challenges and opportunities of Covid-19?

In this chapter we frame the examples of what worked well and what the opportunities for increased resilience might be around these three questions.

What is the challenge?

The Covid-19 pandemic has highlighted the need to address NHS Scotland capacity and resilience and emphasised the need to change the way things are done within the system. Existing challenges faced around productivity, workforce and integration have been exacerbated by the pandemic, with concerns about the potential long-term impact on staff wellbeing and the challenge of continuing to operate Covid-19 services whilst restarting routine services. It will be important that the learning and perspectives of key stakeholders are reflected upon as both Scottish Government and NHS Scotland move into the next phase of the response to Covid-19.

What has worked well in Scottish Organisations so far

Question 1) How was the NHS Acute sector set up to respond to the initial wave

A significant amount of feedback focused on this first question. We have grouped these into four key themes below, with specific examples and further narrative included within each of those themes to outline what was done and why this worked well.

Finding A: A rapid reconfiguration of Acute provision

1. The role of National Services Scotland (NSS) in distributing PPE: The central co-ordination by NSS was found to be vital in supplying the health and Social Care sector with PPE throughout the pandemic. Such was the effectiveness of this that the NSS' remit was extended to include distributing PPE directly to General Medical Services, such as GP surgeries and community pharmacies, and Social Care settings, including private providers. From April 2020, NSS established 48 regional hubs, where PPE was stored and distributed to Social Care providers and unpaid carers. Between March 2020 and January 2021, NSS had distributed more than 800 million items of PPE to health and Social Care services throughout Scotland. This central management of PPE was felt to achieve significant efficiencies with regards to the distribution approach and should be highlighted as a clear example of what worked well for the Acute response. As noted in a recent Audit Scotland report on PPE, there has been an increase in the volume of PPE being created within Scotland as the pandemic has continued, mitigating the risks of relying on global supply chains while also creating jobs in Scotland.

2. The repurposing of medical equipment: In the early stages of the pandemic, prior to March 2020, data modelling was carried out suggesting a significant shortage of ventilators, with capacity forecast to exceed in the short-term. During interviews, all stakeholders commended the huge efforts from teams, particularly those in medical physics, who worked around the clock to repurpose hundreds of medical theatre machines to turn them into ventilators whilst elective procedures were at a standstill. This bridged the gap until the first ventilators arrived and mitigated the risks involved in sourcing from a global supply chain during a pandemic.

3. Maintaining performance for cancer services: Cancer service performance was maintained throughout the pandemic, with many boards continuing to meet the 31 day cancer decision to treat to treatment standard. Performance against with 62 day cancer referral to treatment standard remained steady despite many diagnostic services such as endoscopy being paused for all but essential procedures. This was due to NHS boards continuing to prioritise urgent and cancer services while scaling back elective activity. This was supported by the new clinical prioritisation guidance and the Framework for Cancer Surgery published in July 2020 and use of independent hospitals to treat urgent NHS patients. There was an initial reduction in referrals with a suspicion of cancer from Primary Care and the daily Covid-19 press briefings were pivotal in responding to this where the Scottish Government's Interim Chief Medical Officer and National Clinical Director were able to remind the general public that the NHS remained open for anyone experiencing urgent symptoms including those suspicious of cancer. Referrals for suspicion of cancer returned to pre-Covid levels in August 2020.

4. Creation of surge capacity: Resilience of the system to respond through reorganisation of local services was achieved through re-provisioning of Acute beds (approximately 3,000) and quadrupling the base number of adult ICU beds (from 173 to 585), within a short period of time. This acted as an important safety net for Covid-19 related hospital admissions. There is a need for boards to continue contingency planning, including the ability to scale ICU capacity, as required recognising that, this may be affected by other pressures in the future, such as increasing emergency department attendances, staff absences and enhanced infection control requirements.

5. Stand up of NHS Louisa Jordan: The NHS Louisa Jordan, was set up in under three weeks and was operational by 20 April, with an initial capacity of 300 beds, and the ability to expand to 1,036 beds if needed – including 90 intensive care unit (ICU) beds. In the early days of the pandemic it was used for outpatient appointments and for diagnostic services such as X-ray and ultrasound. During the early chapters of this report, colleagues reflected on the success of the multi-disciplinary effort to stand up the NHS Louisa Jordan during the height of the first response.

6. Clinical prioritisation: As planned care resumed the Scottish Government sought to support NHS Boards to prioritise those patients who require to be seen and treated most urgently. This would ensure that the build-up of patients waiting for elective care was tackled on a priority basis wherever possible. To do this the Scottish Government put in train plans to develop guidance to support NHS Boards to assess how a process of 'scoring' patients based on their clinical priority could be developed but which would also allow for flexibility to reflect local circumstances. This work started during the period covered by the report although was brought to a conclusion in October/November 2020 with the publication of the Framework for the Clinical Prioritisation of Elective Care.

Finding B: Flexible supply of, and support for, the Acute workforce within and across organisations

1. The re-registration of retired healthcare professionals: Discussions with representatives from different healthcare professions highlighted that there was variable success in bringing staff back onto relevant registers. In terms of nursing staff, an accelerated recruitment portal with the NMC register was open to anyone who had recently retired, and good work was completed in co-ordinating individuals through the pre-employment checks, with over 16,000 expressions of interest. A key lesson which has come from this is around not being able to place these staff, there is a need to have a much closer relationship with boards in terms of the recruitment process.

2. The flexibility and use of local 'mutual aid': We found evidence of early discussions around mutual aid through directors' letters released in the early stages of the pandemic. The volume of staff that was used in the short-term and for Community Treatment and Care Services to ensure separation between those who might be Covid-19 positive took up a huge amount of resource. With the pauses implemented on identified elective procedures, interviewees referenced how local teams worked collaboratively to supply staff, resources or physical space for any urgent requirements without ever meeting the full requirements of mutual aid. Performance leads were reported to have worked well together to identify escalating areas of concern within local areas, with subsequent redeployment of staff or equipment to mitigate this being implemented prior to resorting to formal mutual aid.

3. The step change in staff wellbeing support: Another area which was highlighted during our interviews, from a nursing perspective, was the work that the Mental Health team in Scottish Government did on wellbeing for staff. Examples of this included the National Wellbeing Hub, and a mental wellbeing support line available 24/7 through NHS 24. It was noted that this took some time to set up but has helped to keep staff at work by supporting staff and taking their concerns seriously and was felt to have contributed to staff sickness rates being lower than anticipated. This was also highlighted within individual boards, with the move away from a 'traditional' health and wellbeing offer that focused on health improvement became more focused on wellness was cited as being a key positive to retain beyond the pandemic response. As an example, NHS Ayrshire and Arran implemented a revised offer that focussed on wellness networks, psychological support and safety, and the opportunities for reflective practice and compassionate leadership and will look to continue this following positive feedback during the pandemic response.

Finding C: A shift to manage demand for non-urgent services away from acute sites

1. Collaborative/ integrated working to support Acute providers. There was a requirement set out in May 2020, for close working between local (Local authorities and Integration Joint Boards) and national level (National health boards) to ensure a whole system response, to ensure that local people were seen and treated in the right place, by the right person at the right time. With regards to cancer services, there was a strong message from colleagues around collaborative working between Scottish Government cancer teams, engagement with cancer management teams in boards, gaining access and support from ministers and the further benefit of remote working with improved IT infrastructure which enabled capacity for meetings and communications. Whole system working was encouraged throughout and the Winter Planning and Response Group (WRPG) included health and Social Care colleagues in trying to cement relationships which previously had barriers. There was a reflection that perhaps the key takeaway from the pandemic to date was the importance of quickly establishing teams with sufficient breadth of knowledge and experience to react speedily and constructively to challenge.

2. The role of community pharmacy: The arrival of the pandemic had an immediate impact on the community pharmacy network across Scotland, as it remained the only Primary Care NHS service to remain fully accessible to patients and members of the public, while providing an almost full range of pharmaceutical care services. The volume of prescribed and dispensed items increased by more than 50% over the last two weeks of March 2020 with workloads remaining increased into May 2020. A notable initiative to ease bottlenecks in the community was the rapid roll out and access to the Emergency Care Summary system to community pharmacists, providing access to medication and adverse reaction information and therefore will have reduced the number of telephone calls to general practices seeking information. In addition, July 2020 saw the launch of the national 'Pharmacy First' service to enable patients to access a wide range of enhanced minor ailment support provided by community pharmacists, this initiative encouraged GP practices and wider multidisciplinary teams to work together with community pharmacy in their cluster to support and enable shared learning and approaches to local pathways which best meet the needs of their local populations.

3. Medication supply for care homes. From a pharmacy perspective, there was an important balance between being prepared for a Covid-19 outbreak in a care home and protecting the medicines supply chain to ensure fair access to palliative care medicines for everyone in Scotland. Key examples of how the set-up of the sector was managed well included:

• Close communication with national procurement was essential to help protect the medicine supply chain across primary and secondary care, especially as two of the essential palliative care medicines are also used in ITU.
• Care homes were not legally able to stock ward medicines therefore, the details of how the 'pandemic exemption' could help support timely and appropriate access to palliative care medicines was explored by a short life working group, with specialist advice from the Scottish Palliative Care Pharmacists.
• In addition to the above work, the short life working group developed a piece of work on how to safely repurpose medicines and the Scottish Government Coronavirus palliative care toolkit which described different approaches that Health Boards could adopt, to support timely access to medicines during the pandemic. For example, information about care homes stocking ward medicines specifically for the symptoms of Covid-19.

Finding D: Rapid establishment of oversight and governance structures

1. Establishment of a network of Covid-19 directorate hubs: The Scottish Government established a network of Covid-19 directorate hubs, with a workforce of staff redeployed from other departments across the government while wider Government business transitioned to focusing on pandemic response, which was coordinated through covid hubs. There was good oversight and regular communication across the NHS and Integration Authorities (IAs) from the Scottish Government for the acute response. In addition, NHS boards revised their governance arrangements during the pandemic with some reducing in size or suspended subcommittees, while maintaining close contact with the Scottish Government and their local partners.

2. Communication: Stakeholders noted that information systems, in the form of daily assessment of Sitreps from Boards were established to react to the pressures of the pandemic, giving as much detail as an hour by hour overview, with three times a day reporting to ministers. Those consulted also noted that engagement in terms of mobilisation planning was good, it allowed for the setting of expectations and discussions around blockers which acted as a very important forum for boards.

Question 2: How well we stood services back up through remobilisation of the NHS?

Finding A: Remobilise, Recover and Redesign

Stakeholders referenced the value of creating a strategic framwework through the Remobilise, Recover and Redesign (3Rs) document as issued in May 2020, as well as the different ways in which bed capacity was increased for remobilisation despite the constraints of Covid-19 protocols.

1. Remobilised/phased return: In May 2020, the Re-mobilise, Recover and Re-design document was published which recognised the importance of building upon the positive changes introduced to date during the pandemic, particularly around the use of digital technology to enable more people to have more of their care at home or in the community and to imbed integrated approaches to delivering health and Social Care support. This document created a good governance structure and set out the assumptions, principles and objectives of safe and effective mobilisation. The framework was clear about rebuilding the NHS differently, with key ambitions described including: developing new priorities for the NHS based on engagement with staff and the public, achieving greater integration, recognising the interdependencies between health and Social Care services, providing more care closer to home, minimising unnecessary travel and reducing inequality and improving health and wellbeing outcomes.

2. The reconfiguration of primary and community care. The set-upof these hubs and assessment centres played a key role in protecting the Acute sector during the pandemic by supporting the whole system through triage of Covid-19 cases away from general practice and A&E where clinically appropriate. From March 2020 up to January 2021, over 250,000 consultations for advice or assessment were conducted through these hubs and centres. There was a letter issued in June 2020 asking for continued support with flexibility and capacity within the workforce to staff these hubs and assessment centres. Staff worked together across Acute and primary care, in partnership with NHS 24 and the Scottish ambulance service, to protect communities and reduce the rate of infection, through early identification, testing, triage and treatment of patients showing Covid-19 symptoms, presenting to the hubs and assessment centres.

Finding B: Management of bed capacity

Stakeholders discussed the flexible use of bed capacity across Scotland to enable increased recovery of elective services. Specific examples of this included:

1. The use of local 'mutual aid' across Boards and the ability to switch resources across Health Boards e.g. Lanarkshire being supported by Forth Valley. Stakeholders reported that while there were national conversations around mutual aid, local monitoring arrangements, particularly within performance teams, were effective at pre-empting potential issues and working flexible to resolve problems locally, rather than resorting to formal mutual aid arrangements.

2. The use of NHS Golden Jubilee for urgent electives and cancers, diversion of emergency admissions to neighbouring hospitals, for specialist services use of facilities in other national tertiary units. Examples cited by stakeholders for the considerable impact of NHS Golden Jubilee include the fact twenty heart transplants took place under COVID-19 restrictions, against a 'normal' annual case load of around 14; the ophthalmology unit was opened and productivity was maximized to a point previously not anticipated until 2034 in previous plans; two theatres have been opened years before they were anticipated to be; and overall productivity is reported as being at 110% of pre-COVID levels.

3. The pivot and re-focusing of the aims of NHS Louisa Jordan, offering training and other opportunities for diagnostic work. This included over 31,000 outpatient appointments and diagnostic tests including CT and ultrasound, being undertaken at the hospital; 6,930 staff had training and education sessions at the site; as well as supporting the vaccination programme by storing the required equipment in fridges and freezers, 175,000 vaccinations were delivered to NHS staff and the general public; 541 people attended at Blood Donor sessions. We note here that while the beds were not required for their original intended use, stakeholders noted potential concerns about staffing availability for the high acuity, COVID-19 clinical model first anticipated for the LJ. The refocus towards outpatient, diagnostics and other work mitigated these risks by drawing on readily available staff and equipment.

4. Another key finding in relation to how bed capacity was managed was through the use of the independent sector: Stakeholders highlighted the crucial role played by the independent sector in the first phase response to the pandemic. In addition to providing additional physical capacity to permit secure sites (i.e. green sites) for non-Covid-19 procedures, the independent sector also provided an additional of qualified staff to be able to support the national response. Stakeholders noted that NHS consultants were able to be rostered into the independent sector flexibly to allow for additional use of capacity. Arrangements were in place by April 2020, reflecting the pace at which both the sector and the NHS itself was able to mobilise in response to the pandemic to provide additional capacity and staff.

Question 3: How well did we adapt services to respond to challenges of Covid-19 and opportunities to change?

Two key examples were cited regularly: the redesign of urgent care, and the way in which digital tools have been incorporated into Acute care. Stakeholders also discussed the adoption of initiatives such as a wider rollout of patient-initiated follow-ups across Boards to be able to manage the back-log of cases in a more effective way.

Finding A: Redesign of Urgent Care

The redesign of urgent care was a unique approach taken by Scotland and was felt to provide a 'significantly transformational approach' to how urgent care services could be delivered in Scotland. The main aim of this was to design a system to deflect people turning up in the emergency department, minimising the risk of spreading hospital acquired infections. This redesign worked well to relieve system pressures which leveraged whole system thinking and integration and was seen as a massive achievement to be set up in such a short space of time.

Launched in December 2020, the redesign of urgent care aimed to provide urgent care as near to the home as possible through two key mechanisms: promoting NHS 24 as the preferred initial contact for carers and the creation of local Flow Navigation Centres with rapid access to senior decision makers. This was piloted in NHS Ayrshire and Arran prior to the national rollout.

Early evaluations have shown that against a benchmark of September/October 2020, all fourteen territorial boards showed a reduction in ED attendances and self-presents, with eleven boards seeing an increase in activity on NHS 24 in hours during the week. An evaluation outlined that while the causality behind changing behaviours is hard to assess, this new approach may be contributing to up to a 5% reduction in all ED attendances. There is also a key consideration taken for patient experience as Health Improvement Scotland are being engaged to ensure that the experience is standardised nationally where possible. Early themes identified from this review of experience show that patients feel safer, report reduced unneccesary admissions and have been able to get more direct access to medical specialties.

Finding B: Use of digital engagement

Embracing technology has allowed care to be delivered even when face to face consultations were not possible across secondary and primary care. As part of the early response to Covid-19, Near Me was scaled up by Feb 2020 and available to almost every hospital and GP practice in Scotland. Prior to March 2021, 336 digital consultations were taking place each week, which increased beyond 17,000 per week by June 2020. Through this increased use of digital engagement (Near Me), there was a reduction of more than 600,000 outpatient attendances in secondary care at this stage. This dropped to over a million outpatient appointments managed digitally in Scotland by the end of the year. In general, people's experience of Near Me was good with over 98% saying they would use the service again, and reasons for this included: its offering of choice of how to access services; and coverage of a wide range of services, ranging from addiction services to wheelchair servicing. Also, an accelerated rollout of new technologies was supported by the Modernising Patient Pathways Programme for scaling up of Colon Capsule Endoscopy and Cytosponge supporting increased diagnostic capacity for patients.

There was a rapid and co-ordinated response by national partners in the design of processes for digital remote monitoring services which has enabled, for example, the protection of women during pregnancy using both blood pressue and urinalysis remote monitoring with Near Me consults.

Digital Health & Care Innovation Centre undertook work alongside partners to repurpose digital tools to support rapid scale up of these throughout Scotland.

The University of Oxford conducted an evaluation of the Attend Anywhere / Near Me video consulting service during the pandemic across 7 local territorial Health Boards in Scotland which discussed, in depth, the reasons for the adoption and use of Attend Anywhere and its relatively limited uptake to March 2020.

Stakeholders also referenced the public and clinical engagement work by the Technology Enabled Care team within Scottish Government in September 2020. This saw the views of 5,400 individuals covering service users and the general public more widely being sought to understand the barriers and potential for video consulting and to identify potential areas for improvement. Specific groups (such as individuals with disabilities and English as an Additional Language) were also consulted to ensure their views were captured as part of the co-design approach.

Finding C: Embedding transformation and change of acute care

The new Centre for Sustainable Deliver was established to support the changes in working in the acute sector during the pandemic. Hosted by NHS Golden Jubilee, it will work with established transformation programmes such as patients safety programme and work led by Health Improvement Scotland to support the recovery plan. It also supports the ambitions of the Redesign for Recovery framework and will play a key role in underpinning the delivery of the Recovery Plan.

Opportunities identified for further resilience in Scotland:

In this section, the chapter goes on to consider the same three questions as above with a focus on what might be done differently in future. Key themes and examples have been cited below each of the three question as raised through interviews and reviews of existing materials.

Question 1: How did we set up the NHS Acute sector to respond to initial wave?

Finding A: PPE stockpiling and early supply

The NHS supported care homes by sending resource, testing and providing PPE supply from its own stock. There is a lesson around having whole system preparedness planning and the need to improve the distribution network in the early stages of the pandemic which was the basis on which many of the initial glitches around delivery of PPE to where it needed to be delivered arose. Stakeholders recognised this during the early pandemic and have already taken steps to mitigate the reoccurrence of this, which should remain part of future planning and preparedness exercises. A key driver of these glitches was felt to be the lack of certainty over who had responsibility for the provision of PPE to the social care sector prior to the intervention of NHS NSS and Scottish Government. It is important to note that Scotland never at any point ran out of PPE proving the resilience of the processes in place, and NHS NSS were able to supply both NHS England and NHS Wales as part of the mutual aid arrangements. There has been huge global demand for PPE since the start of the pandemic. Based on expert advice, The Scottish Government had a pandemic PPE stockpile in place and planning based on an influenza pandemic, as part of a UK-wide approach, but the PPE requirements during the Covid-19 pandemic were unprecedented. For example, in February 2020, NHS NSS shipped 96,911 items of PPE weekly, however by April this figure was 24,496,200 weekly. Stakeholders also discussed whether a more robust system for testing the appropriateness of existing stockpiled equipment, as stockpiles in place were retested to be confirmed as appropriate for current use when required during the pandemic. While managing on-going stockpiles, it will be important to ensure that these are both the right volume and types of equipment in future emergency planning.

Finding B: Overall preparedness

As described in the Audit Scotland NHS 2020 report, the Covid-19 pandemic was caused by a new virus with unknown characteristics. Initially, there was insufficient evidence internationally to show how the virus behaved and was transmitted, who was at risk and what the incubation period was. The Scottish Government had a range of guidance and plans in place to provide a flexible and effective reponse to the Covid-19 pandemic, which was informed by the 2011 UK Influenza Pandemic Preparedness Strategy. Progress in implementing the actions identified during these pandemic planning exercises had been slow. The Scottish Government set up the Flu Short Life Working Group in 2017, which set out priority actions following the recommendations from the Silver Swan and Iris exercises. While the exercises conducted were not in preparation for the specific type of pandemic that arose, some of the areas that were identified for improvement became areas of significant challenge during the Covid-19 pandemic and had not been resolved prior to the on-set of the pandemic.

Finding C: Stepping down of services

Stakeholders commented on the extent to which services were stepped down as part of the initial response. Early modelling and uncertainty around the impact of Covid-19 on Acute sites led to a pause on elective procedures to mitigate the identified risks around Covid-19 capacity. While this permitted the required scaling up of Covid-19 services, the longer-term impact and harms created by the pausing of all services has led to issues with clearing backlogs and residual clinical risk. Interviewees suggested that for either future waves or incidents, a 'stepped-down' approach to pausing work might mitigate the problems now being faced with recovery. A review of specific specialties for outpatients, diagnostic services, or day case surgery, that might be able to continue could be driven by a set of objective criteria against each individual services could be measured. These criteria could be developed as an action during the recovery and remobilisation phases of work to increase preparedness for future waves and/or incidents.

As part of this stepping down on services, those interviewed highlighted the example of strong cancer performance as a potential area for additional reflection. It is important to note that although these performance metrics remained high throughout the pandemic, many cancer diagnoses have been delayed and potentially missed. During interviews, stakeholders reflected on evidence that has since been produced, suggesting that, in hindsight, more treatments such as Systemic Anti-Cancer Therapy could have been administered as the risk from Covid-19 was subsequently found not to be as high as initially thought.

Finding D: Mobilisation of new resources and staff

While stakeholders have recognised the considerable efforts and success managed through the rapid recruitment of additional staff and the standing up of NHS Louisa Jordan above, they have also identified potential areas for increased resilience. Interviewees referenced a potential lack of clarity of the purpose of both exercises, with examples being a large number of recently retired professionals ultimately not being required to re-join the NHS, and the NHS Louisa Jordan being repurposed for other services. While colleagues noted the uncertainty around the impact of Covid-19 as being a key driver for these precautions being taken, a future lesson learned would consider how best to develop options for alternative uses of staff, with clear triggers and routes for scaling up and/or down resources for different uses prior to commissioning. A phased approach in both cases might lead to more efficient outcomes in future incidents, with further clarity on the purpose of these exercises providing a more appropriate estimate of the total actual requirement (be this for staff, beds or other resources).

Question 2: How well we stood services back up through the remobilisation of the NHS?

Finding A: Clinical risk around backlogs and waiting lists

Throughout the pandemic, there were concerns that people with symptoms and conditions unrelated to Covid-19 requiring urgent attention, such as heart attacks, would not seek the help of the NHS. In addition, concerns around pauses in national screening programmes that may cause delayed or missed diagnoses of cancer and fewer referrals have been seen for outpatient appointments and mental health services between April and June 2020. The longer-term impact is yet to be determined and despite considerable efforts and the launch of 'NHS is open' campaign in April 2020 by the Scottish Government, to persuade people to access services, there was a hesitancy from a portion of the general public to seek non-Covid 19 healthcare treatment. A&E attendances increased between April and August 2020 but started to decrease again from September as Covid-19 cases started to rise. The percentage of people who said they would avoid going to GPs or hospitals decreased from 45% in April 2020 to 27% in October 2020. The Scottish Government and NHS boards need to continually monitor this and take action to mitigate any adverse impacts as a result.

The need for rapid review and management of the backlog of patients waiting for planned care applies across the board but will be particularly critical for urgent patients who have been paused for diagnostic endoscopy or radiology investigations. This backlog review process needs to be set within a context of active clinical prioritisation and a recognition of the impact of continuing use of PPE and enhanced Infection Prevention and Control requirements on service and workforce capacity. Interviewees also referenced challenges with referral management with primary care teams referring patients without certainty over how long that patient had been on a waiting list.

Finding B: Tolerance for risk as part of remobilisation

There were a number of challenges in resuming the full range of health services and bringing capacity back to pre-Covid-19 levels. These included: the need to physically distance – meaning operating theatres, clinics and waiting rooms cannot be used to their full capacity; more time needed between appointments; and procedures for replacing PPE and cleaning and management of ongoing cases of Covid-19, which is also continuing to be very resource intensive. When colleagues discussed the 'risk appetite' of services to continue and how these might be delivered effectively, there is a recognition that the lack of knowledge about the impact that Covid-19 might have on services made this difficult and led to risk-averse decision making. Now that there is more knowledge and awareness of the impact of the virus, organisations may wish to reflect on the levels of risk that might be appropriate when assessing the backlog of patients against the need to continue with full Covid-19 protocols within Acute settings.

Finding C: Strategic use of national assets

The clear role for national assets such as NHS Golden Jubilee and NHS Louisa Jordan has been demonstrated while Scotland recovered from the first wave of the pandemic in 2020. Interviewees referenced a collegiate process through which the role for these resources was defined over time. While this brought benefits, the time taken to ensure all parties agreed on the use of these assets. NHS Golden Jubilee has been cited as a clear example of this, with uncertainty about whether or not the site would be a 'green site' or which pathways and services would be managed there. Early, clear decision-making on the role of these assets in the future would allow for more effective planning, clearer communications and faster turnarounds for some elective procedures.

Question 3: How well did we adapt services to respond to challenges of Covid-19 and opportunities to change?

Finding A: Flexibility across services to drive and embed change

As referenced in the above section on what went well, there have been considerable steps towards a move away from patients receiving treatment in acute sites when there are appropriate options either in the community or elsewhere. The challenge for the recovery and remobilisation phases will now be how to ensure affected services embed the changes made during the pandemic response. Clinical teams will need support to prevent them from reverting to old ways of working, and patients and the wider public will need continued support to inform them about the most appropriate contact points within the health and care system for their needs. While hospital productivity remains impacted by Covid-19 and below previous performance for all elective treatment, primary and community services will need to continue to support backlog management and waiting lists by continuing to innovate and work flexibly within their systems to triage patients appropriately and reduce clinical risk.

Finding B: Shielding Programme

The Scottish Government's shielding programme was introduced in March 2020 and advised shielding of those at highest risk of developing serious illness if they contracted the virus. Those who were shielding were given support, including free grocery boxes, home delivery of medication, and priority access to supermarket home delivery slots. By listening to those who were shielding, it became clear that isolation was having a major impact on the mental health of many people, and a more person-centred approach was needed. As a result, in June 2020, changes to shielding advice were issued moving toward more detailed clinical advice about personal risk and to help in understanding the changing level of infection in the community. This will remain crucial for future waves and any future incidents, ensuring that person-centred approaches and public engagement remain crucial to how interventions are designed.

Finding C: Sustainability of the workforce

Recovery of the health and Social Care system must consider the effect and impact of the pandemic on the physical and mental health of those involved at all levels of the pandemic response. All members of the health and care workforce have faced their own issues from concerns about their own health, caring for families, strain on relationships and looking after children during such a heavily restricted time, as well as other reasons. The National Wellbeing Hub was created with an approach which is based on psychological first aid, promoting resilience following trauma exposure. Since its launch in May 2020, it has received over 63,000 visits. The Wellbeing helpline launched in July 2020 providing 24/7 service to those who require confidential support. In addition to these national staff wellbeing programmes there have been multiple local initiatives which have been well received, including delivery of 'Comfort Boxes' to NHS wards, departments and care homes across the Grampian region, and the distribution of "You are Appreciated" postcards in Tayside. The supporting of staff wellbeing is critical, and the welfare of the workforce is a fundamental interdependency that cuts across every aspect of re-mobilisation planning. The evidence base and learning from previous pandemics demonstrates clearly the need to provide on-going support to promote both physical and psychological wellbeing during this next re-mobilisation phase, and it is clear we should be looking embed systems of support for the longer term.

Key Takeaways:

1. Workforce planning: Pre-dating the Covid-19 pandemic, Scotland (as well as other healthcare systems internationally) has faced particular challenges around workforce vacancies in the Acute sector, for example nursing and midwifery have both experienced an increase in vacant posts and the rise of using supplementary staff to meet demand (as noted by NHS Scotland workforce reporting). This example evidences the pressures faced by Scotland's NHS in maintaining a sustainable workforce. Recognising the considerable work done on national workforce planning to date, the development of policies and working conditions that support staff to stay in the profession will be crucial to support the recovery and remobilisation of health and care services across Scotland.

2. Workforce wellbeing: The pandemic has further highlighted the number of vacancies needing to be filled within NHS Scotland and that the risk of burnout amongst healthcare professionals is much higher than before. Supporting our healthcare professions during this time must be a priority for all and should go beyond the scope of showcasing appreciation through a number of initiatives, there is a need for long-term genuine commitment to the welfare of physical and mental wellbeing of healthcare professionals.

3. Agile ways of working: The Covid-19 crisis has required the NHS to operate differently and we have seen throughout this chapter, examples in which rapid reconfiguration of clinical practice has successfully taken place over a short period of time which would ordinarily have taken months to years. We must recognise the achievements of the Acute response to Covid-19 to date and reset the ambition for what the future health system should look like.

4. Governance for a future pandemic response: It is clear that change has happened as a result of the pandemic, in every part of the health and Social Care system. This has been built bottom up by leaders who have worked successfully together to tackle the challenges presented by the pandemic. This united approach has been a success in large due to the removal of various bureaucratic layers that have previously hindered the progress of improving patient care. Virtual meetings and leaner governance have sharpened and accelerated decision making which has in turn altered NHS working culture. It is vital that learning from this work is taken forward and health leaders are listened to, to create a lean, agile and patient focused framework for the NHS.

5. Achieving greater integration: The pandemic has demonstrated the crucial interdependencies between different parts of the health and Social Care system, and with other parts of society. An effective approach to mobilisation needs to recognise the important connections between services and systems and helps them work together. This will be clearly shown during the recovery of elective procedures over the coming months, and the priority work being done to manage the backlog created during Covid-19 will require strong collaborative working, particularly with Primary and Social Care to appropriatley mitigate any clinical risk.

6. Digital integration: The challenge now is to return services as much as possible to being fully open and accessible whilst not losing some of the gains and improvements that have been made during the pandemic. Consideration should be given for a national approach to the improvement of infrastructure and an increased emphasis on wifi availability to enable the use of digital. A good example of this includes significant equipment rollout that has taken place during the initial phase of the pandemic enabling Community Pharmacies to have wifi in place. Boards should be asked to undertake a gap analysis on this as there still remains, particularly in GP practices regarding shortages of kit.

3. Social Care (Care Homes)

Introduction

This chapter specifically focuses on the social care response in the first six months of the Covid-19 pandemic. Key representatives from the Social Care Directorate were engaged in order to frame this focus of this chapter and to provide insights into its content. It is largely illustrative rather than comprehensive but nevertheless provides some helfpul insights to inform future responses. It was agreed that the scope of this chapter was on the synthesis of previous sources with a focus on the care home sector. This review therefore sits within a wider context of lessons to be learned from across the whole Social Care system which should inform future phases of work.

What is the challenge?

Covid-19 continues to present an unprecedented challenge to Social Care and has focussed attention in the media and more widely on the sector, its staff and service users. It has been well reported that in the initial stages of the pandemic, the care home sector experienced a significant increase in excess deaths of residents, coupled with an already stretched workforce which has undoubtedly put a strain on the sector. The pandemic has given the opportunity to rethink how Social Care is delivered, its place in the wider health system and learn lessons from how we responded to the first wave of the pandemic. This is being done alongside the Independent Review of Adult Social Care (Feeley report^[2]).

What has worked well in Scottish Organisations so far

Finding A: Use of data for oversight (specifically through the Safety Huddle Tool)

1. Stakeholders described the development and implementation of the 'safety huddle TURAS care management tool' within the care home sector as a valuable development during the pandemic. The key elements of this were that it enabled a consistent approach to data collection, report staffing decisions and permitted early escalation and warning of issues to allow for timely support and interventions. Throughout the pandemic, providers demonstrated a high level of initial and continuing commitment to the adoption of the tool, and it has been used by multiple groups. At local level this has included local oversight teams and care homes, while at national level the Care Inspectorate and Scottish Government for the GOLD Social Care Group. The tool has generated daily intelligence on the current situation in all care homes across Scotland and has future potential as an important building block for quality improvement infrastructure. This tool has meant that for the first time ever, a standard data set was available in near time from almost all care homes in Scotland. Looking into how this can be used in the future, the tool offers a more partnership-based approach to supporting improvement in care homes.

2. Stakeholders also noted that data has been used to great effect to be able to validate discharges to care homes using hospital and other data sets. This continues to form part of new ways of working, with the Care Inspectorate for example creating a service data dashboard to be shared with Scottish Government to provide rapid notifications of incidents and therefore a clear picture of the challenges being faced by services.

Finding B: The effective use of digital enablers to improve care

1. Where care and support was reduced or suspended during the pandemic, partnerships were required to put systems in place to support clients, families, and carers to ensure they were safe and well. This was done in several ways using technologies such as Near Me, Microsoft Teams and other Telecare approaches (e.g. access to GPS technology for people with dementia). Stakeholders identified that the pandemic has enabled this swift introduction of new technology and adoption of digital working, including expansion of telephone triage and Near Me video consultations for patients. Key findings from video consultations were that they were effective in maintaining continuity of care and allowed staff to build a different kind of relationship with service users.

It is, however, important to note that some concerns have been raised around the ability of all service users to access technology which needs to be investigated and addressed with many areas are working to retain and further embed the use of Near Me. Colleagues reflected that during the pandemic, ways of working changed, and old systems were switched off which created capacity and robustness to the infrastructure for novel innovative ideas.

2. Stakeholders reflected that prior to the pandemic, although the infrastructure between care homes and primary care was in place, this was not well utilised which was a particular issue early on due to some care homes having poor digital access. Although beyond the scope of the first six months of response, we note here that an action plan for digital approaches in care homes was published in December 2020 which responded to the current and emerging needs of care home providers and their residents to realise the benefits of digital technologies, with implementation of this occurring in the preceding months.

3. Finally, stakeholders noted that local teams also benefited from the use of technology to carry out assessments and holding virtual team meetings including ward rounds for care homes. Teams felt this worked better than usual meetings and assessments due to the increased flexibility for those taking part, making participation independent of geographical location. In addition, technology also proved vital in supporting staff wellbeing, particularly with many care staff working from home due to shielding. Wellbeing and a strong sense of community has been highlighted in all three follow up chapters and stakeholders commented that despite being virtual, this ability to provide peer support was still effective through technology.

Finding C: Collaborative working and relationship building

1. During the pandemic, the interdependencies between hospital and community health services were shown to be crucial (as well as other, wider system relationships). It was reflected by stakeholders that there has been a shift in attitude to adopt 'whole system thinking' across the system, with examples cited including system-wide supplies of PPE and joint working between partnership colleagues and external providers.

2. At the local level, every Health Board and its Health and Social Care Partnership in each Local Authority were requested by Scottish Government in May 2020 to put in place a daily multi-disciplinary team comprising of NHS Director of Public Health, Executive Nurse Lead, Medical Director, Chief Social Work Officer and Health and Social Care Partnership Chief Officer. The MDT sought to provide integrated oversight for, and support to, care homes through proactive targeted interventions. Colleagues reflected on the success of this due to its cross-functional make-up and felt both the overall oversight provided and the meeting became a key forum during the initial stages of the pandemic and continues to be of use.

3. At the national level, the Care Homes 'Rapid Action Group' was quickly established to provide a multi-stakeholder focal point for the work being undertaken to support the effective delivery of care home provision during the coronavirus pandemic and future scenarios. Its remit has now widened to social care under the Pandemic Response in Adult Social Care Group and membership includes Scottish Care, the Care Inspectorate, Public Health Scotland, Directors of Public Health, and the Scottish Social Services Council, among others.

4. Another example was the creation of the CMO and CNO Clinical and Professional Advisory Group (CPAG) in April 2020 . It has representation from care home providers, academics, local oversight teams, clinicians, Directions of Public health, the Care Inspectorate and others and has provided clinical and professional advice and guidance on the response to COVID-19 in the social care sector. It consistses of various subgroups including e.g. short life working group on testing, safety huddle group providing national and clinical guidance, visiting, testing and Infection Prevention and Control guidance. The CPAG. Recent work streams have included assisting with the IPC manual, publishing the Open with Care visiting guidance and engagement with relatives of care home residents.

5. Finally, documents reviewed reflected that the development of 'profession to profession' care pathways was key to the response. Improving relationships and effective communication between primary, secondary, community and Social Care was key to successful interface working. This was also supported by the temporary move away from target and number driven messaging i.e. waiting times and attendances at A&E while the key focus of teams was Covid 19 response.

Finding D: Innovative initiatives to temporarily increase workforce capacity

1. There were a number of workforce initiatives both regionally and at a national level put into place to ease the pressure on the existing workforce. This inluded at the outset of the pandemic the Scottish Government commissioning NHS National Education for Scotland and Scottish Social Services Council to develop a new Health and Social Care Covid-19 Accelerated Recruitment Hub (the Recruitment Hub) to enable those with relevant skills and experience to come forward and support health and social care services. Its purpose was to enable social care employers prepare for and manage changes to their staffing levels during the crisis. On reflection the number of people employed through the Recruitment Portal is lower than originally expected due to a range of reasons including employers being able to source the right staff, effective local intiatives to provide support and a reduction in demand for care at home services. Other measures included , the introduction of seven day working which were utilised was reported to work well, and the redeployment of staff from paused services. Some partnerships undertook detailed modelling to predict sickness absence and modelled workforce requirements accordingly. Stakeholders did reflect on the success of these initiatives in the same way as identified in the Acute sector, where large numbers of staff were identified for re-registration but a reported low level of actual placements.

2. When the Covid-19 pandemic took hold in Scotland in early March 2020, the Care Inspectorate significantly increased levels of contact with care homes across Scotland. They put an early warning system of enhanced notifications in place, requiring services to tell the Care Inspectorate about both suspected and confirmed cases of COVID-19, and staffing levels affected by COVID-19. The Care Inspectorate operated these oversight arrangements seven days a week to carry out scrutiny checks and enhanced their communication to providers with daily Provider Updates, a COVID-19 area on website, and information on social media. Working closely with NHS public health and Healthcare Improvement Scotland, the Care Inspectorate commenced onsite inspections for those services where risk was indicated as high.

Finding E: A re-prioritisation of care provision away from Acute providers towards the community

1. In an existing lessons identified report reviewed for the purpose of this work, partnerships reported decision making and discharge arrangements had been streamlined at the start of the pandemic. There was an accepted need to create hospital capacity, therefore discharging people who had no clinical need to be in hospital was deemed an urgent necessity. Coupled with a fear of remaining in hospital for individuals and their families, many of the historic behavioural barriers were removed and key elements of this should be retained for future ways of working. Prolonged delays over choice were dealt with speedily with a desire to be moved out of hospital quickly and family resistance dissipated. These were factors that returned as deaths in care homes became more widespread. In general, there did not appear to be any barriers to fully adopting a 'Home First approach' with long standing behaviours and attitudes to risk being the main obstacles.

2. There have been multiple contributing factors cited for the decrease in A&E attendance and hospital admissions throughout the pandemic including: increases in the use of triage and assessment; increased signposting to other services; primary care teams seeking alternatives to hospital referrals; and paramedics providing more treatment in situ to reduce admissions. Some teams noted more direct access to hospital consultants to enable decisions about whether to admit a patient. It is important to note that there is further thinking and work to be done about the sustainability of maintaining aspects of these as services move into the "new normal".

Finding F: Positive culture shift towards whole system approach

1. Prior to the pandemic, there was a perception that care homes were viewed on the 'periphery' of the provision of care, and it was felt that in some places there was therefore a lack of equality for residents in care homes to be able to access the right care and support. This view has now shifted to care homes needing to be viewed as part of the wider health and social care system including in primary care team. Stakeholders noted there had been a significant shift at both operational and strategic level towards whole system thinking, which has been enabled by information sharing, remote working, teamwork and locality approaches. There was reflection in documents reviewed about how well embedded this view of working was and whether this would be sustainable in the future with barriers including a continued national focus on Acute services and hospital as the default.

2. It was noted that there is a significant piece of work underway in Scotland which is reviewing the clinical and healthcare model of care for provision of whole-needs support for residents in care homes. Stakeholders commented that in some places there was previously a perception of an 'out of sight, out of mind' approach with respect to care homes. The pandemic highlighted some potential weaknesses within the system, particularly with vulnerable service users living in environments that were seemingly unprepared for the pandemic.

3. Early in the pandemic, the minister for mental health chaired a group around mental wellbeing for Health and Social Care staff. From the outset an inclusive approach was taken recognising the significant challenges to wellbeing for staff across both health and social care but particularly in care homes. This resulted in the development of a national integrated digital wellbeing hub for health and social care staff, carers, volunteers and their families to access relevant support when they need it. 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. Although it was felt that there was a multitude of resources available to colleagues regarding wellbeing, it is not clear what the take up was and continues to be for these.

Opportunities identified for further resilience:

Finding A: Limited pre-existing governance structures across Social Care

1. It has been highlighted from documents reviewed, one criticism of the internal Scottish Government response to the pandemic was a lack of subject matter expertise on Social Care (in particular for care homes) among key decision makers within Scottish Government. This led to a perceived overreliance on key members of staff with this knowledge who had limited capacity to support all aspects of the response. Documents reviewed suggested concern that this reliance on key individuals will continue to present an issue if there are further waves or future incidents.

2. Some partnerships have alluded to difficulties presented by new oversight arrangements with a feeling that there was a lack of clarity about levels of accountability within these structures. This challenge was highlighted when there were attempts to use parts of the system in an assurance role without having previously had this experience over care homes.

3. Documents reviewed suggested a devolved management model in relation to care homes meaning that when the Covid-19 pandemic did occur, the information, about what was happening at care homes, and held centrally within Scottish Government was limited. This is a consequence of the arrangements around the provision of Social Care in Scotland, with multiple providers working independently within each territorial Board. Providers had no previous requirement or incentive to provide data in consistent ways or work in an integrated way, and this hindered the ability of Scottish Government to make national-level decisions throughout the early pandemic response. This also raises questions about the level at which these decisions should have been made, with further clarity being helpful over the different roles of local and Scottish Government.

Finding B: Challenges with Communication

1. A lack of effectiveness of communication in general was highlighted as a key point across many of the documents reviewed, including the Coronavirus (COVID-19): care home outbreaks - root cause analysis. Stakeholders highlighted a perceived lack of information available to their service users about how to access the system but also around withdrawals or changes made to existing packages of care as being key examples of areas where communication should be reviewed for future incidents.

2. There was recognition that guidance for care homes was iterative as the pandemic progressed and knowledge about Covid-19 developed. However, stakeholders highlighted a fine balance between updating latest guidance and being able to implement and understand repeated sets of new guidance. Stakeholders reported this caused a substantial amount of stress and frustration, and in some areas strained relationships with care home providers. A suggested change here was the inclusion of a summary of 'key changes' or similar for any iterations of guidance, as providers reported not being able to clearly distinguish changes in guidance between iterations.

3. In terms of the national guidance, several partnerships made comments around a theme of "one size doesn't fit all" – meaning national policies were not always tailored appropriately to local requirements. This contrasts to elements of the Public Health response, where the importance of both local knowledge and national oversight was a key facet of the response. This is exacerbated by the devolved management model as referenced above, but any future guidance with relationship care homes ought to consider local circumstances alongside national consistency where possible.

4. Partnerships within documents reviewed commented on the timing of announcements as being unhelpful, for example guidance being released on a Friday with changes to be made by the following Monday. We note this finding is also consistent with other chapters in this report and is not exclusively applicable to the Social Care response.

Finding C: Lack of consistent data

1. It was noted from previous work that the initial data which was available to the central Scottish Government team from the care homes and Local Authorities was limited and sometimes lacking in quality and consistency. This is reflected by the devolved management structure overseeing providers in Scotland. Considerable work has been done by the Scottish Government and other national agencies to create infrastructure for robust data collection and drive standardisation, which provides a platform for enahanced further planning and development into the future. The developments and large amount of work required reflects the relatively weaker starting position from which the care home sector found itself. Interviewees referenced that while they felt data in general had helped the response, particularly in the earlier phase of the pandemic it was often hard to locate when needed.

2. Documents reviewed stated the importance of information shared by care home providers, but also the need for processes to be improved to keep the demands on them to a sustainable level, coupled with the fact that care homes are not always well linked in digitally in terms of email, and IT skills. This reflects a potential risk to continued reliance on digital tools and ways of working wihtout accompanying training and on-going technical support for those wokring on the frontline.

3. There has been on-going improvement work between Public Health Scotland, NHS Boards and suppliers to ensure more standardised data around admission to care home from hospital discharges. In addition, it has been highlighted that priority should be given to the development of a national dataset recording care home residents on an ongoing basis, to allow for a better understanding of the capacity and use of the sector.

Finding D: Negative perception about Social Care

1. Throughout our review, documentation provided highlighted that the Social Care workforce felt undervalued and underrecognized prior to the pandemic, and that there were reports of similar feelings during the early response. It is thought that the inclusion of Social Care staff, alongside their health colleagues, in public campaigns has helped but there is a deeper underlying sense that Social Care workers have not had parity of esteem with their NHS counterparts as noted in the Independent Review of Adult Social Care. It will also be necessary, in going forward, to consider some basic terms and conditions on issues such as sick pay, time-off, and travel time for social work colleagues and to renew focus on the importance and value of Social Care.

2. Numerous participants from previous interviews mentioned the Lord Advocate's decision to enable Police Scotland investigations into deaths in care homes. While acknowledging the need to assess what went wrong, participants expressed that this approach was substantially increasing the very high levels of anxiety being experienced by professional, skilled staff who support and care for the most frail and vulnerable people in our society and there is a perceived and felt search for blame.

Finding E: PPE distribution challenges

1. Many areas of Social Care have reported issues with accessing PPE at the start of the pandemic, with concerns over the quality and the ability of independent providers to access it. All areas set up local PPE hubs to help distribute PPE across partnership services, with some areas also bulk buying and distributing to all sectors. Some partnerships felt that the guidance at this stage was influenced by availability, and in some areas, there was real anxiety felt amongst staff and service users. After overcoming the initial issues several partnerships praised NSS for the supply process that was established via community-based hubs and triage support line and felt that it had worked well. It was reflected that in the future, the development of a national or regional PPE purchasing consortium would help address issues of quality and help share PPE fairly across whole sector.

Finding F: Workforce Challenges

1. There have been many workforce challenges highlighted throughout the documents reviewed. A few examples include the lack of initial prioritisation of Social Care workforce in early stages regarding PPE including possible diversion of pre-pandemic resources towards NHS and other public authority provided services, trauma experienced by workforce during pandemic which is thought will have long lasting effects and potential inequalities in access to testing between staff.

2. Staff absences was cited as a significant challenge for many areas of Social Care. In some areas, care at home staff have been described as an ageing workforce, which resulted in many staff shielding. In general, colleagues reflected that once regular testing of staff commenced areas saw absences reduce significantly as people had the confidence to return to work knowing they had tested negative.

3. It was reflected that there is currently no national oversight of workforce planning for Social Care in Scotland with around 1,200 social care employers in Local Authorities and the third and independent sectors, the complexity of the sector made it sometimes difficult to ensure appropriately skilled staff were trained, supported, employed and available in the right place at the right time. However, in some local areas through partnership working between Boards, IJBs, Local Authorities and social care providers it was possible to deploy appropriate staff quickly and at scale. Longer-term, problems that have surfaced, given the complexity of the social care sector there are difficulties in planning ahead for training, recruitment and retention, and failure to work with partners in health and housing in particular to model innovative new approaches that depend on the availability of a suitably trained workforce who understand each other's contributions.

Finding G: Infection prevention and control challenges within care homes

1. Several documents, in particular the Root Cause Analysis report, reflected on the support provided by Public Health consultants and staff during the crisis which had proved extremely helpful in terms of addressing staff and union concerns around PPE and providing advice and guidance on appropriate infection control procedures. However, it has been reflected by colleagues that different guidelines and support for health and social work around infection control and safeguarding led to some confusion within the sector initially with the continually changing guidelines around the use of PPE were also noted as challenging.

2. It was reflected by colleagues that responsiveness at the point at which issues were raised and became a matter of concern was good however there may have been issues that could have been anticipated earlier. There is a need for both health and Social Care to promote more proactive and anticipatory interventions in the future.

3. It has been reflected by colleagues that it is likely that there was a presence of focused interventions by way of training and support, around specific care homes which had experienced outbreaks. It is possible that these were prioritised over care homes that hadn't experienced an outbreak meaning that these care homes were underprepared when outbreaks did occur. While documents reviewed recognized the importance of this prioritisation, the inability to share good practice through a lack of existing integrated working or information sharing was felt to have led to inconsistencies across providers.

4. Managing transmission risk in relation to isolation of those residents with dementia was also reported by colleagues as constrained by the built environment within the care home and required enhanced monitoring. Some of the IPC advice was challenging in the context of balancing harms, as keeping an individual's environment familiar to them, in terms of personal belongings, was an important aspect of care in this context. Partnership organisations expressed concern that Infection, Prevention and Control (IPC) was making care homes into 'mini hospitals' and that there was a desire to return to recognising care homes are people's homes. This concern also featured in documented discussions with the care home managers from the four homes currently experiencing large outbreaks in this second wave, and additionally it was raised by national organisations and by the family representatives. The importance of risk-based and proportionate IPC, inclusive of its application to visiting, is critical to the sector.

5. Symptom recognition in older people was highlighted as key to the control of Covid-19. In documents that have been reviewed, there was evidence that primary care and emergency services colleagues had brought recognition of wider Covid-19 symptoms to the attention of care home staff during a resident review. In May 2020, Scottish Government's Health and Social Care Directorates issued guidance detailing the wider spectrum of symptoms seen in older people, to be considered for all care homes.

Finding H: Visiting of external services and resident families to care homes

6. Colleagues reflected on the provision of healthcare services to care homes during the pandemic and that this was described as inconsistent before the pandemic. Providers reported a range of visitation experiences, from minimal ''ignored' GPs input to other care homes where Primary care services including GPs are actively providing clinical advice and support. There was a reflection about the need for more consistent clinical input required for care homes in general. Stakeholders felt that, that there is a process of remobilisation of H&SC services across the sector, and guidance was issued around return of visiting professionals for care homes.

7. Colleagues reflected on delays in recognising the impact of closing care homes to visitors in March 2020 and highlighted that this evolved as a consequence of experience and through listening to the voice of relatives, there was a question around if care homes could have been opened to visitors at an earlier than June 2021 for the benefit of residents. Visiting issues began to materialise particularly in April and May 2020 when colleagues were working towards was the contribution towards the route map out of lockdown. Colleagues reflected that it is important to note now with hindsight reflecting on the duration of the pandemic, the mitigations in place and the impact isolation has had on residents and their families.

Key Takeaways:

Greater collaboration and integration: Stakeholders referenced care homes in particular as being perceived as being neglected within systems prior to the pandemic. Initiatives such as the daily safety huddle and the MDT meetings have highlighted the crucial role of Social Care during incident response and new ways of working. The role for Social Care going forward should be reviewed in the context of recovery, with stakeholders noting the perceptions of care homes as being 'mini-hospitals' needing to be avoided in particular.

Workforce planning: Stakeholders reported the devolved management structure within Social Care (particuarly for care homes) placed a significant strain on the ability for a national workforce planning approach. Reactive measures were required at local levels with inconsitent data upon which to base decisions more widely. This could be mitigated by a more systematic, regional or national approach to workforce planning, with a focus on new, integrated ways of working, building a diverse and skilled pipeline of future staff, and embracing system working.

Agile ways of working: Enabled by the significant advancements made in digital tools and technology, there is now an opportunity for those working both within and with care homes to embed new ways of working. Such progress in this area can, in part, help address highlighted concerns by some stakeholders around visitation (of other services to provide greater, more consistent clinical input and families of service users), and integrated working with wider system partners.

Governance for a future pandemic response: A key finding highlighted by all stakeholders and in documents provided pointed to the challenges faced by those working in the response by the devolved management model for care homes in Scotland, in so far as the large number of different providers made coordination and standardisation challenging where desired. As with other areas of the pandemic response, significant work has been done to address these limitations to date, particularly around the lack of consistent data. Further work by Scottish Government and within territorial Boards to drive consistency and encourage greater collaboration would support the pace of any future responses to incidents.