Mobilisation Recovery Group minutes: 16 April 2021

Attendees and apologies

Members present (in alphabetical order):

• John Burns, NHS Board Chief Executives’ Group representative
• Donna Bell, Director of Mental Health and Social Care
• Dave Caesar, Interim Deputy Chief Medical Officer, Scottish Government
• Sandra Campbell, Convenor, Scottish Social Services Council
• John Connaghan CBE, Chief Operating Officer, NHS Scotland (Chair)
• Iona Colvin, Chief Social Work Adviser 
• George Crooks, Chief Executive, Digital Health and Care Institute
• Cllr Stuart Currie, Health and Social Care Spokesperson, COSLA
• Amy Dalrymple, Royal College of Nursing (Scotland)
• Graeme Eunson, BMA Scotland (deputising for Lewis Morrison) 
• Tom Ferris, Chief Dental Officer
• David Garbutt, NHS Board Chairs’ Group representative
• Cllr Kieron Green, Vice Chair, IJB Chairs and Vice Chairs Group
• Philip Grigor, Scotland Director, British Dental Association
• Annie Gunner-Logan, Coalition of Care and Support Providers 
• Pauline Howie, NHS National Boards’ representative 
• Donald MacAskill, Chief Executive, Scottish Care
• Peter Macleod, Chief Executive, Care Inspectorate
• Carolyn McDonald, Chief Allied Health Professions Office, Scottish Government
• Harry McQuillan, Chief Executive, Community Pharmacy Scotland
• Patricia Moultrie, Deputy Chair of BMA SGPC
• David Quigley, Chair, Optometry Scotland
• Sir Lewis Ritchie, Mackenzie Professor of General Practice
• Claire Ronald, National Staff Side representative, Chartered Society of Physiotherapy
• David Shackles, Joint Chair, RCGP Scotland
• Alison Strath, Interim Chief Pharmaceutical Officer, Scottish Government
• Angela Thomas, Royal College of Physicians Of Edinburgh
• John Thomson, Vice President Scotland, Royal College of Emergency Medicine 
• Ian Welsh, Chief Executive, Healthcare and Social Care Alliance Scotland
• Carole Wilkinson, Chair, Healthcare Improvement Scotland
• Andrea Wilson, Convener, Allied Health Professions Federation Scotland

Apologies:

• Dave Caesar, Interim Deputy Chief Medical Officer, Scottish Government
• Amanda Crofty, Chief Nursing Officer, Scottish Government
• Jane Anderson, UNISON representative   
• Andrew Buist, Chair, GP Committee, British Medical Association 
• Nicola Dickie, COSLA
• Caroline Lamb, DG, Health and Social Care and Chief Executive, NHS Scotland 
• Angela Leitch, Chief Executive, Public Health Scotland
• Jason Leitch, National Clinical Director 
• Joanna Macdonald, Chair, Adult Social Care Standing Committee, Social Work Scotland
• Miles Mack, Chair, Academy of Medical Royal Colleges and Faculties
• Kathryn McDermott, UNISON National Staff Side representative
• Christine McLaughlin, Director, Test and Protect, Scottish Government 
• Lewis Morrison, Chair of Scottish Council, British Medical Association
• Peter Murray, Chair IJB, Chairs and Vice Chairs Group
• James O’Connell, National Staff Side representative, UNITE
• Linda Walker, National Staff Side representative, GMB
• Gregor Smith, Chief Medical Officer
• Cleland Sneddon, Health and Social Care Spokesperson, SOLACE

Apologies due to the pre-Election period:

• Jeane Freeman MSP, Cabinet Secretary for Health and Sport 
• Mairi Gougeon MSP, Minister for Public Health, Sport and Wellbeing
• Clare Haughey MSP, Minister for Mental Health

In attendance:

• Marion Bain, Deputy Chief Medical Officer 
• Derek Bell, Special Advisor, Scottish Government
• Heather Campbell, Interim Deputy Director, Primary Care, Scottish Government
• Catherine Calderwood, Clinical Director, Centre for Sustainable Delivery (Golden Jubilee)
• Jann Gardner, Chief Executive, Centre for Sustainable Delivery (Golden Jubilee)
• Aidan Grisewood, Interim Director, Primary Care, Scottish Government
• Steven Mackie, Head of Primary Care Finance, Data and Digital, Scottish Government
• Helena Jackson, Health Performance and Delivery, Scottish Government
• Michael Kellet, Director of Population Health, Scottish Government
• Helen Maitland, Director of Unscheduled Care, Scottish Government
• Jennie Marshall, Health Operational Planning, Scottish Government
• Diane Murray, Deputy Chief Nursing Officer, Scottish Government
• Gillian Russell, Director of Health Workforce, Leadership and Service Reform, SG 
• Stephen Gallagher, Director for Local Government and Communities (Vaccination Policy)
• Colin Sinclair, Director of Vaccination Delivery, Scottish Government

Official support:

• Andrew Fleming, Health Performance and Delivery, Scottish Government
• Angela Gibson, Health Performance and Delivery, Scottish Government
• Jake Macdonald, Health Performance and Delivery, Scottish Government

Items and actions

Welcome

John Connaghan chaired the fifteenth meeting of the Group and commenced proceedings by welcoming attendees, noting apologies, and highlighting that the future of the group will be for the new Cabinet Secretary to decide. From his perspective, the discussions have been extremely valuable and influential in terms of business during the pandemic and he offered his thanks to everyone who has contributed, including the secretariat for ensuring meetings ran smoothly. He also welcomed Dr Catherine Calderwood and Jann Gardner from the Centre for Sustainable Delivery as guest speakers at the meeting. 

The Chair provided an update to the Group on key issues of importance since the last meeting: notably that further restrictions have been eased in Scotland, including relaxations on travel and the full return of pupils to schools; the Moderna vaccine has been deployed in the Greater Glasgow and Clyde Health Board; the JCVI has issued advice that people under 30 should not be offered the AstraZeneca vaccine; and John Burns has been appointed as the new Chief Operating Officer for NHS Scotland and will take up post in July. 

Note of previous meeting held on 26 March 2021, action log and matters arising

No amendments had been received from Group members and there were no outstanding action log items (other than the action that encourages members to approach the secretariat with any feedback on the work of the group); nor matters arising noted.  As such, the note of the meeting on 26 March was agreed and will be published on the Group’s page on the Scottish Government website.

State of the pandemic, primary care and vaccinations

State of the pandemic

Dave Caesar provided an update on the state of the pandemic and noted that whilst there was justifiable optimism in the air, case rates are mixed across the world and variants continue to pose a threat. On the R number, he noted that it has remained steady over the last few weeks and currently sits between 0.8 and 1.0. The 7 day incidence per 100,000 of the virus provides the most accurate picture, however our testing rates are high and so we must take that into context when interpreting the case rate. As expected due to the vaccination programme, case rates in the older age groups are falling and transmission is predominantly in working age adults. The full return of schools means there is still much in the way of uncertainty in terms of infections, but case rates have reduced across the board and deaths have also reduced. However, the threat of new variants is a concern and we do have cases of variants other than variant B.1.1.7 in Scotland so managing the importation of the virus will continue to be crucial in conjunction with effective genomic sequencing. The vaccination programme is continuing at apace and uptake is extremely high, as is confidence in the vaccine. Second doses are the focus at this time and the 45-49 age group are now being invited for their first dose. In terms of modelling, the best case scenario suggests that we will continue to have cases into May and beyond. Whilst we are not on tracking against the worse case modelling, we do have a number of easing still to undertake before we see the impact of those easings. 

Discussion

The Chair thanked Dave for his update and queried what we knew about variants in terms of vaccine efficacy. 

Dave Caesar responded by referring to both John’s question and Donald MacAskill’s written question about the ‘Indian’ variant. On variants, Public Health Scotland (PHS) data suggests the numbers of cases which are not the UK variant are very low. In terms of vaccine efficacy, there is a degree of uncertainty. For example, we know much more about how the vaccine works against older variants. However, research methodologies are not uniform and as such we cannot make generalizable conclusions at this stage. Nevertheless, it is likely that vaccines will have some degree of efficacy on new variants, though we will need to keep this under review, and the pharmaceutical companies are already taking such work forward. 

Alison Strath confirmed that the Scottish Government is in regular contact with the pharmaceutical companies who are actively considering the effect of new variants. Some types of vaccine, such as the MRNA vaccines, are easier to manipulate to deal with new variants. Notably, the Valneva vaccine which is being developed in Scotland lends itself particularly well to being amended to deal with new variants. In the meantime, we must continue to take all of the necessary precautions to ensure that new variants do not spread. 

Stuart Currie asked about the impact of media coverage on vaccination hesitancy, notably in relation to the second dose, and whether this could have an effect on overall efficacy and coverage. Dave suggested that reporting on Covid19 vaccine safety concerns has been remarkably balanced and responsible in the main. Broadly, confidence in the vaccine, especially in the harder to reach groups, has increased and some of the most powerful advocacy has been from the families of those who have been affected by the complications. Alison Strath also reiterated that there is ongoing work on whether vaccine types can be mixed between doses. We do not yet have enough data to make an informed decision on this but it is in the pipeline. 

Angela Thomas noted that there have been no reports of thrombosis after the second dose of the AstraZeneca vaccine and that it is important to convey this message. Secondly, the vaccination programme has progressed at an historical pace: we have never administered 24 million doses of any drug or vaccine in such a short space of time before. Normally, complications such as thrombosis take years to identify. In sum, this vaccine is extremely safe, but due to the increased scrutiny of the programme, in conjunction with the extraordinary number of people who have thus far received the vaccine, this complication has been identified very early on and that is a positive thing. 

Primary care

Steven Mackie provided an update on the primary care sector, in particular the ways in which Scottish Government is measuring activity in primary care. Officials have been taking forward work to increase the quality and regularity of data in (in-hours) general practice. This has included working with a range of stakeholders over the last 6 to 9 months to understand the level and type of activity in general practice to allow SG to analyse pressures and provide support where appropriate. Automatic data extraction remains the goal and work has begun with NSS and PHS to better understand what we can do post general practice IT upgrade.  The GP survey allows SG to begin to feed the analysis into wider system monitoring and pressure management, and promotes discussions with stakeholders about what is happening nationally. There is further work to be done to ascertain the type of data we need, and it is hoped that we will move to an automatic opt-in model in the near future. To conclude, an update on the results of the GP survey was provided and next steps outlined, including the continuation of the survey, working with stakeholders, and scoping the work that can be done following the general practice IT upgrade. 

Discussion

Aidan Grisewood emphasised the importance of this data and the requirement to look at whole systems pressure and how we can address them. This means ensuring that as many practices as possible provide data. 

Lewis Ritchie reiterated Aidan’s reflections and suggested that the progress made in this area is welcomed and very much needed. 

David Garbutt noted the importance of collaboration and suggested that it was essential that all stakeholders are included in the development of high quality data sources.

Patricia Moultrie thanked Steven for the presentation and stressed the importance of communicating to practices what is being done with the data to ensure that it is viewed as a worthwhile activity. The move to an automated system is also a positive development. Finally, tracking activity is important, but does not measure pressure in the system. There is also a need to include workforce in any data analysis. 

Amy Dalrymple reinforced the points made by Patricia in relation to the need for data on workforce. Further, engaging around the survey process and results beyond GP’s may help boost the understanding required to sustain and improve response rates to ensure that the quality of the data is maintained. 

Harry McQuillan asked about future plans and whether there is a possibility to expand this data capture to other primary care providers. 

Steven Mackie responded to the points made, noted his agreement with the issues raised, and sought to provide clarity where appropriate. On widening this beyond general practice, Steven committed to working with colleagues in primary care beyond general practice, including Community Pharmacy and the Royal College of Nursing.

Vaccination programme

Stephen Gallagher provided an update on the vaccination programme: we have now effectively given a first dose to everyone aged over 50 and everyone in priority groups 1-9. The uptake rates we have observed so far are phenomenal but this does not mean we can be complacent and we must continue to ensure the programme is inclusive as possible. We are now at the stage of offering second doses and over the next few weeks the data will be balanced in favour of second doses as we are 12 weeks after the application of the first doses. The data suggests that we will meet the target of offering everyone a first dose by the end of July, however the situation is very dynamic and there are ongoing supply issues from week to week. Last week the JCVI issued guidance which will have a significant impact on vaccinations, in particular for those under 30 who will no longer be offered AstraZeneca. It is crucial that we understand who is not attending for their vaccination appointment, and as we move down the cohorts there will be further issues at play such as balancing work commitments with attending appointments. More broadly, inclusivity is key and we will build on the best practice as set out in Health Board inclusion plans. Finally, as we run through this programme, we must begin to look at winter 2021-22 to ensure we have the appropriate procurement and logistic strategies in place. This will ultimately mean looking at the type of vaccination service we want to have in Scotland in the future. 

Colin Sinclair thanked everyone who has helped to deliver this programme. The commitment to make this work has been huge and the biggest challenge we face in the long term is planning to support the sustainability of the programme. 

Discussion

John Connaghan queried the ‘did not attend’ (DNA) rate and the potential root causes for not attending an appointment. 

Colin suggested that the initial work is defining what we mean by the DNA rate. Sometimes people will not be able to attend simply because the appointment did not suit; the data suggests that people are rebooking their appointments in the main but there are clearly issues around inclusivity which do need to be properly analysed. 

Graeme Eunson questioned the workforce aspect of the vaccination programme. Many of the staff supporting the programme have been redeployed from their core work and so the issue of workforce is incredibly important and will continue to be so as we recover and remobilise. As such, it would be helpful to understand the long term workforce planning supporting the remobilisation phase. 

Gillian Russell provided reassurance that officials are considering very closely the workforce requirements of health and social care in the medium to long term, especially in terms of sustainability of the workforce through flexibility and agility. 

NHS remobilisation planning and the Centre for Sustainable Delivery 

Yvonne Summer provided an update on NHS remobilisation plans and outlined the key risks which have been identified, notably properly addressing workforce issues such as decompression and sustainability, and increased infection prevention and control (IPC) measures, which will reduce overall capacity. Policy and sponsor teams across health and social care have been reviewing the plans and John Connaghan, as Chief Operating Officer, has now written to all of the territorial boards to sign off their plans. The plans will be published following the election and following approval through the normal governance processes at Health Board level. We will continue to work with Boards closely in the coming months and will be providing guidance and advice on implementation to enable Boards to maximise their activity over the coming months. Due to the ongoing uncertainty, officials will carry out substantive mid-year reviews in Autumn to assess progress and where necessary refresh the plans to take account any changes in the operational and strategic context. In terms of assessing and mitigating risks, this is an ongoing process and we are beginning to think about the types of issues we will want to be covered in the next iteration of the plans, notably the ability to deal with future waves, IPC measures, winter planning, maintain a whole system response, innovate to delivery, to deliver in a person-centred way informed by realistic medicine, and to support staff at every step of the way. As we move forward, we must change the way we deliver services, continue to engage with the population throughout, ensure that staff have the support they need, and focus on outcomes not just on input. 

Jann Gardner updated the group on the work of the Centre for Sustainable Delivery (CfSD). The 2021-22 work plan has just been published and will be refreshed in line with the next iteration of the remobilisation plans in September. The centre is focused on supporting and driving forward transformation at pace, underpinned by the Remobilise, Recover, Re-design framework. The centre’s vision is to become an internationally recognised centre of excellence, which promotes and embeds best practice. This means optimising collaboration with Health Boards and partners across health and social care and the third sector to create new opportunities to support both existing services and new health innovations. In doing so, it is important that we support service providers to optimise the implementation of new innovations, aligning the priorities of the Scottish Government to foster new innovations and ensure quality care is at the core of what the centre does. The centre also provides bespoke support to Boards using subject experts, skills, and best practice to make a difference. The annual work plan was commissioned by the Scottish Government and was published for transparency. The work of the centre will take a steer for the ongoing Care Programmes and will involve clinicians and patients, ensuring it is a bottom-up programme. The centre also links across regional and national Health Boards and continually assesses the potential of each programme as well as progress towards implementation. 

Catherine Calderwood provided an update on some of the work streams the CfSD has been involved in over the past years, including a surgical enhanced recovery programme, the rollout of cytosponge during the pandemic, and an innovative digital app. To close, she asked members of the group to nominate a senior manager with influence as a sponsor for CfSD, and the CfSD will match with a nominated lead to work with their organisation.

Discussion

John Connaghan thanked Jann and Catherine for their updated and reinforced the need to reconsider how we deliver services as we recover from the pandemic,  emphasising the significant patient safety element of the work. 

Graeme Eunson made three points. Firstly, that rest and recuperation is extremely important for staff working in our health services and this must be recognised in the context of future plans for NHS remobilisation post-election. Secondly, recruitment and retention of staff is crucial and there needs to be a further drive to retain existing staff to make jobs attractive and sustainable. Finally, national plans must be fit for purpose to be deployed in rural Scotland and should not focus on the central belt. 

Claire Ronald queried whether remobilisation plans have been audited to assess the facilities commitments and noted that many rehabilitation spaces have been repurposed and so we need to understand how and where space has been lost and when that space will be returned to allied health professionals.

Dave Caesar agreed with the importance of Claire’s point in relation to rehabilitation and pointed to the work of the CfSD in reducing length of stay to maximise patients ability to return to the life they had prior to their procedure. On Graeme Eunson’s point, much change is being driven by the clinical workforce and so there is a careful balance to achieve given the complexity of the workforce and their experiences of the pandemic. On the issue of services being focused on the central belt, this is a recognised challenge and the solution will require a hybrid approach which is efficient and inclusive. 

Stuart Currie noted the importance of agreeing what we mean when we discuss the ‘whole system’ response and suggested there are services and groups, such as third sector or volunteers, beyond health and social care which form part of the whole system. This has been particularly evident during the pandemic and different sectors of the system are recovering at different paces. 

Jann Gardner, and Catherine Calderwood thanked everyone for their input and agreed to take conversations offline where appropriate. The issues raised are on the radar and there is a  commitment to finding solutions rather than exasperating pre-existing issues. Patient experience is key and the examples provided today demonstrate this. 

Yvonne Summers closed the meeting by reiterating that the remobilisation plans are only part of the process and there will be ongoing work to assess, implement, and develop the plans. 

John Connaghan thanked everyone for the helpful discussion, noted that the work of the CfSD and an update on remobilisation planning should come back to the group in the future, and closed the meeting.