Mobilisation Recovery Group minutes: 22 January 2021

Attendees and apologies

Members present (in alphabetical order):

• Derek Bell, Specialty Advisor, Elective and Unscheduled Care, Scottish Government
• John Burns, NHS Board Chief Executives’ Group representative
• Dave Caesar, Interim Deputy Chief Medical Officer, Scottish Government
• Sandra Campbell, Convenor, Scottish Social Services Council
• John Connaghan CBE, Chief Operating Officer, NHS Scotland
• 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 (deputising for Theresa Fyffe)
• Nicola Dickie, COSLA
• Graeme Eunson, BMA Scotland (deputising for Lewis Morrison) 
• Tom Ferris, Chief Dental Officer
• Jeane Freeman MSP, Cabinet Secretary for Health and Sport (Chair)
• David Garbutt, NHS Board Chairs’ Group representative
• Mairi Gougeon MSP, Minister for Public Health, Sport & Wellbeing
• 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 
• Clare Haughey MSP, Minister for Mental Health
• Pauline Howie, NHS National Boards’ representative 
• Caroline Lamb, DG Health and Social Care and Chief Executive, NHS Scotland
• Jason Leitch, National Clinical Director 
• Donald MacAskill, Chief Executive, Scottish Care
• Miles Mack, Chair, Academy of Medical Royal Colleges and Faculties
• Joanna Macdonald, Chair, Adult Social Care Standing Committee, Social Work Scotland
• Peter Macleod, Chief Executive, Care Inspectorate
• Kathryn McDermott, UNISON National Staff Side representative
• Harry McQuillan, Chief Executive, Community Pharmacy Scotland
• Patricia Moultrie, Deputy Chair of BMA SGPC
• Peter Murray, Chair IJB, Chairs and Vice Chairs Group
• James O’Connell, National Staff Side representative, UNITE
• 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
• Stephen Moir, Health and Social Care Spokesperson, SOLACE (deputising for Cleland Sneddon)
• Gregor Smith, Chief Medical Officer
• Alison Strath, Interim Chief Pharmaceutical Officer, Scottish Government
• Linda Walker, National Staff Side representative, GMB
• Ian Welsh, Chief Executive, Healthcare and Social Care Alliance Scotland
• Carole Wilkinson, Chair, Healthcare Improvement Scotland

Apologies:

• Jane Anderson, UNISON representative   
• Marion Bain, Deputy Chief Medical Officer 
• Heather Bryceland, Programme Manager of the 3R’s Portfolio, NHS NSS
• Andrew Buist, Chair, GP Committee, British Medical Association 
• Iona Colvin, Chief Social Work Adviser 
• Richard Foggo, Director of COVID Public Health, Scottish Government
• Theresa Fyffe, Director, Royal College of Nursing (Scotland)
• Paul Hawkins, Delivery Director, Vaccinations, Scottish Government  
• Angela Leitch, Chief Executive, Public Health Scotland
• Richard McCallum, Interim Director, Health Finance & Governance, Scottish Government
• Fiona McQueen, Chief Nursing Officer
• Lewis Morrison, Chair of Scottish Council, British Medical Association
• Diane Murray, Deputy Chief Nursing Officer
• John Thomson, Vice President Scotland, Royal College of Emergency Medicine 
• Andrea Wilson, Convener, Allied Health Professions Federation Scotland
• Cleland Sneddon, Health and Social Care Spokesperson, SOLACE

In attendance:

• Donna Bell, Director of Mental Health, Scottish Government
• Heather Campbell, Interim Deputy Director, Primary Care, Scottish Government
• Mairi Cameron, Strategic Reform Unit, Scottish Government
• Michael Chalmers, Director of Children and Families, Scottish Government
• Carol Goodman, Programme Director, Redesign of Urgent Care, Scottish Government 
• Derek Grieve, Interim Head of Vaccinations Division, Scottish Government
• Aidan Grisewood, Interim Director, Primary Care, Scottish Government
• Helena Jackson, Health Performance and Delivery, Scottish Government
• Michael Kellet, Deputy Director, Scottish Government
• Carolyn McDonald, Chief AHP Officer 
• Christine McLaughlin, Director, Test  andProtect, Scottish Government 
• Jessica Milne, Health Performance and Delivery, Scottish Government
• Sean Neill, Deputy Director, Health Workforce, Scottish Government 
• Gillian Russell, Director of Health Workforce, Leadership and Service Reform, SG 
• Tracy Slatert, Interim Deputy Director, Test and Protect, Scottish Government 
• Malcolm Summers, Head of Strategic Reform Unit, Scottish Government
• Yvonne Summers, Head of Operational Planning, Scottish Government 
• Sharon Wiener-Ogilvie, Educational Project Officer, NHS Education for Scotland

Official support:

• Jack Downie, PS/Cabinet Secretary for Health and Sport 
• Andrew Fleming, Health Performance and Delivery, Scottish Government
• Angela Gibson, Health Performance and Dlivery, Scottish Government
• Dan House, Health Performance and Delivery, Scottish Government
• Jake Macdonald, Health Performance and Delivery, Scottish Government
• Marty Shevlin, Health Performance and Delivery, Scottish Government

Items and actions

Welcome

The Cabinet Secretary started the tenth meeting of the Group by welcoming attendees. Ms Freeman also noted that Caroline Lamb has taken up post as Director General of the Health and Social Care Directorates, and as Chief Executive of NHS Scotland; and Paul Hawkins had been appointed as Delivery Director for Vaccinations. Carol Goodman, Programme Director for the Redesign of Urgent Care, was also welcomed to the meeting as an observer.

The Cabinet Secretary noted a number of developments since the last meeting of the Group, including: mainland Scotland had moved into level 4 restrictions from 26 December 2020, taking account of the impact of the new, more infectious ‘Kent’ variant of SARS-CoV-2; and the AstraZeneca/Oxford vaccine had been approved for use in the UK by the MHRA on 30 December 2020. Whilst the overall level of COVID-19 infection in Scotland appears to be stabilising, the NHS remains under significant pressure; there had been a rapid rise in the number of COVID-19 hospitalisations since the turn of the year: as at the date of the meeting, some 35% more than at the initial peak of the pandemic in April 2020, and the highest to date.

Notes of previous meeting held on 11 December 2020

No amendments had been received from Group members and there were no outstanding items (other than the standing action that encourages members to approach the secretariat with any suggestions for future agenda items); nor matters arising noted. As such, the note of the meeting on 11 December was agreed and will be published on the Group’s page on the Scottish Government website.

State of the pandemic

Jason Leitch and Dave Caesar provided an update on the state of the pandemic; speaking to the accompanying slides. They noted: the impact of the new, dominant ‘Kent’ variant (which is 50% to 60% more transmissible) in recent weeks on the 7-day incidence rate per 100,000; with the average of around 300 cases per 100,000 in Scotland’s main population areas masking some significant regional variation, e.g. around 600 cases per 100,000 in Dumfries and Galloway at one point; nonetheless, there are some positive signs that the rate appears to have decelerated; with the ‘R’ rate falling to around 1.0 in Scotland. Polling also suggests that personal contacts may now be at a lower rate than during the initial outbreak in April 2020, and down almost a third in recent weeks since the re-introduction of tougher restrictions; with new cases in Scotland remaining lower than other parts of the UK. Nonetheless, as noted above, the NHS remains under significant pressure: 2,400 inpatient beds have been notionally re-purposed for COVID-19 from the adult acute total of around 13,000 beds across Scotland, with COVID-19 admissions at the date of the meeting running at around 2,050. Some NHS Boards in the West and South West of Scotland are under particular pressure. To summarise, Health Boards are currently extremely busy but coping; they are continuing to prioritise the delivery of urgent and emergency care, including cancer care, but most elective activity is being postponed to preserve capacity.      

Discussion

Graeme Eunson queried whether it was possible for the modelling to project further in time than the coming weeks. Jason Leitch confirmed that longer term modelling is available and considered, but it is often not reliable: with an increasing margin of error in relation to time that means it would not be a robust basis on which Health Boards could effectively plan. The Cabinet Secretary further assured the Group that the Government continues to carefully consider all the available information and take a prudent, cautious approach to planning.  

James O’Connell asked whether stricter restrictions on the public and businesses might be necessary, given the impact of the new COVID-19 variant and pressures on the NHS. The Cabinet Secretary confirmed that the restrictions were being kept under very regular review by Cabinet, as informed by a wide range of data and expert advice, including the surveillance of further mutations of the virus across the world; and that the Cabinet would not hesitate to propose the strengthening of measures, if it ultimately concluded that such action is necessary to further protect public health and services.    

Patricia Moultrie asked whether the modelling looked at likely demand on community hubs and assessment centres; to enable GPs and others to effectively plan the deployment of their resources; not least given the additional imperative to deliver COVID-19 vaccinations. Dave Caesar provided an assurance that community pathways are being carefully considered as part of the necessary redesign of services, such as that underway with urgent care; modifying approaches, adapting roles and processes to ensure that people are treated in the right place at the right time. This item was concluded with Harry McQuillan helpfully reminding the Group that, as of Monday 18 January, a medicines delivery service will be introduced which should help more people remain at home, thereby reducing the risk of further transmission.    

Winter planning update

John Connaghan spoke to the accompanying slides: reiterating the significant pressures on NHS Boards since the turn of the year; with a 71% increase in COVID-19 hospitalisations and a 130% increase in ICU admissions; NHS Dumfries and Galloway experienced a 107% increase in COVID-19 hospitalisations in the first week of 2021, and NHS Tayside had a 121% rise over the same period; NHS Ayrshire and Arran is significantly beyond its notional COVID-19 bed capacity and receiving mutual aid, including from the Golden Jubilee National Hospital and private sector (from which additional capacity has been secured for the coming months); the Golden Jubilee also stands ready to support ICU capacity for NHS Lanarkshire, if required; and ICU provision in NHS Borders is being supported by NHS Lothian. In summary, it is an exceptionally busy time for the NHS but the service is coping, with mutual aid arrangements in place.  Latest information suggests some stabilisation in admissions with smaller rates of growth expected over the coming week, but this would indicate plateauing at a very high level.  

John updated the Group on the redesign of urgent care with flow navigation centre activity increasing daily: Boards are reporting that feedback from patients has been overwhelmingly positive; the next phase will build on the de minimis specification and will include interfaces with: GP in hours, mental health hubs, community pharmacists and the Scottish Ambulance Service. In terms of wider health harms, elective activity levels are down by around 50% on last year with NHS Boards prioritising urgent activity. Boards are now preparing remobilisation plans for 2021/22 that are due with the Government by the end of February, and these plans will set the foundation for wider service recovery. It will also be key for the NHS to retain as many of the positive and innovative changes made to the service as possible during the pandemic, in order to address the considerable challenge of the electives programme in 2021/22 and beyond.  

Christine McLaughlin spoke to the slide on testing: noting that capacity continues to grow and has almost doubled since November 2020; with turnaround times largely stabilising; and growth in local test sites and mobile provision. On the nine pathways of the testing expansion plan: these are complete for medical and emergency admissions; healthcare worker testing should be fully rolled out by the end of the month; and significant progress has also been made with care home testing, including staff; as well as the care at home, schools, student and community pathways.  Further testing expansion is under active development.

Sean Neill spoke to the slide on workforce: it is a challenging position with around 3% of the NHS workforce reported absent each day for a range of reasons related to COVID-19. Non-Covid related sickness absence (typically 4%-6%) remains higher in all Boards, with the exception of NHS Ayrshire and Arran. The number of COVID-19 positive absences in the NHS workforce has increased by roughly a third since Christmas and is reflective of the overall increase of infection across the population.  In addition, approximately 67% of total leave entitlement had been taken in 2020 to mid-January, compared to around 93% in the same period last year: recognising how the pressures on the NHS are building fatigue and anxiety in staff. This is being addressed as far as possible by being flexible around the carrying forward of leave, and about prioritisation through redeployment and optimising capacity, including through the use of the accelerated recruitment portal; and increased emphasis across sectors on training and education; alongside a continued focus on staff wellbeing. The Government has set up a number of services dedicated to supporting the mental health and wellbeing of the workforce, including the National Wellbeing Hub (www.promis.scot) and a National Helpline staffed 24/7 (0800 111 4191) which can signpost colleagues to further support if necessary. Further work is ongoing with Boards and other stakeholders to develop specialist services for those staff who need timely access to more specialist psychological therapies and treatment.

Aidan Grisewood spoke to the slide on primary care pressures: there have been marked pressures on the Scottish Ambulance Service and NHS 24 since the turn of the year; these services remain under close review but there has been an improving trend in recent days. GP Out of Hours provision over the holiday period had been more robust than in recent years; not least due to the support of GP trainees in the workforce, which will now continue to beyond Easter. GPs are also playing a significant part in the COVID-19 vaccination effort, alongside other primary and community care providers.

Donna Bell provided an update on the social care sector, noting that there were around 180 care homes with active, confirmed COVID-19 cases; with infection broadly aligned to community prevalence. Staff absence was around 4% with some significant resilience issues at the local level. Further work is actively underway on additional oversight and support; alongside additional efforts on effective infection prevention and control. Current arrangements in support of the provision of PPE to social care will continue until June, and around 65,000 care home staff have used lateral flow tests since the programme rolled out. Public Health Scotland are undertaking further work on the impact of COVID-19 vaccinations in care homes to help inform future decision-making.

Discussion

John Burns commented that, notwithstanding the enormous efforts of all involved, workforce remains the biggest operational challenge for health and social care; with quite significant absences in care at home teams, which impacts on the ability to deliver some transfers of care. These pressures are being kept under continuous review with staff being deployed and redeployed to ensure resilience, as far as possible. Whilst there has been considerable and understandable focus on ICU pressures, John pointed out the similar impact on medical high dependency units, with associated staffing challenges; as more patients are cared for in those settings. John also highlighted the significant non-Covid pressures associated with normal winter activity, such as a rise in orthopaedic trauma cases, as a result of the recent icy weather. Patients are generally being admitted in a more ill condition than usual with an increased lengths of stay. John commented that mutual aid and support with neighbouring and national Boards is critical during this period; as is the ongoing wellbeing work, which staff truly value.          

Pauline Howie explained that, since Christmas Eve, there had been a significant increase in the number of COVID-19 patients that required to be taken to hospital. Non-Covid emergency activity is around 9% lower than what would be expected at this time of year. Around 40% of patients are being seen and treated or referred through flow navigation centres and community pathways; largely through video or telephone triage and consultations delivered by advanced practitioners. Significant efforts continue to help with staff resilience, including the return of seconded and retired staff, increased bank staff, and requesting the cover of additional shifts; balanced with the provision of appropriate rest breaks.          

Stuart Currie noted that the geographical areas of most pressure in the NHS are not that dissimilar to the areas of greatest challenge in terms of delayed discharge; and that we should therefore focus efforts on effectively tackling that.      

Donald MacAskill recognised that the issue of staff absence is patchy and, in some areas, critical. He commented that the main difference from the initial outbreak of the pandemic is the cumulative fatigue, exhaustion and demoralisation in the social care workforce. He was nonetheless very grateful for the roll out of both the testing and vaccination programmes.    

Annie Gunner-Logan reiterated the points made by Donald MacAskill about the stress and distress experienced by staff, coupled with the pressures of higher absence; recognising that further efforts may be required to promote staff wellbeing, as far as possible. Annie further noted that there are significant issues for children’s services: the staffing issues are often very similar; as well as pressures associated with the targeting of social care staff by anti-vaccination campaigners, alongside other misinformation; which needs to be countered in a productive and positive way. The Chief Medical Officer asked that such campaigns be brought to his attention so they can be investigated and responded to by the relevant authorities. 

Claire Ronald queried whether there is a national, consistent approach to dealing with the relatively large number of COVID-19 patients who will require post-ICU care, both physical and psychological, and do we have the workforce to deliver it? Similarly, Claire asked if there is a consistent pathway and workforce for long-Covid patients to access the care and support they will need. Jason Leitch confirmed that work is actively being progressed on considering those pathways, with associated, appropriate clinical guidelines.   

The Cabinet Secretary concluded this agenda item by thanking the officials for their presentations and Group members for the helpful points that had been made. Ms Freeman asked that work be taken forward to ensure that the Group can consider the planning assumptions and framework which is informing NHS Boards’ remobilisation plans for 2021/22 at the next meeting.

COVID-19 vaccination programme update    

Tracy Slater spoke to accompanying slides: over 360,000 people received their first dose of the vaccination in the period since 8 December; with a sharp increase in daily uptake recently: around 30,000 per day, compared to around 17,000 the previous week. All Health Boards were on track to complete first doses for priority groups one and two by 5 February; 94% of care home residents had been vaccinated to date, alongside 85% of health and social care workers, and just under a third of all those aged 80 and over. Around 100,000 vaccinations will be carried out per week through January, with 400,000 vaccinations per week planned from the end of February. Supply should be the only constraint to delivery. Work is underway for wave two; to support the scaling up of vaccine supply; to increase the vaccination workforce (both vaccinators and others); and to stand up additional vaccination locations.  

Alison Strath recognised some concern about the scheduling of second doses, assuring the Group that this is being actively considered as part of the ongoing planning for the vaccination programme. A second set of FAQs is being prepared for distribution which will include updated guidance on avoiding wastage. A third vaccine from Moderna has also been approved by the MHRA but supply is unlikely to be available until the beginning of April.  

The Cabinet Secretary thanked all those involved with the programme and its remarkable progress to date and opened up the agenda item for discussion.

Discussion  

Miles Mack reflected on a very positive experience so far with the vaccination programme. He commented that the clinical guidance meant that vaccinations were being carried out with set intervals and that any safe relaxation of this would be very welcome; radically increasing throughput, whilst reducing the risk of nosocomical infection. The Chief Medical Officer provided an assurance that the UK CMOs are actively monitoring safety data in relation to the programme, and that any updated guidance would be provided as soon as possible.                         

Patricia Moultrie concurred that there is a real appetite amongst GPs to get involved with the vaccination programme; and was supportive of the ongoing efforts to improve the distribution of the vaccine, as far as possible.

Graeme Eunson referred to the current workforce pressures on the NHS and asked whether Boards would have the flexibility to bring forward second doses for those staff supporting critical services, such as critical care in hospitals. The Cabinet Secretary confirmed that the Government is following the JCVI and UK CMO guidance on the risk prioritisation of groups for vaccination. There is a degree of flexibility for some Boards that recognises particular local circumstances, such as the effective use of resources on small islands.  

Harry McQuillan requested as early warning as possible for pharmacists, should they be asked to act as vaccinators, so that they can plan resources appropriately. David Quigley echoed this request on behalf of optometrists, and raised the associated issue of indemnity. Alison Strath confirmed that discussions were ongoing with Health Boards, pharmacists and other groups, and that clarification should be provided in the near future.  

Clare Ronald asked about points of access for independent health care workers and it was agreed this would be taken forward separately by officials.

Stuart Currie noted that there are ongoing discussions around how local government can redeploy staff to non-clinical, non-vaccinating roles to take some of the pressure off vaccinating colleagues; and that these are most effectively taken forward at the local level, based on local circumstances.

James O’Connell reflected that it would be important for the communications effort which is supporting the programme to address any concerns that the vaccines might not function as effectively against any new variants of the disease; thereby dis-incentivising take up.  

The Cabinet Secretary concluded this discussion by thanking all participants and asked that the points made by Group are appropriately covered in the second set of vaccination FAQs, referred to by Alison Strath.  

Any other business and future meetings

There was no other business. The Cabinet Secretary invited Group members to approach the Secretariat with any suggestions for agenda items at future meetings. The next meeting of the Group is scheduled for Friday 12 February 2021 between 09:00 and 11:00.  

The meeting closed with the Cabinet Secretary thanking all presenters and Group members for their valued contributions.

Scottish Government
22 January 2021