Chamber and committees

No—I accept that.

There is probably little for me to add, other than to say that I agree with Sarah Boyack. We have been talking about what things will be like a year from now; I am very confident that we will be out of the immediate grip of the pandemic by then, and we are making progress in absolutely the right direction. This and the last couple of weeks have felt extremely difficult, but we will get through this wave, as we have with other waves. However, the challenge is that the NHS’s recovery will take years. I do not think there is any Government, certainly across the United Kingdom, that would suggest otherwise.

Secondly—and, again, I agree with Sarah Boyack in raising the point—how people access their health service might well change, too. GP access is a good example. We want to restore face-to-face access to GPs where we can and as much as we possibly can, but we know now that that kind of access will be part of a hybrid model that will also include telephone and video consultation. We also have to ensure that our digital infrastructure keeps up, which I know is a particular issue in the NHS. If we are going to do this through digital means, we have to take on the point about digital exclusion that Sarah Boyack highlighted.

After all, we know that inequality exists, and more so in areas of deprivation. Thinking about the pandemic—and I will finish on this point—I do not think that there is any way that anybody can truthfully say that we were all in it together. We were not. There are people in communities that have been harder hit by the pandemic; for example, a look at the excess death figures shows that people in areas of deprivation are 2.5 times more likely to have died from Covid. Therefore, we cannot say that we were all in this together, and any work that the cabinet secretary and I do to build upon culture and the arts as part of mental and physical health and wellbeing solutions for the future has to be equitable. Indeed, that is something that those in the deep end project, who might be known to the committee, say to me very often: we have to make sure that we continue to direct resources into the communities that need them the most.

Yes, I agree. It would be foolish not to agree with that statement. It is absolutely the case that the pandemic—I often describe it in these terms—is the biggest shock that our health service has faced in its existence. It is impossible for that not to have had an impact on access to services and, therefore, on outcomes for people’s health and public health more generally. I have looked at the evidence that the committee has taken thus far, and clinicians and third sector organisations have given compelling evidence that people have not presented in the way that they would have done before the pandemic, which undoubtedly will have had an impact. There will have been an impact right across the country and right across the patient pathway, from diagnosis through to treatment and aftercare.

In asking your second question, which was about particular parts of the patient pathway, you referenced primary care. That is often the front door, as everybody round the table knows well, and the first port of call. Doctors, dentists and people across the range of primary care have been affected. I was at a surgery that Murdo Fraser probably knows well: the Taymount surgery—

I actually find that incredibly interesting—perhaps I am in the minority, but it is genuinely interesting.

We have a lot—a plethora—of data. As cabinet secretary for health, I regularly get reams of data. However, is that data joined up in the way that I would want it to be? Absolutely not.

I commend to Brian Whittle—he may already have seen it—and to any member who has not seen it our recently published document, “Enabling, Connecting and Empowering: Care in the Digital Age—Scotland’s Digital Health and Care Strategy”, which is available online. I was looking at the strategy again as Brian Whittle was talking. On page 8, it lists three important aims. The second aim—I am paraphrasing the strategy—is to ensure that our health and care services have the important digital foundation that can allow access to, and the ability to share, relevant information across health and care systems. Care is a really important part of that, too.

This is not necessarily about uprooting every digital system that we have—that way of thinking could almost be described as old school. Instead, on page 18 of the strategy, we go into more detail about how we create the cloud infrastructure that will allow data sharing to happen. We do not have to upend every element of our digital IT infrastructure in primary care, various health boards and so on; we just have to create the cloud infrastructure that will allow greater sharing of data.

We have got to do that, but how do we do it with the third sector and those who are external to health and care? My direction to my digital team—the approach goes across Government, too—is that, while obviously being mindful of and aligning with various frameworks and obligations around data, including data protection, we should not be putting up any artificial barriers to sharing data with the third sector, where that is appropriate. We still have work to do on that, but I would commend the digital health and care strategy to those who have not had a chance to look at it, as it goes into a fair bit of detail about our ambitions in that regard.

Thank you for giving that important context to your comments and questions. I do not disagree with the notion that we could do even better in relation to integration. The third sector plays a massive role in that.

Not too many months ago, I was in a meeting on the issue of delayed discharges—I know that Alex Rowley has raised that issue on many occasions in committee and in the chamber. The local third sector interface was part of that conversation, and a number of people from the third sector said exactly what Lawrence Cowan said. They felt that they were having to be proactive. I have certainly communicated to health boards and local integration authorities that they should be using every single resource in the community that they possibly can.

Over the past two years, and in deprived communities in particular, our welfare rights and money advice services across 150 primary care settings, and our community link workers—probably all MSPs have a good relationship with our community link workers—have been vital in helping to make those connections. However, I will be frank in saying why—a more detailed debate on what I will say is for another day—the national care service is so important. Social care is vital in helping us to deal with the pressures that we are facing, and it is under enormous pressure. However, we know that, if there is consistency of care throughout the country, that could make an important difference to the pressures that our NHS faces. I do not disagree with that.

Just last week, we published a really good piece of work by our primary care health inequalities short-life working group. Dr Carey Lunan, who is, I suspect, known to everybody in the committee, and some of her colleagues from the Scottish deep end project have done some brilliant work in that regard. I commend that piece of work to anybody who has not seen it.

Jason Leitch might want to respond to that, too, but I do not see and have never seen such things in a binary way. For example, a number of people who are in hospital with Covid might have been admitted for other reasons and have caught Covid while there, and we know that Covid can exacerbate underlying health conditions such as respiratory problems and diabetes. I do not think that we can say, “Let’s stop focusing on Covid and start focusing on other conditions.”

It is also true to say that the pressures that we are facing will diminish significantly when we are able to control Covid. Although 2,000 Covid patients might in the grand scheme of things seem like a small enough number, given how many beds that we have in our hospitals, the IPC that goes around those patients puts significant pressure on the health service. With community transmission as high as it is at the moment, levels of staff absence in our health and social care system will tend to be higher, and there has also been an increase in delayed discharges, because, as I have mentioned, our ability to discharge people into care homes has been severely diminished as a result of the increase in outbreaks. Controlling Covid will therefore be essential in helping us recover with regard to the non-Covid conditions that John Mason has mentioned.

At the same time, though, we are focusing on those very conditions. Before I became health secretary, we had the cancer plan, which was backed by £114.5 million; when I came into post, the early cancer diagnostic centres were being rolled out; and we have recently launched the “Endoscopy and Urology Diagnostic: Recovery and Renewal Plan”. We are looking to recover our position with regard to non-Covid conditions, but I do not see it as a binary choice of focusing on one thing or shifting the focus to something else.

We know that this probably will not be the last wave of Covid, or even the last period of concern in relation to Covid. The real challenge is how, when we have waves, we protect the diagnosis and treatment of non-Covid conditions, including carrying out elective surgery and unscheduled care, while managing and treating Covid. We have not been able to crack the answer to that yet. Part of the answer must be some of our work in and around the hospital at home programme, which includes a treatment pathway for Covid. Another part is about how we treat people with antivirals at home as opposed to admitting them to hospital.

There was a lot in that. I do not know whether Jason—

There is a need for communication. I think that it was Dr Shackles who said that there needs to be an open and honest conversation with the public. If it was not Dr Shackles, I will be happy to correct the record, but one of the clinicians who gave evidence to the committee talked about having an open and honest conversation. I hear that from clinicians day in and day out, time and again, and I do my best to be up front about the fact that the recovery will not take just weeks or months—it will take years. People are now coming to accept that, and the reasons for it.

I should say that we had a hybrid model before the pandemic. People were able use telephone and video consultations, but those were being used nowhere near to the scale that they were used during the pandemic.

There is a balance to be struck. My direction, which is spelled out in the recovery plan, is to increase face-to-face access to GPs, because we know that there are possible issues with digital exclusion and we must work hard to narrow that exclusion and eliminate it altogether. I hope that I am not overgeneralising, but we know that some of the older constituents that we represent might want to see their GP face to face, and it is important that, when people wish to see their GP face to face, and when it is clinically appropriate, it should happen.

However, we must also continue to invest in telephone and video consultation facilities. To go back to the question that Brian Whittle asked, there is something about how we access the NHS and health and social care through digital that is going to increase. There are good pilots that show how we are doing that, and we probably need to upscale those.

I have a few points on that. There has not been any progress on the matter that I raised with the UK Government. I always thought that it would be a long shot, given the financial pressures that everybody is under. That said, I will continue to pursue the issue to see where pension changes could be made, if it is possible, to help with retention. I have given the BMA a commitment on that.

The BMA has rightly challenged the Scottish Government and asked what more we can do in this space. For example, it has asked me to give active consideration to a recycling employer contributions scheme, and to giving health boards the ability to activate such a scheme if it would be in their interest to do so. As I said, that is, and continues to be, under active consideration.

However, I go back to the point that Jason Leitch made. Of course we have to deal with any financial disincentives that might be in the system. However, if we can control Covid—or rather when we control it, because we will—and begin to recover in stages, in a managed way, we have to do so in a way that does not exhaust a workforce that is, to be frank, already knackered.

In a GP practice, that is not just the GP alone—although, of course, they will be knackered. It is the multidisciplinary team, including the receptionist, who will always be the first person that people talk to. Receptionists tell me that they have experienced an increase in abuse over the phone and in person, so we need to ensure that they and their wellbeing are well taken care of. We have invested record levels in the wellbeing of NHS and social care staff, and we will continue to do so.

We will do what we can to rid the system of financial disincentives, and we will actively consider that issue. We will ensure that staff are well paid. As you would expect me to do, I reiterate that we have the best-paid NHS staff in the UK. We will also ensure that we do what we can to retain staff. There is a whole section in the recently published workforce strategy on nurture—in fact, it is a thread throughout the entire strategy—which looks at what needs to be in place for the wellbeing and retention of staff in order to help with recovery.

No, we are not giving that advice. There is no doubt that the dentistry sector has been hit hard, for all the reasons that I gave to Murdo Fraser, particularly given the aerosol-generating procedures that dentists have to carry out. However, dental practices are opening up and are taking the appropriate precautions. We have provided dental practices with support and grant funding for ventilation and for drills that can be used to mitigate the effects of aerosol-generating procedures.

Through what is in essence a multiplier, we will reward dentists who do more NHS activity. We had a good debate about dentistry in the Parliament recently. I am sure that this is happening only in a minority of cases, but we heard some concerning stories of dentists upselling private plans to their patients. That is, of course, not allowed within the regulations, but it is also deeply unethical. Through our funding arrangements, we will reward dentists who see more NHS patients.

We will recover, but I cannot give an exact date for when the recovery will be complete because, as we have discussed, we are still in the midst of the pandemic. Until we get to pre-pandemic levels of activity, I am afraid that the backlog will continue to increase. That is true across the health service. Only when we get to pre-Covid levels—or, I hope, above pre-Covid levels—will the backlog begin to reduce. Given that we are still in the midst of a global pandemic, it is difficult to give a definitive date for when we think the recovery will be complete.

Thank you for putting that plea on record. Again, I want to assure you that I am not going to treat anybody around this table like a fool. We are under significant pressure, and there is a huge list of priorities, at the top of which is the pandemic and the recovery. I do not see what we are discussing as being separate to that, but coming back to Dr Allan’s earlier point, I think that the challenge will be how we embed it within the recovery. As we have admitted, there is a piece of work that has to be done on this aspect of the recovery. If we can embed all of this as first principles in that recovery and as part of the national care service, it will make things far easier as we move forward. As I have said, I do not see these things as separate, something nice to do or a bolt-on. We already have some good practice, particularly in the mental health base, but the issue is how we build upon that and make it part of the recovery.