Chamber and committees

Again, Sir Lewis Ritchie might want to add to what I will say.

I have often been asked about a number of cottage hospitals from which, unfortunately, we had to take staff during the height of the pandemic to send them to large acute sites, and whether there is merit in bringing them back on stream to help us with the social care challenges that we face. I have raised that issue with the chief officer in Dumfries and Galloway in particular. Her response was very interesting. She said that the staff who were taken from particular cottage hospitals can offer more hours of care to more people receiving care at home. Instead of being able to look after 10 people at a time—I am making up the numbers for the sake of illustration—they were almost doubling that and were able to look after and provide care for almost 20 people in their own homes.

Cottage hospitals play an enormously important role within our health and social care services. Decisions about where the balance of benefit is in staffing and the care that the staff can provide have to be made at the local level.

I think that both my colleagues want to comment on that.

I will hand over to the CMO shortly for him to add his clinical expertise, but it is fair to say that they are well understood. One of the most difficult decisions that was taken during the pandemic was the decision to pause elective care, and there is no doubt about the effect of that. If someone is on a waiting list, the effect of cancellation is not benign. People deteriorate and decondition. We are seeing people present sicker and with higher acuity, and that deterioration and deconditioning are contributing factors to that.

I regularly speak to orthopaedic surgeons in particular and to the Scottish collaborative orthopaedic trainee research network—SCOTnet, as it is known—and they often tell me that there is no doubt that given the difficult but, I would say, necessary decisions that were taken during the pandemic, people on waiting lists are deteriorating and deconditioning, particularly if they are on long waiting lists. That is why, when I announced certain targets in the summer, the focus was on those long waits, because we know that people who wait for excessively long times for elective care will come to harm. There is no argument from me on that. My goodness—when we speak to people who suffer with chronic pain, we can really understand from their perspective how detrimental that is to them, and I will not pretend otherwise.

In the context of the winter pressures, Evelyn Tweed will be aware that three health boards have taken the decision to have a time-limited pause on elective care. I stress the term “time-limited” because, although those are local decisions, I have made it clear to those health boards—they understand this and there is certainly no argument from them on it—that the measure should be in place for as little time as possible, given all the impacts that pausing elective care can have.

That is also one of the reasons why we did not move the entire NHS to an emergency footing during the winter. Some people called for us to do that, and I understand where those calls came from. However, if we had moved the NHS to an emergency footing, as we did during the early days of the pandemic, instead of three health boards pausing elective care, all 14 territorial boards would potentially have done that. That would have had a severe impact on people up and down the country.

Please forgive me for again giving a fairly long answer to a short question, but I hope that that gives you an understanding of the situation. I will bring in Dr Smith.

I referred to the RCN round table that Gillian Mackay and I both attended. I will not reiterate everything that I have said about the retire-and-return policy, but I am happy to provide more detail to the convener, who could share it with committee members.

First, that policy came as a direct result of our hearing nurses in particular say that, after 20, 30 or 40 years in the profession, they were thinking of leaving because of the inflexibility around the possibility of retirement and return. Many of them just wanted to reduce their shifts, but the inflexibility of the system did not allow them to do so.

Secondly, it is worth reiterating the obvious point that one of the most significant things that we can do to try to retain our workforce is to reduce workload pressure. All of us round the table have spoken to NHS staff, and whether they are nursing, medical or midwifery staff, they always use the word “relentless” to describe the past three years. They have often told me that in a typical NHS career in a hospital—the same thing happens in community, primary and secondary care—they gear themselves up for the winter, during which they know that they will have a rough few months, then the pressure begins to ease, and they then gear themselves up once more as we get towards winter again. In effect, however, that has not happened for three years: there has just been relentless pressure.

Notwithstanding how difficult the past few weeks have been, the work that we are doing to try to reduce workload pressure means that, although it will not be easy, we will begin to see an easing of the most extreme pressure that we have seen throughout the winter. The question is what we can do to try to stabilise the service so that it does not feel as relentless as it has felt in recent months and years.

Pay is important. We cannot skirt that issue. Ensuring that people who work in our NHS and indeed in social care are appropriately rewarded is really important. I will not rehearse again everything that I have already said on that, but we have a fair pay offer on the table. Gillian Mackay will know that, at the end of last week, we came to an agreement with the three trade unions that were in dispute and had a strike mandate that they will pause strike action, and we will enter negotiations on 2023-24 pay this week.

Pensions are really important, too. The point on the disincentive around pensions comes up regularly, particularly from the medical workforce. I will not rehearse again what I have already said, but the Government can take and has taken action in relation to the BMA wanting to go further with pensions.

That is important in a rural setting. It is important everywhere, but the real advantage of a rural setting is the improved work-life balance that attracts people to work there. For retention purposes, we have to work and are working across Government and across portfolios to deal with housing, education and later-life provision for people, all of which has to form a holistic package.

Again, please forgive me for giving a long answer. I think that Sir Lewis wants to comment.

First, there is no doubt that the feedback overwhelmingly suggests that, if we can train people locally, there is a better chance of retaining them locally.

I will not rehearse what has already been said about the ScotGEM programme, but our GP fill rate for that in the north of Scotland is exceptionally good. I have mentioned the shortened midwifery course, which involves distance learning so that people can stay in their localities while they study and train to become midwives. We are already doing a lot in that space.

I have said to health boards that they should be as innovative as possible. We are looking at how many of the additional training places that we have made available for the medical workforce can be filled by those from remote, rural and island health boards.

For the sake of brevity, it is worth saying that there is no doubting the premise of Carol Mochan’s question. A fair bit of work is going into making sure that we have as many training places as possible in remote, rural and island Scotland, whether those are for nursing, midwifery, GPs or other parts of the medical workforce.

I know that we are tight for time, but Sir Lewis Ritchie probably has the necessary expertise to comment on that.

It is certainly not a situation that I would want to find my wife in, and I would not want to be in that situation myself if I was driving my pregnant wife along the A96. I am sure that we will touch on Caithness, too. It would be the same for people there. Let us consider what the weather is like in Caithness now and has been over the past few days.

I would not want to be in that position. However, it is worth saying at this stage that there is not another local matter that I have spoken more about in the chamber—in ministerial statements or debates—than Dr Gray’s hospital. Rightly, it gets significant attention from me, as cabinet secretary, and from the Government. I will not rehearse the latest position on it, because I think that Sandesh Gulhane was in the chamber during the last debate, and if not, he will certainly have apprised himself of the latest position.

The safety of women and their unborn children has been at the centre of our thinking on Dr Gray’s hospital. We could not, in good conscience, have a consultant-led service tomorrow, because if we said that all pregnant women in Elgin and Moray should give birth in Dr Gray’s from tomorrow, next month or later this year, we would be putting women and their unborn children at risk of very serious harm.

Part of the discussion on that can be understood if we look at what Ralph Roberts said in his report about Dr Gray’s. He referenced “low risk” elective C-sections. I am very aware that I am talking to a doctor, who I suspect will have far more clinical expertise than anybody else at the table has, and who will therefore be the first to understand that a low-risk elective C-section can quickly turn into a high-risk elective C-section, as there is potential for bleeding or haemorrhaging and for blood transfusions and other such things to be needed. The facilities at Dr Gray’s hospital would not allow for such issues to arise, so even what is termed as a low-risk C-section in Ralph Roberts’s report requires significant investment in the facilities and the workforce.

As the member knows, NHS Grampian has recently come forward with a plan for the return of consultant-led maternity services sooner than was previously predicted. In the chamber, a number of people referenced a 10-year or seven-year timescale, but the member will know that the timescale that NHS Grampian proposes is far shorter than that—it goes just beyond the end of this parliamentary session, in 2026. That is positive, but I do not underestimate how much of a challenge it will be to get there, and that is why workforce and recruitment and retention issues will be at the core. Investment and capital infrastructure are not as difficult as recruitment and retention.

Forgive me—that was a long answer to a short question, but I do not feel that it would be safe if we instructed that all pregnant women in Moray should give birth at Dr Gray’s hospital; it would not be safe for the women or for their unborn children, given the challenges around the workforce and facilities. The chief medical officer might want to add to that answer, given his clinical expertise.

We always do our best to do that. As soon as we have got through one winter, we start planning for the next. Of course, the remote and rural challenges can be significant. I will highlight two aspects that have been central to our planning for winter—and even before winter—with regard to the extreme pressures that we face in the NHS. We take a whole-systems approach to both the front-door and back-door aspects at our very busy acute sites.

At the front door, we try to reduce attendances, which is definitely having some purchase—we see that it is working, although we will continue to look at whether we can reduce attendances even further. We do that by ensuring that people get the right care in the right place at the right time through access to other services such as NHS 24, the pharmacy first Scotland service and out-of-hours general practice.

From a remote and rural perspective, that can be more challenging, because the nearest service might be further away from someone. Even if they have a car, access can be tricky, and if they do not have a car, it might involve taking a couple of buses. That can be tricky, and people might think, “If I’m unable to get there, perhaps the safest option is to go to A and E”, because they are worried about their condition, or a family member’s. That is one of the real challenges.

Our colleagues in NHS boards—and particularly the remote, rural and island boards—have been working hard to try to make services as accessible as possible. That goes back to David Torrance’s very good question on the use of digital. NHS 24 is a service from which anybody across the country can get clinical advice; it has a number of clinical supervisors who provide excellent advice.

At the back door, we know that one reason why we are facing such significant pressures this winter—I note again that we were facing pressures before winter, too—concerns the high levels of occupancy and delayed discharge in the system. Again, I highlight how important social care is, as it is critical for us to be able to discharge people who are clinically safe to be discharged. Looking at the landscape of social care, there is no doubt at all that those social care providers in remote and rural areas, both care-at-home providers and care homes, are really struggling. There are a range of reasons for that, but they include fuel costs, which are often higher in remote, rural and island settings. Our local health boards will work with those care providers to see whether they can make adjustments or provide any additional support to assist with those particular challenges.

To summarise, it is vital that we look at the unique winter challenges that those in remote, rural and island Scotland face. The answer to Evelyn Tweed’s first question, which was about whether our remote, rural and island partners are involved in that winter planning, is yes—absolutely. Of course they are. I have given two examples, but I could give many more, of where there are unique challenges for places in Scotland with particular geographies. We are very alive to them and we are trying to assist during a very difficult winter.

Thank you, convener. Long time no speak. I am keen to take any questions that the committee might have.

As you heard in the session that we have just concluded, it is so important that the health service is able to meet intense challenges, such as we are currently facing, as they arise. The order gives additional flexibility to the GDC and NMC to help the health service to respond to some of those challenges.

Since the end of 2020, European law on recognition of qualified healthcare professionals from the European Economic Area no longer applies in the UK. Current stand-still arrangements mean that the UK professional healthcare regulators continued to automatically recognise EEA and Switzerland-obtained qualifications for up to two years after the end of the transition period. The period of automatic recognition ends in early 2023, when the Secretary of State for Health and Social Care will review the approach to registering professionals who have qualified in the European Economic Area.

The order is being made under section 60 of the Health Act 1999. It will amend the Dentists Act 1984, and the Nursing and Midwifery Order 2001 and other subordinate legislation. The order will change the legislative frameworks of the GDC and the NMC to allow them to amend their registration processes for international applicants.

Both the General Dental Council’s and the Nursing and Midwifery Council’s governing legislation prevents them from making changes to their registration processes. In the case of the GDC, the legislative structure makes it quite difficult and time-consuming to make changes to its registration process. Likewise, the NMC must follow an overly detailed procedure to carry out assessments for international applicants.

The order makes a number of changes to the legislative framework on the NMC’s and the GDC’s international registration requirements. First, it allows the GDC to apply a range of assessment options to determine whether applicants have the right knowledge, the right skills and the right experience to practise in the UK.

Secondly, it removes the requirement for dental authorities to use an assessment for overseas applicants, such as the overseas registration exam, known as the ORE.

Thirdly, it allows the GDC to charge fees to international institutions for expenses that are incurred in relation to international registration, so that it can cover the costs of recognising international qualifications that meet UK standards.

Fourthly, the GDC will be able to make rules that set out the details of its international registration processes without the need for Privy Council approval, so that that change can be made far more efficiently.

Fifthly, a transitional period for the ORE will continue to apply for 12 months after the order comes into force, at which point the GDC will publish new rules for its international registration processes.

Subject to parliamentary approval, of course, the effect of the order will be to allow the GDC to use increased flexibility to set out two international registration routes based on an assessment of an applicant’s qualifications, skills or training, and completion of an ORE-style assessment, and the recognition of an applicant’s qualifications where the GDC has assessed that qualification and considers that it provides applicants with the required knowledge, skills and experience.

With regard to the changes to the Nursing and Midwifery Order 2001, the NMC will continue to apply its test of competence as the main assessment route for international applicants, which will remain in the legislation as one of the ways that the NMC can ensure that an applicant meets its standards.

However, the order will bring in other pathways for registration. First, there will be recognition of an NMC-approved programme of education from outside the UK. Secondly, in limited situations, there will be a qualification comparability exercise, which the NMC will use to judge whether the applicant’s qualification is of a comparable standard to an NMC-approved UK qualification. In either situation, applicants would still need to meet the NMC’s other registration requirements, such as on English language, indemnity and payment of the registration fee.

I fully support the instrument as a pragmatic solution that will improve consistency and give the regulators much-needed flexibility in responding to the changing circumstances. I am happy to answer any questions that members have.

I will let Dr Smith come in in just a second, as he has been integral to the ScotGEM programme. We have already grown the intake. We often get calls for health boards that are not part of the ScotGEM programme to be involved—in fact, the convener is one of the advocates for the expansion of that programme.

Now that we have had the first cohort of graduates, it is important to ensure that the programme is stabilised before we consider expanding it to additional health boards, for example. At the moment, as you say, it is a graduate entry programme. I think that extending it to undergraduates would be challenging and quite disruptive to a model that we are trying to stabilise.

The programme is hugely popular, and we should be open minded about potential expansion in the future. My view is that, at the moment, we need to ensure that it is stabilised and that we are getting the benefit from the programme. Dr Smith might be able to add to what I have said.

I could be very brief and just say yes. There is the potential to use digital or mobile technology and equipment to deliver training. I have seen fantastic examples of simulators in our training facilities. It is incredible just how real it feels—even as a non-clinician, I could feel my heart racing as those who were training were dealing with a medical emergency in that simulated environment. In short, yes, we are exploring that and seeing what more we can do in that respect.

That is a good question, because it is clear that a delay in diagnostics has the potential to have a real impact on an individual’s health outcomes. None of us wants to see any delay in diagnostics.

Dr Gregor Smith and I were involved in the press briefing yesterday, and the issue of diagnostics came up on the back of the FOI request and relevant articles. I will say a few things in response. First, the pandemic has had an obvious impact. That situation is not unique to Scotland; it is replicated not just across the UK but around the world. People have had to make exceptionally difficult decisions.

Dr Smith and I spoke about the difficult decisions that were made on elective care. I do not think that I would be overegging it to say that one of the most difficult decisions, if not the most difficult decision, that was taken during the pandemic was on the pausing of cancer screening. It was paused only for a brief period, but even a single day of pausing screening can have an impact, let alone pausing it for a period of months, as we had to do in the early days of the pandemic. Such a decision is never taken lightly, but those decisions were taken as a result of the pandemic, and they had an impact on our health service, which is why there is a backlog of that scale. I am not suggesting that there were no delays in diagnostic testing before the pandemic, but I think that an objective observation of the figures would show that the pandemic had a significant impact on the level of delay.

In the information that resulted from the FOI request, I noticed that a few people had, unfortunately, waited for far too long. I will go back to what the First Minister said yesterday: no one should be waiting for as long as five years, as happened in one case. That is an absolute anomaly. We need to understand why that happens in individual cases, because even if that happens in only one case, or in a few cases, it will have an impact on the individual who is involved. However, waiting for that length of time is not the norm.

What are we doing about that? I will double check the detail, but we have invested in, I think, six mobile MRI scanners and five mobile CT scanners. That is relevant to rural Scotland. The investments that we have made thus far have provided some additional capacity. We have also looked at the winter pressures that we have clearly faced and are facing, and I have put an additional £1.5 million towards diagnostic and radiology services. From memory, that will give us in the order of 15,000 additional scans between January and the end of March. I will double check that number, and if I am way off, I will come back and correct the record. We will keep investing to try to increase the capacity of diagnostic services where we can.