 i'r next item of business, which is a statement by the Cabinet Secretary for Education and Skills and the Cabinet Secretary for Education and the Deaf, Shona Robison, on response to exceptional winter pressures. The minister will take questions at the end of her statement. If members wish to ask a question, I would encourage them to press their request to seek buttons as soon as possible. Shona Robison. The staff of the NHS are the beating heart of the service. They have been nothing gyda'r cyd-grifennidol yn y cyfnodol o'r cyd-grifennidol sy'n gyllid y cael eu cyfnodol. Mae'n cael eu cyfnodol yn gynhyrch, mae'n cyffredinol i'r cynnig ac yn gwych yn bwynt ac mae'n gynhyrch i gael unrhyw sy'n cael ei ffordd a'r cyfnodol i'r cyd-grifennidol yn y gweithio cyfnodol. Mae'n dwylo'n cyfrifennidol gan ymddangas i'r syfrigol i'r cyfrifennidol i gyfnodol i'r and social care staff for their continuing dedication. That thanks is shared by patients and their families, many of whom have contacted me to praise the efforts of staff. Equally, I want to apologise to patients whose treatment has been delayed. I want to take this opportunity to thank them and their families for their patience and understanding during this extremely busy time. Each year, we try to prepare for the additional pressure winter can bring. That includes working with the service and other partners since the summer to prioritise and invest an extra £22.4 million to meet A&E and winter pressures. However, our NHS is facing a number of sustained challenges this winter. Emergency departments seeing the highest level of attendances over the festive period in a number of years. During the two-week festive period, attendances were up 10 per cent compared to the same time the previous year. In the week leading up to Christmas alone, that level rose to 20 per cent. We saw a huge surge in falls and fractures before Christmas, which has undoubtedly impacted on the number of admissions and length of stay in hospitals. Some hospitals reported the level of demand in one day, being the equivalent to average demand for a week. Flu rates in Scotland doubled in December, with the most recent figures from Health Protection Scotland showing that around 46 Scots in every 100,000 were suffering from the virus compared to 22 in every 100,000 for the same week in 2016. Over the festive period, there were over 73,000 calls to the Scottish Ambulance Service between 15 December and 2 January. Indeed, overnight on Hogmanay, the Ambulance Service saw its control centres take almost 40 per cent more calls compared to the same time last year. NHS 24 received more than 45,000 calls in the four days over Christmas, almost double the number of calls of the same period last year, with thousands more calls being taken over the new year period. Christmas Day in particular was the busiest for NHS 24 since it began in 2002. In short, the demand for emergency care services has been unprecedented over the festive period. Our NHS has sought to manage the impact of that in a number of ways. For example, we are necessary for infection control. Hospitals have on some occasions closed wards, which means that those beds can be closed for a number of days. NHS boards are taking decisions to manage the exceptional demand based on their local plans, which may include some deferral of non-urgent elective surgery. Boards are reporting that over the festive period, the level of cancellations were consistent with that of previous years. It is important to say that, unlike in England, there is no blanket cancellation of non-urgent elective procedures planned. In England, it was reported that an estimated 55,000 non-urgent operations could be deferred as a result of their deferral of all non-urgent inpatient elective care to 31 January. I would like now to take some time to set out the impact of flu on our health service and on our population and what action has been taken. I have already outlined the increase in flu rates this year, which is at its highest level in the last six years and double that of last year. It is right that we take flu seriously and note that Scotland was hit by flu earlier than elsewhere in the UK. As we do every year, we put in place preparations ahead of the flu season commencing. We have worked to ensure that flu vaccines are available to those who need them and that people are aware and encouraged to be vaccinated. Each year, the World Health Organization reviews evidence from previous years and determines the most likely flu viruses that should be covered by the vaccine programmes in the northern and southern hemispheres for the next influenza season. Those are the only vaccines that are available on the global market. The data tells us that the most commonly found flu types in Scotland so far are well matched to this year's vaccine, and it is ill-informed and alarmist to suggest otherwise. Sustained exceptional levels of demand or regular peaks in demand, such as during increased flu levels, requires different clinical processes from the usual systems in place in hospitals. Of course, the vaccine is only useful if we can make sure that as many people as possible receive it. I note that the Conservatives claimed over the weekend that uptake rates in Scotland have dropped. The fact is that our uptake rates are broadly in line with the uptake in previous years. Overall, to the end of the second week, the second last week of 2017, over 1.4 million people had been vaccinated by the NHS in Scotland. That is 26 per cent of the whole population. To the same point in the previous year, 26 per cent of the population had been vaccinated, so we are in line with where we were last year. In fact, in some eligible groups, we have increased uptake. For example, pregnant women with risks have increased to 57.5 per cent, which is a higher rate than in England. In Scotland, all primary school children have been offered the vaccine since 2014-15, providing improved immunity to the wider population. This year, 71 per cent of that primary school population has been vaccinated, but in England this year, only children in the first four years of primary school are offered the vaccine, and uptake in that group, by the way, is 50 per cent or less for each of those four-year groups. I want to say a word about healthcare staff vaccination. It is lower than we would want it to be, and I am absolutely grateful to the NHS staff for all the hard work that they do, but in this particular area, I think that we can go further. We estimate that so far, more than 40 per cent of healthcare staff have been vaccinated. That includes both patient-facing and non-patient-facing staff, whereas the English figure only includes front-line healthcare workers. I would caveat that by saying that the figure may be an underestimate, as it will not reflect the proportion of staff who may have been vaccinated through the national programme because of clinical eligibility. We have made clear to the NHS that free seasonal influenza immunisation should be offered by NHS organisations, including primary care employers, to all employees directly involved in delivering care. I know that NHS boards across Scotland have worked hard to promote uptake through innovative approaches and in providing leadership through senior clinicians and managers. We have supported them with national resources, including developing a toolkit that helps those charged with promoting and delivering planning of their local flu campaign and providing campaign posters and leaflets to every health board in Scotland. This year, our public campaign, which launched in October, included adverts for the childhood flu and seasonal flu programmes for adults ran on television, radio, digital and social media platforms. We have also worked with a wide range of partners to distribute promotional materials, including the British Heart Foundation, British Red Cross and Scottish businesses that are healthy working lives registered, in total that resulted in 106 organisations supporting the seasonal flu campaign and 93 organisations supporting the childhood flu campaign. Campaign materials for the general public, from GP surgeries, nurseries, libraries, community centres and antenatal clinics, have also been distributed. Although, ultimately, the decision about whether or not to be vaccinated is down to individuals, I am sure that we would all want to take this opportunity to urge all those who are eligible to get the flu vaccine as soon as possible if they have not already done so. Finally, there has been some rather alarmist commentary on flu mortality rates that have been reported, which needs to be corrected. Four people have passed away in hospital who were admitted with flu-related symptoms. Each one of those deaths is a personal and family tragedy. However, all-cause mortality is not the same thing as flu-related deaths. That data reflects deaths due to any cause—accidents, other diseases, old age—not just about flu. On that point, timing is important. This three-week period at the end of 2017 reflects a period before we really started to see flu infections presenting in our hospitals, so it is too simplistic to say that this excess is explained by flu. What I can say is that work is under way by public health experts to investigate this urgently so that we can use facts rather than speculation. As I have said, there are a number of factors contributing towards the current pressures, which have not just been about flu, but clearly it will be a key factor over the coming weeks. Usually, the winter flu season has an eight to 10-week duration, so it is too early to say what the end-season picture will be, but we must view the current and emerging data in the right context. We must also allow space for our health service to continue to treat our sick patients with flu-like illnesses or other conditions and to allow them to recover from what has been and still is a very challenging time. NHS and care staff have worked incredibly hard over the past few weeks and have pulled together to cope with winter pressures. I want to pay tribute to them again. They deserve the collective support of this Parliament in their endeavours, and I hope that that is what they will get today. I start by thanking the cabinet secretary for advance copy of her ministerial statement. I also associate those benches with what she has said today. All of us in this chamber have been able to see over the past few weeks the tremendous work that those who work in our health service have provided to our constituents and our families, and we all pay tribute to them and their dedication. Can the cabinet secretary answer that question? Is she able to confirm the alarming reports that the Scottish Ambulance Service's national command and co-ordination centre, normally reserved for major incidents such as terrorist incidents and emergencies, has been set up and operating for several weeks now because there has simply not been enough call handlers in local call centres and not enough crews out on the road to cope with current high levels of demands? Can she tell Parliament what extra support she will be providing hard-pressed ambulance staff, paramedics and call centre operators? I thank Miles Briggs for his comments about the staff. It is really important that the messages that we send out are in support of our hard-working staff, because they have pulled together in a way that has been absolutely astonishing. It is, upon each and every one of us, in the comments that we make to get behind our staff in those efforts. Miles Briggs talks about the Scottish Ambulance Service. The Scottish Ambulance Service has escalation procedures that kick in when they are under pressure, so if you look at the 40 per cent rise in calls on Hogmanay, what the senior management team will do is to escalate procedures to make sure that the command and control processes reflect that level of demand. Of course, we would expect them to do nothing less than that when they are faced with those demands on the service. Of course, we support the Scottish Ambulance Service and all the other parts of the system in responding to that. I, on a daily basis, get updates of what the service is looking like, including the Scottish Ambulance Service, and we keep very, very close to monitoring that. What I would say is that the Scottish Ambulance Service has done a tremendous job in responding to the unprecedented level of demand, and I want to put on record my particular thanks to them. That is similar. We all give our heartfelt thanks to all our amazing NHS staff who go above and beyond all year round, but particularly at Christmas. To be clear, any failures in our NHS is despite their fantastic efforts, not because of them. However, this is not just a winter issue. It has been left overworked, undervalued and under-resourced all year round, and this is now amplified in winter. Yesterday, the First Minister and the Health Secretary issued an apology for winter failures, but every month cancer patients don't get their treatment on time. Every month, children are denied mental health support, and every month patients are waiting too long. A new analysis has shown that more than 100,000 patients failed to meet the four-hour A&E standard in 2017. There is not just one apology in winter that is needed from the First Minister and the Health Secretary, but more than 100,000 apologies are needed all year round. Can the cabinet secretary tell us when the warm words will stop because thank you alone is not enough and when we will actually see meaningful action in support of our NHS staff and in support of Scotland's patients? I say to Anasarwar that the actions that we are taking is making sure that through the draft budget, which I hope he will support, will provide record levels of new investment to the NHS, and I look forward to his support for that budget. I say to Anasarwar that we are also making sure that we provide the support and resources all year round. In winter this winter, we have provided the biggest level of injection of resources that we have seen in any winter, £22.4 million specifically to help the service to cope with winter pressures. In terms of an apology, all health systems across the UK have issued an apology to patients who have had to wait longer. Do you know something? Patients have been hugely praising of the staff. The public has been very understanding that, in the face of winter pressures an unprecedented level of flu doubled the rate of last year, they understand the pressures that are upon our system, even if Anasarwar does not. A final word on A&E, Scotland's A&E departments have been the best performing over two and a half years, but this winter, for even our best performing A&E departments, my local A&E department in nine wells has never fallen below 95 per cent over the last two weeks because of the pressures of fractures, of flu and unprecedented winter pressures. I think that the most reasonable people would understand that. John Finnie, to be followed by Alex Cole-Hamilton. Thank you, Presiding Officer. I thank the cabinet secretary for the early sight of her statement. I would also like to thank the national health service staff. Cabinet secretary, you talked about working across and beyond boundaries, and I heard of a situation where there were frequent falls in an area of the local hospital, being inquiries with local authority and discovered that the local authority no longer gritted that area around pensioners houses, but indeed the NHS paid to grit it. Now, if correct, I would commend that approach in the preventative steps that have been taken, and you alluded to in your statement, including the few flu inoculations. Cabinet secretary, do you recognise the benefits to the NHS of additional funding for local authority, social care and indeed gritting operations? Will you ask the cabinet secretary for answer to direct more money to local authorities for those specific purposes? First of all, to John Finnie, one of the main issues before the flu epidemic hit Scotland was the level of fracture. He makes an important point about the impact of those falls on the NHS, in that we had a wave of mainly frail elderly people, many of whom had to have operations, and I know that in Ninewell's hospital there were theatres dedicated only to fixing fractures. Many of those elderly people are still in hospital, so usually Christmas and New Year you see bed availability increase as people leave hospital this year and have not seen that because of that wave of fractures. In terms of the resources put into social care, we have now got about £550 million of resources that have gone through the health budget into social care. That will be added to by £66 million in the budget for 2018-19, but what has been more important than that is the joined-up service. When I visited the Perth Royal Infirmary yesterday, I visited the discharge hub, and there you had side-by-side local authority colleagues working with the NHS, making sure that people were getting home as quickly as possible and, in many cases, preventing people from coming into hospital in the first place. That is integration, working well and we should pay tribute to all the staff involved. Alex Cole-Hamilton, to be followed by Jenny Gilruth. Thank you to the cabinet secretary for advance sight of her statement. I absolutely echo the praise that has been rightly delivered by all sides of this chamber to our hardworking NHS staff. Does the cabinet secretary expect Parliament to believe that a bout of icy weather and an uptick in flu cases are genuinely all that it would blame for the worst waiting times on record, or is this not just symptomatic of a health service on its needs, where those additional pressures are heaped upon hardworking staff fighting fires in every overstretched shift that they do? No, because those are unprecedented winter pressures, unlike what we have not seen for years. We cannot have a doubling of the flu rates and not expect that to have a severe impact on our front-line services. Alex Cole-Hamilton says that we have put in additional resources of £22.4 million in anticipation of a colder winter. The doubling of flu has exacerbated those issues, and it is not just an issue for Scotland—all of our health systems across the UK are facing the same, if not worse, winter pressures. Alex Cole-Hamilton says that our A&E departments, because they were performing at such a high level going into winter, had a resilience. Many A&E departments across the rest of the UK did not, and it will be interesting to see when their figures eventually come out what the comparison is with the festive season here in Scotland. I think that that will be interesting indeed. Jenny Gilruth will be followed by Brian Whittle. To ask the cabinet secretary how attendance at A&E departments during the festive period compares with the past few years. As I laid out in my statement, they have been much, much higher than in previous years, 20 per cent higher in A&E in the week leading to Christmas. We have seen around 3,000 more attendances than usual. Of course, that was off the back, as I said in answer to John Finnie, of the trauma cases that the service was still trying to deal with and the numbers that they had not seen previously. Plus, we had NHS 24 working at levels again that have been unprecedented and the Scottish Ambulance Service also. Despite all that, we have seen a service rallying around people pulling together. Even the A&E figures that have been published today at 78 per cent are, by no means, not challenging. They are too low. For the service still to be seeing, treating and discharging 8 out of 10 patients within A&E in the face of all the pressures, I think that it is commendable to the staff involved. Each and every one of them deserve our praise. Brian Whittle, to be followed by Ivan McKee. The number of hospital beds in Scotland has fallen by over 7 per cent in the last four years, and that has a particular impact in winter when beds are full. A&E departments are overflowing and delayed discharge, preventing people from going home. Does the cabinet secretary accept that more has to be done to improve patient flow throughout the health and social care system, particularly in the busy winter months? Let me deal with acute beds first of all. Acute bed usage has changed dramatically over the 10 years as far more people come in and have day case surgery. I am sure that Brian Whittle is aware of that. The way that our health service is used has changed dramatically. He is also sitting beside his health spokesperson, who has demanded that we shift the balance of resource away from acute spend into primary care spend, so that he cannot sit side by side asking me to do two different things. We need to do with the investment that we are making, and I hope that you will support the budget in 2018-19 to make this investment. It is to make sure that our investment in community health services can avoid people going into hospital in the first place and get home more quickly. There has been a 10 per cent reduction in delayed discharge since last year. Yes, there is more work to be done, but when you consider that now most of the delays are within about five or six areas of Scotland, yes, there is more work to do, but I would hope that Brian Whittle would acknowledge the progress that has been made in tackling delay. Can the cabinet secretary confirm that there has been no blanket cancellation of elective surgery in Scotland this month? That is correct. Elective cancellation so far is in line with last year over the festive period. That is quite an astonishing thing, given that in England we are seeing a blanket cancellation of elective procedures for the whole of January to the tune of potentially up to 55,000. In Scotland, we have not done that. We have seen some limited cancellation of elective procedures. We would expect boards to do that on a day-to-day and week-to-week basis to minimise that, because the reason why it is important to minimise it is that it causes problems for the service further down the line. We will expect boards to keep that under review. I should also point out that the last published figures back in November showed a reduction in cancellations. We are starting from an improved position, so no blanket cancellations about boards will look at that on a day-to-day and week-to-week basis to help to manage pressures. David Stewart will be followed by Emma Harper. Thank you, Presiding Officer. Would the cabinet secretary join with me in thanking all the hard-pressed and dedicated energy staff for the work that they do, not just at Christmas but all the year round? Would the cabinet secretary agree to review the eligibility criteria for the flu vaccine, both in terms of age and vulnerability? Finally, does the cabinet secretary share my view that GPs have autonomy to apply clinical judgment to extend the flu vaccine to non-eligible patients if the risk of flu would exacerbate illness? I thank David Stewart first of all for the tone of his question. That is a very constructive question. First of all, the eligibility criteria is guided by the public health experts. We have seen changes over the years in the groups that have been covered by the eligibility criteria, and that is kept under constant review. In terms of the GPs using their clinical judgment, clinicians always have that option, but we would be guided by the priority groups because they need to make sure that the focus of the campaign and of the vaccine supply is focused on those priority groups. That is certainly something that, once we are out of the winter pressure period and we reflect on winter as we do, we will look at whether there is further work to be done around eligibility criteria, guided by what the public health experts tell us. Emma Harper will be filled by Annie Wells. I think that the cabinet secretary might have covered this in her statement when she spoke about world health organisations determination of the most likely flu viruses, but could the cabinet secretary reiterate how the current strain of vaccine matches with the prevalent strains this year? The vaccine is a good match for the current dominant strains that are in circulation. That is a very important message. To say otherwise, I think that risks undermining the confidence that people have in going to be vaccinated. It is very important that all of us use the opportunity here and outside to encourage everybody who are in those priority groups to go and get vaccinated. It is never too late and it is a good defence against flu. We know that, particularly if you are someone who is under 65 with an underlying health condition, that the impact of flu can be very severe indeed, so it is very, very important. I think that one of the issues that we need to address is that, because of the relatively mild winters and low rates of flu that we have seen in previous years, people have forgotten how difficult and severe flu can be. I think that this winter is a reminder of that. I suspect that what we will see over the next few weeks is a rise in that vaccination rate, as people realise how important getting the vaccination is to their health. Thank you, Presiding Officer. Figures today have revealed that, over the Christmas period, A&E waiting times reached an all-time low. Between Christmas and New Year, 21.6 per cent of patients across Scotland were forced to make beyond the target of four hours, and on one health board, that figure was a shocking 42.7 per cent NHS 4th valley. In that single week, 272 people had to wait longer than 12 hours, as compared with just two in the same period last year. What action will the Scottish Government take to restore confidence in our emergency department? I say to Annie Wells that the week ending 31 December, which were the figures that were published today at 78 per cent, is disappointing. However, I think that it is understandable that, in the light of all the pressures that we have seen, the levels of performance in A&E that we have seen over the past two and a half years—the best in the whole of the UK—were unlikely to be able to be maintained in the face of unprecedented winter pressures. I think that most reasonable people would understand that. What is important now is that we are focused on helping those A&E departments to recover. The fact that, despite all those pressures, still nearly eight out of 10 patients were seen treated and discharged within the four hours is quite a remarkable thing in the light of all those winter pressures. I would gently point out to Annie Wells that the Prime Minister and the Tory health secretary would not have had to apologise if they were not facing some of the same winter pressures within their A&E departments. I would have thought that coming here and somehow saying that the position in Scotland is somehow different from elsewhere in these islands is really disingenuous in the extreme. We are all facing winter pressures and what we should be doing is getting behind our hard-working staff rather than talking down their efforts. Can the cabinet secretary advise what alternative services are open to people who are concerned that they may have flu-like symptoms short of going to A&E? Are there more appropriate services to try first, for instance? Yes, there are. One of the best first ports of call would be NHS Inform. I can tell the Parliament that the NHS Inform website on Christmas day had 60,000 hits, which is unprecedented. NHS Inform is a hugely important source of information and has now become a key part of the health advice system out there. In addition, there is NHS 24, which many, many, many patients have used. There is local GP practice, the out-of-hours service, out-of-hours and, of course, importantly, there is community pharmacy. We would say that if someone has flu-like symptoms, we would not be wanting them wandering about potentially infecting others. The advice is to stay at home, but family and friends will be able to get over-the-counter remedies from a community pharmacy. However, if there is any doubt, please contact NHS Inform where you can get good advice and information. The cabinet secretary will be aware that NHS staff in Lanarkshire have not only done their day job, but they have also been brought in as volunteers to cover clerical and cleaning roles. They are the heroes that have kept our hospitals in here, Myers and Wishot and Monkland's running. However, staff and patients in my region are wondering why NHS bosses in Lanarkshire have had to go looking for volunteers when other health boards in Scotland have not. Does the cabinet secretary agree that a properly resourced health board with a strong workforce plan should not have to resort to this kind of plan? First of all, I would pay tribute to the staff in NHS Lanarkshire. No one forced them to do that, but they rallied round and came out in huge numbers to support the front-line staff. I would pay tribute to each and every one of them. We have been looking at that NHS Lanarkshire had particular challenges, partly because it had three A and E departments that were hugely under pressure and flew particularly as NHS Lanarkshire very hard. Indeed, we have been working particularly with NHS Lanarkshire to support them, to make sure that they are able to keep patients safe and keep services operating. I would also pay tribute to the GPs who have come out and worked that last Saturday morning. That is a real credit to them in doing so and did help to relieve some of the pressure on the hospital services. It is not something that we see and would not expect staff to have to do very often, but it says a lot about our staff that when push comes to shove and services under pressure, people roll up their sleeves and they get on with the job, and they are to be commended for that. Sandra White Thank you very much, Presiding Officer. I think that we all welcome the extra 22.4 million to support boards that meet A and E in winter pressures. In addition to that in extra investment, can the cabinet secretary confirm to me anyway that the Scottish Government will continue to work with health boards and be available to system with the pressures that they are under, not just at this time, but in the future also? Sandra White We monitor every day and I get a report every day on what is happening across our system. I also should pay tribute to our civil servants and senior officials who have been out and about in the service, providing really important support to the front line and to our senior management teams out there. Once we are through this winter period, and it is important that we are all focused on getting through the winter period, because flu is going to be around for another few weeks and all of the impact that that will bring, so we are not out of the woods yet, is to then, after winter, do a proper analysis as we do after every winter. I can say to the Parliament that if there are lessons to be learned in terms of where we need to make changes, other things we need to do, then of course we will do that for next winter. That is part of the normal course of the way that we would do winter planning and preparations in advance of the following winter. I thank the cabinet secretary and members for their participation. That concludes our statement on winter flu, and we will now move on to the next item of business. We will just take a few moments for members to change seats.