 Good morning, and welcome to the 19th meeting of the COVID-19 Recovery Committee in 2022. The committee has agreed to focus its pre-budget scrutiny on how the Scottish Government plans to fund its COVID recovery strategy, and the ongoing costs associated with the pandemic as set out in the COVID-19 strategic framework. Today we will focus on the strategic framework, and I would like to welcome our witnesses to the meeting this morning, Richard Robinson, Senior Manager of Audit Scotland, Mary Morgan, Chief Executive and Carolyn Lowe, Director of Finance at NHS National Services Scotland, and Dr Nick Finn, Organisational Lead at Strategic Engagement and Policy at Public Health Scotland, and Dr Graham Foster, Director of Public Health NHS 4th Valley and Chair of the Scottish Directors of Public Health. Thank you for giving us your time this morning. Beattynwyd will have approximately 15 minutes to speak to the panel and to ask their questions. We should be okay for time this morning, but I apologise in advance if time runs on too much. I may have to interrupt members and witnesses just in the interests of brevity. Can I ask the witnesses to briefly introduce themselves and their organisation? Richard. Richard Robinson, Senior Manager at Audit Scotland. During the last couple of years in particular, Felly, we have been looking at the Covid-19 from the finances side, part of the public finances team that looks at things to do with the operational of the fiscal framework and the Scottish budget. Thank you. Dr Nick Finn? Yes, I am director of public health science and medical director for public health Scotland. I started in January 2021 so I am fairly new to public health Scotland. I have been working down in Cullindale, London as deputy director for the National Infection Service. I have come back home, so to speak. I am happy if I can't provide any information prior to my appointment. I am happy to submit that written evidence afterwards. I will try my best. Thank you very much. Dr Graham Foster? Good morning. I am Dr Foster. I am a public health doctor. I trained as a general practitioner originally in 1992 and then trained in public health. I have been a fellow of the Faculty of Public Health since 1997. I did do four years as a senior medical officer in public health policy with the Scottish Government and I have been at NHS Four Felly as a consultant since 2001. I have been the director of public health there since 2014. I am also the current elected chair of the Scottish directors of public health group and I would like to explain that. That is a voluntary network of the 14 directors of public health who sit in the territorial boards in Scotland. We were part of the front line response to Covid in Scotland. I am able to represent the views of that group. I am not formally part of that group and it is not a legal group. My views today will be largely my own but I can help you to understand what I believe the collective views of the group would be. Mary Morgan? I am Mary Morgan. I am the chief executive of NHS National Services Scotland and have been so since 1 April 2021. I have a long career in the NHS in Scotland in a variety of roles. I am sure that NHS National Services Scotland offers and provides a variety of national and shared services to the NHS in Scotland. Thank you. Good morning. I am Karen Low. I am director of finance for NHS National Services Scotland and I have been in post for eight years now. I am also the chair of the directors of finance for the national boards so I can also bring a perspective from both NHS National Services Scotland and PHS to the committee today. Thank you very much. Welcome everybody. I am going to turn to questions now and if I may begin by asking the first question. Can I ask the witnesses what particular areas of Covid-19 spend they would prioritise at the moment? Should we stop Dr Finn? Yes. Thank you very much. There are probably two main areas. One is vaccination because vaccination remains the sort of heart of the response and provides protection and mitigates severe disease and deaths. So vaccination services and we are about to what we have actually started the vaccination of people for Covid and flu just a week ago. That is starting so vaccination is going to be key both for current and future protection. The second area is testing and surveillance. A surveillance function would be really important to help us understand what is happening across Scotland to give an indication of a potential resurgence of either a new variant or a new mutation and to then allow us to take the appropriate response. A surveillance will also give an indication of a severity. For instance, if you look at Omicron, Omicron was highly infectious, but with retrospect we know that it was probably 50 per cent less severe than Delta, which was the strain that preceded it. Having that understanding and insight is really important. The surveillance function also extends to other respiratory infections because we have what we call syndromic surveillance, which is general practitioners, emergency departments reporting respiratory illness. It is important that we understand how much of that is attributable to flu, Covid etc to know whether our strategies or our response is effective. Those are probably the two key areas that we would be focusing on and I wanted to focus on. The last area would be preparedness and that is around the future pandemic. I am a member of the Scottish Pandemic Preparedness Committee and was involved in the interim report that was published last week. Those would be my priorities. We have quite a large panel this morning. Does anybody want to add to that? I am in danger of saying that I agree with Nick a lot this morning. I will try not to do that. As a representative of the directors of Public Health, I would like to add to what Nick said and stress the importance of robust and resilient front-line public health teams in our 15 or 14 NHS health boards. The front-line teams are in place at all times, so we are always going to be part of our immediate response to any new evolving public health threat. Indeed, that was the case in Covid-19. For the first few months of Covid, it was the public health teams in the boards that were in the front-line doing the immediate advice and management and protact tracing of early cases. The advantages of having strong robust teams within local health boards is that they are very flexible and we turn our attention to all sorts of different public health threats and public health improvement projects. Whilst we were able to turn ourselves fully to Covid when it was an emergency, those staff were not in any way wasted. It is a very efficient way to provide your resource because in times when we are not dealing with infectious disease, we are dealing with poverty, inequalities, cost of living, health issues, improving health services and so on. On behalf of the directors of Public Health, I would like to make sure that we remember the importance of those teams and we keep them within our sites. I would just finally say that they are not big teams and they are not hugely expensive, so in a typical health board, less than half of 1 per cent of the board would be spent on front-line public health. In my own example, I am in a medium-sized health board, so I am a director of public health and at the start of the pandemic I had three and a half consultant colleagues and two nurses and that is the sort of size of team we are talking about. But we were able to maintain a really strong and effective response for several months against Covid and I think that is an important thing to remember. Thank you Dr Foster. That will just bring me on to the next question that I wanted to bring up. RSI did indicate that the total pay bill will be held at 2022-23 levels, although we know the pay levels will be increasing. At the moment, from the latest data, we have got vacancies of medical and dental consultants at 7.7 per cent, we have got nursing and midwifery at 8.7 per cent and we have also got the sickness rate in the NHS at an overall 5.7 per cent where the target is 4 per cent. How visible is it for the NHS and public health services to reduce staff? Did you want to come in on that? Yes, I will start with that one. Partly it is the wrong question. First of all we just need to remember that it might be staff costs rather than staff numbers so I just need to be careful that I don't give the impression that I am talking about something that I am not. I do think that there are significant opportunities for us to increase efficiency and the skill mix of staff to achieve more for the money that we spend. I think that if we look at it as a simple head count it is very unlikely that we would ever move to a situation where we have less individuals employed. Changes in working practices, flexible working, retiring certain policies, all sorts of things, mitigate against the actual head count coming down. We need to hang on to the specialists and the expertise that we have in the face of an ageing population and a large number of people moving towards retirement age. These are all complex issues. It is incredibly difficult at the moment in the national health service to maintain staff numbers. It is not a money issue. There are not the specialist trained staff out there to do the jobs that we need. People use the term fishing in the same pond. We are all trying to recruit the same staff. In Scotland, across the UK and internationally public health specialists are in great demand for example and we find it really difficult to fill our posts. That is the same for every medical specialty. It is difficult to get surgeons, it is difficult to get physicians, it is difficult to find enough GPs, it is difficult to get nurses and indeed our partners in the care sector are finding the same thing as well. It is very difficult to staff our care homes and our community care services. The whole of the health and social care system is under huge pressure and it is proving very difficult to get enough staff at the moment. Mary Morgan, do you want to comment on that? Across NHS Scotland overall, there were around 3,200 additional staff recruited and employed across NHS Scotland boards undertaking test and protect work. That does not include the number of people who are taking for vaccinations. That number has already reduced to 1.5 at 1,500 and those staff are being redeployed wherever possible to those vacancies that you have spoken about. Much depends on what the demand for Covid response is going to be remaining. In NSS, for example, we employed around 800 staff for the National Contact Centre to support the national work around contact tracing that Dr Foster has referred to. That number has now reduced to 260 staff through natural attrition, so people finding other employment are also being redeployed. However, the demand for that service continues to support vaccination. We are very good, as Dr Foster has said, at pivoting staff and pivoting services to deal with the new challenges that present. Where those staff are for contact tracing, now they are responding and supporting the vaccination programme. 30,000 calls in the first week of the vaccination programme to help Scotland citizens access the vaccination programme. We could cease that service if it is no longer required, but we really need to see what this winter brings in terms of the demands placed upon staff and also understand what the future vaccination requirements and demands might be in order to get people vaccinated across Scotland and what the digital solutions might be in order to reduce the number of staff that we have. I think that it is quite a complex position and bearing in mind how a lot of work is done is inseparable from patient care. You cannot go down a computer, you cannot go down teams to do many of the in-hospital care, although we have used these digital means to reduce the burden on staff where possible. Did any of the other witnesses want to come in on that point, Richard? I think that starting with the RSR, I suppose that is the starting point for where we are with the figures in the staff and the prioritisation within that, has also been raised in the notes. The RSR is a good starting point for understanding what the priorities are, but it is separate from the budget. What it does is it gives you a sense of the challenges ahead and where those challenges might lie. It is clear from the RSR that the managing staff cost serving the medium term is quite an important part of keeping that trajectory of continued balance budgets. I think that there is an acknowledgement of, within the RSR, a kind of trade-off, if you will, between staff pay and staff numbers. One of the points I would make is when it comes to the data, some of this is going to be really understanding the data and the reasons for the increases over time. The future plans, as we have heard about redeployment, are temporary permanents at the front or back house. Some of those things are probably going to matter to understanding the extent and way that things can be managed. The other point that we have raised through the Covid-19 period, but before, is that there were financial sustainability issues with the NHS position before we went into Covid-19 and those have not gone away. Within that is also reflecting the fact that there is need for reform and a continuation of reform. There are NHS recovery plans in place, which we will be looking at as part of the NHS overview work, but it is continuing that sense of reform alongside controlling what numbers may be in the future. I am going to move on to Murdo Fraser. Thank you, convener. Good morning to the panel. Before I come on to the question, I would like to ask a follow-up question if I can to Mary Morgan in relation to the answer that you gave to the convener. I was really interested in the numbers that you quoted about the reduction in staff that has been in relation to the vaccination programme and the contract tracing. Should we, perish the thought, have a new wave of Covid or a new variant of Covid as we go into the winter? How practical and realistic would it be for you to staff up again to the numbers that we have seen previously? Do you think that that is going to be necessary? If it is, can you do that without pulling people back out of NHS front-line services given the tightness of the labour market elsewhere? Wether it might be needed as a matter for public health colleagues perhaps, our job is to be ready and to be prepared for that eventuality, and that is factored into our plan. So what surge do we need? For example, we are making sure that we are maintaining the training of staff in the contact centre not only to handle calls in relation to vaccination but also to maintain their contact tracing capability. We have a number of flexes there, so not only are we retaining the employed staff, the 260 whole-time equivalents are employed directly through NSS, but we are also maintaining bank capability for those people who perhaps do not want to regularly work with us. We also do retain contracts with third party suppliers in order to be able to give us that flex and to give us that flex up. I think one of the things that we learned through Covid, although the recruitment process was a monumental effort, we were able to do that really, really quickly and really, really nimbly in the event that we would see another wave and another preparedness needed to go through. So we have learning from that that we could apply. It is not in our plans to have another start out at the end of Covid. We are much more prepared than we were, and we obviously have capability that is being built into play. We also have all of the scripts that are available, all of those kinds of things ready to step up. So yes, we are prepared for that. OK, thank you very much. Maybe I could just ask that same point to either of the public health colleagues whether they've got any comment on the impact on public health and the NHS should the same thing occur. Dr Foster. I'm happy to do that question. So when Covid arrived, we didn't have any of these big national structures. We just had our local frontline responses and these small teams stood up and did as we have always trained to do, which is to do the initial stages of dealing with a pandemic. We've been very fortunate that all of the national arrangements have been in place, and there's been a huge recruitment effort, and we created Test and Protect, which did all the contact tracing and so on, supported by the local teams. Where we are now is that we are gradually scaling that back, and by the end of September pretty well all of the staff who came in to do Test and Protect will no longer be with us. They've largely found other roles, so it's been a very positive experience, so that's been very helpful. And we would expect to go back to the situation we were in, which is that we have local teams who are ready to respond, and if we were to find a situation where either Covid or indeed another infectious disease, and we still have the same risk of a pandemic of influenza that we've always had, for example, so those risks are still there, we would need to go through a process of scaling back up. There is a special provision around Covid, which is that we have retained a small number of staff, we call them VAM teams of EAM, who will be with us until the end of March to get us through this winter. But the size of that staff group is not huge, but it's an efficient assessment of what we would need to keep us going to get us from where we are now standing start back up to scaling into a full response position if we needed it. So we do have that plan in place. Again, a local example, that's four staff for a board the size of 4th valley, it might be 20 staff for a board the size of Greater Glasgow and I can't remember the number for the whole of Scotland, but it's that sort of order. So we've got our local teams, we've got some extra, but we stood down the big national response because frankly we just need to be efficient with the spend and we won't have it back unless we were to absolutely need it. And I think question about whether it's likely to happen is nobody actually knows, we just don't know, but that risk is with us all the time and we were ready for a new pandemic at the start of this and we're probably significantly more ready now. So I think we've got reasons to be relatively cheerful in terms of our plans and we know we can mobilise that whole national effort, which was a huge partnership which worked incredibly well and I think we should be proud of actually. If I can come in on the potential likelihood, it is an unknown, but we've got previous flu pandemics to draw on and they've been characterised by two or three waves of activity. And basically what happened is on pandemic is when the whole population is immune and there is non-immune rather and therefore susceptible. With each subsequent wave more and more people become immune and therefore the sizes of the waves tend to reduce and therefore the impact reduces. We've got the added bonus here of a vaccination programme. Many people have had three or four boosters. We know that the vaccination will stop or mitigate severe disease and death and that includes hospitalisations, even with the different variants. So the vaccination that's being used this autumn, one of them is what we call a bivalent vaccine. It's got the original Wuhan virus, but it's also got Omicron, which is one of the more recent viruses. And gradually over a period of time, as the virus evolves, it becomes more different and therefore being exposed, let's say, six, seven months ago to an original variant. If it was to change, you may still be susceptible to a new one, but you will get at least some protection. So I don't think we'll be seeing the measures that we saw back in 2020-21, but it may have an impact given flu is a bit of an unknown this year coming forward. The last point just to wind up is that we've worked through what we call a variant mutations plan, and this is a plan for how we will respond to a new variant mutation. And we've also described the new surveillance that we put in place and how that links in. That should have been up on our website this week, but it will be up next week. So I'm very happy to send a copy of that to the committee for their information, but it basically describes how we'd identify and respond to a new variant working with the boards. Thank you all. That's very helpful. It leads me on very neatly to the question that I was going to ask about the question of public sector reform. The convener was quoting earlier from the resource spending review, which frames the background to all this. Maybe I could direct this question first to Richard from Audit Scotland. Just so you're aware, Richard, it's coming to you. A couple of quotes from the RS are, it identifies there has been quite substantial growth in employment in the devolved public sector. It says, continued growth of the public sector away from frontline services is not sustainable. And it goes on to state that the Scottish Government recognizes the need to reset the public sector following the Covid-19 pandemic, including by returning to pre-pandemic size. So I wonder from an Audit Scotland perspective how realistic you think it is to return the public sector to pre-pandemic size and from a practical point of view how quickly that can be done and what are the practical implications of that. To pre-empt this by saying, my experience is probably more with the public finances than the specifics of the NHS audit. Having said that, there's two things there, one of which is speed and one of which is almost like viability of doing that. Where we are clearing Audit Scotland, and we have been through a number of reports, is that, as I mentioned earlier, returning to just the way that things are being done before, we'll probably end up with the same results, which is a problem with financial sustainability. Alongside that, we now know, which aren't reflected in the RSR, additional pressures around inflation, which means that your money buys you less, et cetera, as well as a number of other pressures. So, I think, where the Audit General has been very clear, is that this is about actual reform, this is about reconsidering the way that services are delivered and encouraging them to be delivered in different ways and thinking about the cost implications of that. Now, what does that mean for the speed at which it can be done? I think my colleagues will be able to say on the panel here today, will be able to say more about the speed. I think it's reasonable to say that reform and changes in the ways that things are done take time over several years. Again, this is where the medium-term financial strategy and how it continues to link to the budget and how the budget reflects it is going to be important, not just for this coming budget, but for budgets over time, especially given the importance of staff costs as a kind of lever by which the Scottish Government are keen to maintain the balance in spending given funding. So, it will take time. I think our point as auditors would be that the plans to reform should be clear and costed and monitored closely through the budgets and linked again to the medium-term financial strategy to see whether these are causing any difficulties or whether these are on track or off track and whether action needs to be taken. OK, thank you. I don't know of any of the NHS colleagues. Carolyn Lowe, do you want to come in? Yes, thank you. So, there are plans in place to reduce all our Covid additionality over this financial year, so by the time we get to the end of March, all additional spend will be reduced and the workforce will have been redeployed. And what we'll be left with is the core around vaccination and the surveillance element that Nick mentioned, but also some elements of managing and maintaining the preparedness in NSS around PPE, and that's the extent to which our Covid activity will be contained going into future financial years. I guess the challenge we're seeing is just how quickly the additional capacity in hospitals that was introduced can be stepped back, because in practice that capacity is currently being used to support recovery and to tackle capacity needed to address waiting times etc. So, it's argued, I guess, and certainly that that's possibly moving out of Covid funds and into the recovery plans and how they are resourced going forward. OK, thank you. Mary. So, thank you for your question. I think it's actually a very difficult and very complex question, and I think my answer in relation to the pace and the magnitude of the reform that is needed is what is society's view of what will be acceptable and prioritised against the reform. It is very difficult in the health system, for example, to modernise a service or to remove a service. People want their services, as we've said, as close to home as they can possibly be, but sometimes better care and certainly more affordable care, patient care can be provided if we were to do things differently. So, does every hospital need to have an emergency department? Are there different ways of modelling some of our elective care to have different ways of providing those services, and sometimes that's not acceptable to society? So, I think that's some of the question I've put back. The scale and pace of reform is dependent on those views. Thank you. Before the pandemic in the respiratory disease department in the new public health Scotland, there were something like seven or eight people dealing with legionality, flu, respiratory viruses and everything. Throughout the pandemic, that went up to just over 200, and that was to meet the demands, the data demands, the information requests that we're getting. And even despite that, we've got overtime bills of somewhere in the region of one and a half million because we simply could not get the staff to deal. Going back to those seven or eight people, we could do it, but I'm not saying that we'd be able to do very much or deliver very much. So, it really comes back to what sort of public health response and service the Scotland want, and what we've tried to do is, throughout the pandemic, take advantage of new technologies, we're automating, so we probably don't need as many people as we had at the peak, and in fact we have reduced. But we will need more than we started with back in March 2020. There's no question, in my view, having worked in public health for nearly 40 years. So, I can't see us going back to those levels, but clearly there are opportunities, and in fact we're undergoing a restructuring reorganisation to focus on the new priorities and to do what we can to be as efficient and effective as possible. So, there will be reductions, but if you're asking us to go back to six people, we won't be able to deliver what I would consider to be an adequate service. Thank you. That was very interesting. Alex Rowley, please. Good morning. I mean, that question there, does every emergency, for every hospital needs an emergency department, is perhaps a theoretical discussion? Because most people out there just now would think to themselves, well, the emergency departments are struggling to cope as it is. People are being left in ambulances for hours and hours sitting outside emergency departments, and hospitals seem like they are completely run off their feet and struggling to cope. I mean, that seems the reality of the situation right now. And so, I suppose my question is, is the budget in this current year adequate to get us through and meet any challenges that might come? So Audit Scotland said, in a quote, in the public services phase, financial pressures before the pandemic, Covid-19 funding was used to ensure financial sustainability for councils and other public bodies. But now, Covid-19 specific funding from the UK government has ended, pre-existing pressures must be balanced alongside continuing to spending demands related to Covid-19 response and recovery. Is the budget that is there adequate to be able to do that? Because in that recovery is these massive waiting times. I mean, we've got waiting times like we've never seen in my lifetime, people waiting for happy replacements, lots of other replacements. Is that for me would be recovery? You know, because although Audit Scotland pointed out that public services face these massive financial pressures before the pandemic, these financial pressures now must be much, much greater. So is this budget that you've got now, is the budget for NHS Scotland adequate to actually fund the recovery of these services? I'm going to defer to Carlin. I can't speak to the overarching budget for NHS Scotland that would be for Scottish Government. I think to answer to you, but Carlin may be able to give some insights. I think our challenge is that our overall resources are finite and therefore we need to make sure that we're managing within the financial limits that we're able to. And it's not just restricted to health. I think that's a challenge that all parts of the public sector face. The NHS budget has been, we have been given additional resources this year, but what we have seen is the money that we've had in the past to respond to Covid, which in practice was, it was unlimited during the pandemic. It felt as if we were resourced properly to do what we had to do, and the response that we were able to do on behalf of the country was phenomenal. But the reality is that that spending resource has stopped and we need to now get back to a position that's more sustainable and we've got greater and wider pressures around inflation that we need to deal with. So there are real choices that need to be made within health around prioritisation and what we have to spend our money on, but clearly our choices are limited when we're facing the scenario that you describe that we have real pressures in our hospitals and we have to tackle that because we have no option but to do that. So what we are doing now is actively working with Scottish Government health colleagues, particularly their finance teams, and working collaboratively as a finance system to look at where we can identify opportunities to reduce costs and redirect resources. But it is a challenge and it would be wrong of me to say that it looks as if we're able to do that comfortably. I think the reality is that there will have to be some prioritisation discussions and these are actively being pursued at the moment. So with that in mind in the potentially winter spikes in Covid, flu, goodness knows what else, if we had a return of spikes in Covid or flu or whatever, is your organisation in a position to deal with the possibility within the current budgets or would there be an expectation that if there are major spikes in any of these areas that you would have? Do you think that you would need emergency funding to be able to deal with that? The way that the Covid funds are managed, the test and protect element of it is being managed separately. That is being held as a managed resource at government level. My understanding around that is that what will be needed to spend to deal with any peaks in the winter will be made available, but what we are trying to do actively is to reduce that cost and to work as effectively as possible and to make our response as efficient as possible so that we are managing that resource. In our wider Covid spend we started the year with a forecast of what we thought we needed at the end of March and we have been funded to 65 per cent of that and we are actively managing our response and prioritising how we do that to be able to manage. From an NSS perspective, we believe that we are able to do that. We have been able to manage and prioritise our resource and we are comfortable that the elements of our response will be able to manage within the funding envelope that we have been given. It has been a lot of work and a lot of difficult choices to some extent to get us that position, but we need to be realistic. We are unfortunately no longer in a space where resources are infinite as far as the Covid response is concerned and we need to make sure that we are prioritising our efforts and our resources to the aspects of our response that will make the biggest impact. That is about prioritising vaccination and the surveillance activity as well as making sure that we have got preparedness. If there are any major spikes, will we need emergency funding? We saw yesterday the statement from the Deputy First Minister on the overall budget and the cuts that are having to be made in order to fund pressures. Are we in a situation where, if there are any other major spikes in health over the coming months, we will need emergency funding to be made available? For Public Health Scotland, we have had discussions with the Scottish Government and we have been given funding for 2223 in relation to the vaccination programme to surveillance and in the small team that we will be using to investigate any variants and mutations. We are actively recruiting and filling the posts that we need. From that perspective, I think that we are reasonably comfortable, but obviously we are not involved in the acute direct response. What we will be doing is giving an early indication of whether or not the vaccine is working, whether a surge is likely, what the impact might be, so helping to prepare if you like. Can I just quickly ask a question to marry it about your comments about these labs and the fact that the labs have been ramped up? You do say that there is this balance of whether you will require on going funding for the labs to need to be operated at a underutilised level to maintain them. Is these labs not still under a lot of pressure? I understood that. No, they are not. The testing strategy was, first of all, we participated in a UK basis with the Lighthouse Laboratories to do testing initially and obviously people saw all of the efforts that were made in that regard. We utilised hospital existing testing capacity for laboratories and built three regional Covid testing laboratories that are kitted out to manage many thousands of samples going through them. That is not the case now, is the testing, the PCR testing, the hospital-based testing has reduced and we have seen the rise of LFDs, the tests that people do in their own homes. The PCR requirements have really reduced considerably as the testing strategy has come down. The regional labs are there in readiness. There are a large number of staff who are recruited for them by medical scientists as an area as a job family that is also quite difficult to recruit to. We have blood transfusion labs that are quite difficult to recruit by medical scientists, so those staff have been redeployed and so on. Really what we are doing just now is pending a wider strategy. Pending seeing what happens after this winter is maintaining those laboratories in a state of readiness. There is quite a lot of regulatory requirement around them. There is obviously servicing and maintenance costs of the equipment that is there, not least the consumables that go through. They are there, they are in premises. They meet regulatory requirement function as annexes of where they are held. However, they are not just now fully staffed. In fact, I visited one just a couple of weeks ago and there was no activity going through it at all. That is my big question in all this. How much money do we put into being ready for next time? As compared to yesterday, we had £500 million of cuts of our savings across Scotland. There is a huge pressure on resources. How do we get that balance right? I think that is where I would like to start and that is what Mr Rowley was saying. Even at an empty lab, there must be a bit of a cost. I do not know if you have to keep a bit of heating on and then presumably the equipment gets out of date after a few years. Perhaps more obviously, PPE is also mentioned in your letter. I do not know how long a rubber glove lasts but I think it has got some kind of end date. We could spend a lot of money on rubber gloves and then have to throw them all out after three years, unless you correct me. I think that at the beginning of the pandemic there was a bit of a concern. Some doctors were saying that they have been given PPE that is out of date even though maybe it was still okay. I am struggling a bit to know how do we get the balance right. I will come to Audit Scotland in a minute to see if there is a mathematical answer to this. I do not think that anybody can say what size is the right size for going forward. We can do some planning and we can definitely make things very different. We have addressed some of that storage capacity. The PPE example is a really good one to focus on because what we had in Scotland was a separate pandemic stockpile that sat in a warehouse waiting for the pandemic to come along and it really did not have stock turnover. One of the things that we have realised through this pandemic is that we really need to use our existing stock that staff know and understand and know how to use and that we get turnover from it. We just hold more of it. What that really means is that we hold more stock but we have always got turnover. I think the learning for us is how do we leverage our single national procurement for example in the NHS. How do we leverage that to perhaps service more of the public sector in that way and make best use of making sure that we have got turnover. We have got turnover so that what we have got in has got turnover and does not expire. It is kept abreast with what is modern and what staff need to use by way of PPE and also staff are fully trained in its use and how we distribute it to people. I think that is the biggest learning that we have had out of that PPE place. The other thing that we need to bear in mind, one of the great things that has happened through the Covid is that we have got a really good local supply chain for PPE. Manufacturers came forward in Scotland and helped Scotland to get its PPE. We have got minimum orders that we need to put through to maintain that and to maintain those jobs and people within Scotland so that supply chain piece needs to keep coming through. It is a different model. We are not holding a separate stockpile of PPE in a warehouse somewhere down the road. We really want to make that part of how we operate on a day-to-day basis. Having those supply chains in place and learning from what we did means that we can flex up and flex down as necessary, but volume is critical to us. Mr Robinson, I do not know if Audit Scotland has a view on that kind of thing. Can you say that there is a 2 per cent chance of a pandemic in any one year where it is worthwhile putting so much money into that kind of thing? There is clearly a cost to keeping more stock in storage instead of just in time. Is that something that Audit Scotland would look at? We would not look at the specifics of the percentage of chance that our colleagues would be much better placed to carry out that. I think where it does emphasise though is that point around the data that would inform the likelihood of scenarios and has been discussed by Morgan, the learning from the past pandemic in terms of methods and where there is efficiencies and money is there. I think what we have said before the pandemic as well as you and me is that managing a budget in a period of extreme and significant uncertainty and volatility is hard. There is lots of unknowns. So where data can be used to bring a little bit of shape to those, then that is useful to understand where the budget would flex to be able to do that. I think that in terms of the balance, it is almost like a perennial question really is the balance between the short term pressure and the longer term objectives and outcomes that the Scottish Government are looking for. We can kind of see that within the strategic framework. There is a number of shorter term and often more quantifiable elements such as vaccinations and PPE and surveillance. But also within that is addressing and recovering from the longer term effects of COVID-19 such as mental health and health inequalities. I think in terms of the balances, well that will change over time depending on what the next of the circumstances is, but it is almost maintaining that oversight. Are we delivering against the overall shape of what this strategic framework is including supporting the longer term objectives? And I think if I could just finally say around the budget and spikes, one of the things within the public finances of the work that we've done there is that Andrew has reflected through our COVID-19 finances report is that what the rest of the UK does also matters. So if there's a spike which is also reflected in the rest of the UK and that results in additional spending in an area, they may be or may not be bonnet consequentials in that area. So it's also about reflecting that the way that the barn consequentials work the way through to the Scottish budget will make a difference. So in a way, if the problem is being held with a spike or a new variant at a UK level, that might be different than if there's divergence, if there's something specific to areas of Scotland which is not felt or responded to in the same way. Because even if England built up a huge store of PPE and we got a share of the money, we wouldn't be bound to spend the money on the same thing? You're not bound to spend barn consequentials on anything that they're not linked necessarily to where they've come from. There may be some conventions there, but that's not the nature of things. And there are examples of with PPE where the amount of barn consequentials received through different arrangements and spending differently was less was spent to get the same result. So I think there is something about considering what we were saying within this quote from earlier was about that kind of specific COVID-19 barn consequentials guarantee, not being there anymore. But the budget process and the funding process will still work, the same as it has in other years. Dr First, you've got both the national picture and you've also got a health board picture. The health board obviously, the health boards are under pressure financially. How are they thinking about keeping this long term a bit more in reserve or ready for the next pandemic as opposed to let's fix replacements tomorrow or whatever? Thank you. You're absolutely right. I do think it's true that the NHS health boards are under exceptional pressure. It feels like that. It feels like that to our staff. Everyone's working really, really hard. But I do think I've got something useful to add to that discussion. In terms of what we've been talking about, we've been talking about the capacity of the NHS, we've been talking about the budget that we've got and we've been talking about trying to deliver frontline services. And I think that then boils down to the efficiency of the system and how we run the system. It's unlikely that we're going to get a vast amount of more resource from the public sector to provide health services. So the way to provide better frontline services is to be more efficient. I think it's important to reflect on how we run health services. So there is a sort of a wisdom, which others are more qualified to talk about, that the most efficient way to run a health service is about 85 per cent bed occupancy and 85 per cent efficiency. I'm sure you've heard that sort of suggestion before. We've been in the habit of Scotland of trying to run our NHS at 95 to 98 per cent efficiency with all of our beds full all of the time and using every single available pound as efficiently as we can. And that's very, very efficient in a normal situation, but what it means is you have no reserve, you have no resilience, you have no ability to bring in extra patients when things get bad. We don't tend to have mothbald wards or hospitals that we can bring on to deal with the extra peaks. And that's the nature of being a very, very efficient system. And at the moment it feels like we're almost running at sort of 120 per cent efficiency. So we're actually, we've got more patients in hospital beds than we've got beds to put them in, which is the reality of the situation. So that's really quite challenging. I can only really see two ways forward to fix that. One is you either commit to having more capacity, which is your question about would more budget help. And actually at the moment in the short term more budget probably wouldn't help because we can't get any more staff and we can't build any more buildings in the time that we need to get through this winter. So really the only thing then that's left to us is about efficiency. And my thoughts about efficiency would actually relate back to an earlier question, which is about how much of our activity is on frontline services. So I do think there is learning to be had from the pandemic when particularly in the first year we shut down a lot of our back office functions and we had a lot less meetings and we had a lot less boards and we had much less governance and we devoted our entire effort to the front door. And during that time things felt that we were a lot more efficient. And so there is a question to be asked about whether there's learning from that and whether we could be more efficient in the NHS in terms of spending less time in front of computers at committee meetings in more time with our patients. And I do think there's some avenue to be explored there. That's quite an exciting one for politicians, fewer meetings and fewer times in front of the computer. Dr Finn, I don't know if you have anything to say on that but you also mentioned vaccinations earlier on and I'm just wondering are we talking about one vaccination per year for Covid just the same as flu or do we not know that yet or could it be two a year and if it is two a year does that make a big difference to the cost? We don't know that yet. The hope is that if we get through this we may not need it at some point in the near future. But I think we're probably looking at the very least at probably an annual one. And yes, if you're giving two there will be a cost, the cost of administering vaccines. It's not just buying the vaccines, it's storing, distributing, getting the staff to put them in arms. So there is a cost associated with that. I was going to say there is a third element and it's one that I passionately believe and that's the prevention. Covid clearly demonstrated the impact that Covid had on the most deprived communities. It was higher in terms of deaths, hospitalisations, severe disease and tackling deprivation has to be an underlying priority. We're not going to stop people dying but what we can ensure is that the life they have is long fulfilled and as disease free as possible so that the use they have of the healthcare service is minimal. And I do think my concern would be, and yes it's not addressing the immediate problems but at some stage we have to start the investment in the prevention field to try and ensure that our population is as healthy as possible because that will have the biggest impact. One of my concerns is that we've identified that in 2020 when we looked at obesity in five year olds or overweight in five year olds there was a 25% increase in the number of children aged five who were considered overweight and obese. If we don't do anything about that that cohort is going to go right through, they'll become 35 year olds who are obese and at risk, 45 year olds etc. And I suspect if we look at the 2021 we'll see a very similar picture. So there is an issue for me that we've got evidence of the impact on our children and we need to be focusing in and trying to address that otherwise we're actually going to worsen the problem at some point in the future. That cohort that's obese, presumably are the same people especially when they get older who would be at risk from either Covid or some other pandemic? Well, the risks of obesity is associated with an increased risk of cancer, diabetes, blood pressure, a whole series of things leading to premature death and disability. And it's that disability that has the biggest impact on the health service that need for healthcare. So trying to address these groups at the moment I would say is where we need to be looking at some of our focus, the prevention tackling some of these inequalities. It would be a good investment if you like for the future. Okay, that's great. And if I could just have one more question, if I could go back to the submission that came from National Services Scotland. I was intrigued, it was on page 5 of your paper. It talked about the National Contact Centre if you've got it, it's about the third paragraph. The stability and expertise offered by the NCC will be key in delivering strong vaccine uptake rates. Alternative solutions which prima facie offer a more cost effective approach to vaccine delivery could undermine the strategic framework through reduced or delayed vaccine uptake. I wasn't quite sure what that meant. What are the alternative solutions? I think what we're trying to say there is that the most effective way would be to have a digital first channel. So you encourage people to book online to get their slots for vaccination and it's all then supported through digital first means. There's the cost of setting that up and maintaining it but actually you don't then need to spend money on letters. You don't have all that additional cost because there's a significant amount of expenditure during the first few waves of the vaccination campaign. Just lettering people, we all remember the blue envelopes, all of that came through and it's a significant cost attached to that. So if you move to a digital channel you remove all that but then you're excluding the most vulnerable of our society that are excluded digitally. What the National Contact Centre does is provides that channel for them to be given that advice. It takes pressure off local public health teams. They don't have to necessarily deal with that type of questioning that comes in. So we're offering that channel which is an efficient front door to support and it's a very useful adjunct to the digital first channel because you have to recognise digital inclusion and the connection that has to the most vulnerable and the most at risk. So we want to make sure you've got that take up of vaccination across the population. OK, thanks. We could pursue that but I think I've used my time, thanks. Thank you. Thank you. Good morning to the panel. Dr Finno opened a whole Pandora's box there around my specialist subject of prevention but we could probably take up the whole time in that. I wanted just to go back to a point you made, Dr Finno, about vaccination being a key element of Covid recovery going forward. Currently where we are just now is over 50s that we're vaccinating again. This is anecdotal but the people I've been speaking to, there seems to be a higher number of people who will not be taking or have decided not to take the next vaccination. So I think to your point about that that we require that to stay high to prevent Covid going forward. How do we keep the rates high? How do we keep the public informed? And how do you maintain that importance of vaccination? One of the areas that we think we should be focusing more on is the public engagement and communications. So trying to help people to understand the benefits of vaccine and also help them to understand what potentially the risk is. The plan will be to do that through a variety of different means. One, we provide statistics which is giving people an indication of what is happening in their area. That allows people to hopefully make a decision if it's high or maybe prompt them to be vaccinated. The second area is obviously around the communications working with NHS Inform, which is the main route through the communication with the public. It's taking every opportunity we can just to keep pressing that the vaccine does offer protection. What is becoming clear is that the protection can be long lasting because we rely on two facets. We rely on a high antibody level to stop the virus attaching itself in the body. And we've got what we call cell mediated immunity, which is the cells that remember and therefore will fight the white blood cells that will actually fight the virus. The cell mediated immunity has a much longer duration. The antibody level peaks and then drops after three or four months, which is why you see a lot of people getting milder symptoms, but not necessarily then going on to develop the very severe disease. So our understanding of the benefits is still evolving. The 50-year-olds will have been vaccinated already as part of the... Sorry, the larger part of the population will already have been vaccinated. The focus is therefore on trying to boost the immune systems of those people who are more at risk. And the one thing we do know with Covid is that age is a key factor in determining risk. The older you are, the more likely you are to have severe disease and to suffer the effects of it. So it is targeting it and it's trying to use it in the most effective way. I want to go back to what the convener started with and is around the NHS workforce and the pressures on the NHS workforce. And while we're given these statistics of vacancy rates, but of course that's an average across the whole of the country. And one of the benefits, I suppose, of being a list MSP is a work across a number of NHS boards. And it's very obvious that these statistics and being an average are very greatly across different NHS boards. I think, you know, in South Lanarkshire it's extremely difficult to get an appointment or even speak to a GP. Yeah, in South Ayrshire it's easier to do that, but in South Ayrshire the neonatal units down there are under extraordinary pressure that perhaps are not elsewhere. So I think in linking to that I was looking at the excess death numbers over the period of the pandemic and cancer dementia, circulatory issues, respiratory issues were significantly less than expected during the Covid period. Now we can read into that what we will and obviously understanding that how we measured Covid, the importance of that was being consistent so we could deliver trends. But I suppose when we're looking at the budget, which is becoming increasingly under strain, how do we take all those factors into account when we start to looking at managing the NHS going forward because it will change. I'm not quite sure perhaps Ms Morgan will maybe start with that one. Easy question to start with. Yeah, well there's an awful lot in there isn't there really about the public health aspects of how does one change a system. I think resources are finite, I think a couple of things. First of all in relation to staffing across the NHS and the workforce across the NHS there are really two areas that you go to, one is recruitment and one is retention and there are a number of actions and activities in place to help to retain our staff to make sure that they are feeling valued and also to continue on recruitment. Committee may well in future like to take evidence specifically from those workforce professionals and HR professionals that are not in the room today given that that's a big part of the spend. I think the other thing to say is while I'm national services Scotland I'm not the NHS in Scotland so making comment across the experiences right across the country is difficult to make a response to. But resources are finite and we have choices about what our priorities are, what our spending is and we continue to make plans with Scottish Government colleagues and collectively in order to see how we spend our money through our national planning processes, our regional planning processes and also those local processes that are in play. Priorities are kind of contributed to an influenced for us. I'm kind of struggling a little bit to give you a definitive answer to something which is why does the NHS and the health and social care system exist across Scotland. We have got money that we need to think about how that is deployed and I think there is a, sometimes it seems to be a tension for me between what is a local priority and a community partnership and community priority versus what there may be somewhere else in terms of tertiary services. So it's very, very complex and probably needs broader consideration than I can give or perhaps colleagues can give in this space. I think I probably should declare an interest here and my daughter is a medic in the neonatal unit. I've got to say I knew how complicated that question was. My point is that through Covid the priorities shifted drastically unnecessarily but that's left behind a major issue that we're going to have to deal with at some point. So in terms of when we're putting the pressures on the NHS budgets as it is, how is all that going to be considered? I think the real challenge we have and we possibly need to work very closely as finance professionals between health and with government colleagues is just to understand the difference between local needs and pressures versus the way the funding is distributed in the first place. So we get a formula allocation which reflects population and deprivation and health economy. So there's a formula that's developed called NRAC which allows the funds to be distributed to health boards in an equitable fashion. The income is at where but the pressures that are faced locally are different and it's making sure that we fully understand those collectively and are able to then say to challenge whether or not we need to do something different about that distribution. That's a big system-wide challenge that is easy to talk about but very difficult to put in practice. The other aspect of our funding is around policy priorities. So we will get ring-fenced resource which is distributed for particular purposes. So there's funds made available in the budget for mental health, funds made available to tackle drug deaths, et cetera. So where there are real areas which are of concern across the country there's usually resource made available for that particular purpose. But the challenge we have is the dynamic locally is different and then when you devolve aspects of the budget down to local IJBs and the distribution of that and priorities are taken at a local level you then get different priorities in different areas. And that's arguably the right because it's important that you tackle local concerns and put resources where they'll make the biggest impact locally. But when you then look at that and what that means overall sometimes there's a disconnect and that's why you sometimes you get the disparity of service in different parts of the country. So it's a really complex issue and actually it's understanding I think the pressures and thinking about how we can deliver the services in different ways which will allow for a more equitable distribution of service across the country I think should be important. And that's really where we need to start focusing in terms of our reform agenda. So it's that longer term view of what health and care looks like and how the service will be delivered in the future. And at the moment we're reacting to real pressures locally and all the resource thinking and effort is about tackling the day to day and somehow we need to have an opportunity to draw breath and stand back and think about what we do for the future and that longer term vision for health and care in Scotland. Because that for me is the difference and it's important in doing that that we really reflect on some of the real positive legacy from Covid. So the way that the system came together and worked together was amazing. So often we have challenges and boundaries and you know where different organisational entities meet then there's conflict and I think if you were to speak to citizens and you talk about their experiences in accessing care between different entities they'll say that's a frustration. That was largely resolved by the way that we worked in the pandemic response. It was all we're all on it together, a national response. So how can we learn from that to make sure that we work in a seamless way? And we've also introduced a huge amount of digital technology and capability at pace and so it's really important that we don't miss the capability. We don't forget about that and we use that capability in different ways to enhance our services. So I think there's lots of opportunity. I think for me the challenge is very difficult in the now at the moment and the pressures that the system faces for us to be able to take that step back and think about what the future holds. Thank you very much, that's really interesting. I'm a big advocate of increasing the way in which we adopt technology in the healthcare. I think that's a major way in which we could step forward. And if I could just push that point a little bit with the powers itself, Dr Foster on Luke, when we're looking at Covid recovery I think what I was probably trying to highlight there is one of the impacts of Covid is in non-Covid related conditions and quite understandably we had to focus very hard on Covid and the public would expect that to happen. I think Ms Morgan you talked about the fact is what's acceptable to the public. I mean imagine now that it is starting to be a shift back towards non-elective surgery and cancer care and all that kind of, all those kind of issues. And to Ms Low's point about around the adoption of technology, how realistic is it under the current situation that we are going to give the health service the space to breathe and the space to consider how the long term strategy of healthcare will be in the future. Thank you, I'll be brief because I'm aware of time, but I think one thing ties together all of the questions that you've just asked and that's actually the importance of behavioural science in understanding what motivates people. And so a lot of our problems are about being able to recruit and retain staff, our issues are about encouraging the public to take up vaccination, our issues about people understanding how to engage with health services and what's sufficient. Why is it that people, we're not coming out of a pandemic with a population that would be proud to move into care services, nursing, doctoring, all that sort of thing. So we need to understand the motivations and I think actually we do, we have an opportunity to reflect on the pandemic and to step forward positively out of it. I think it's important to stress we haven't stopped all the elective care, there's massive amounts of elective care on going, it's really difficult just now because we're under huge pressure, but we are making progress. There are elective care centres and so on coming online and things will step back up, but the critical factor is we need the staff to do them. And it's about understanding how we create a situation where people are still proud to want to work in the care services and care professions and stay with it and contribute to that because that's how we'll get out of this. We just need the people, the NHS and the care services are all people businesses, they're all about people and if people don't want to be part of it then that's our real challenge. So I think there is a positive future, I think we can get there, but I think it's all about recruiting and retaining staff and making people proud to work in public service. If I can just come in here just because I think we're slightly off topic because we know that the health committee is looking at the NHS reform and we're more of the Covid recovery strategy. Did you want to have another question before we move on? No, I was blessed as anybody else to ask a question, I'm happy to leave it there. Nick? In Covid recovery, we shouldn't forget those people with long Covid. The ONS has estimated that there's about 200,000 people in Scotland with long Covid which presents in variable ways depression, mental health issues, suicidal ideology, lethargy, listlessness, a whole series of people. This is part of our legacy and I just wanted to make the point that we shouldn't forget about them, it's a substantial proportion of the population. Absolutely, a valid point. Jim Felly? You clearly read my mind, Dr Felly, because that's exactly where I was going. However, one of the problems being the last speaker is there's lots of wee questions that have sprung up throughout the course of this so I want to just try and rattle through them very quickly. You might have actually answered some. The first thing that came to my head was the cost of funding the pandemic in the first place. I've never done a budget scrutiny before so I was thinking, where did that budget come from? Caroline, you said that that was just an unending amount of money that was available to you to be able to deal with it. We're now in the position where Dr Finns is talking about, we need to make sure that we get vaccine uptake, I'll come on along with Covid in a minute, but there are a whole lot of other costs now. Is that being absorbed by the original NHS budget or have you got extra funding over and above that in order to deal with the extra challenges that are coming out of Covid, despite the fact that we might not be out of Covid? There is no additional specific Covid line that stopped at the end of March last year, but there are still expenditure consequentials for vaccination, for example, that will continue to flow. There will be elements of the pandemic response that we think will have to be maintained on a recurring basis so that we should see elements of Barnett consequentials flowing into that and then see that it's not clear the extent to which that will be yet. We need another budget settlement to see where that lands. Can I stop you there then because that brings me back to something that Richard You were talking about earlier on, the Barnett consequential thing really interested me. If Scotland has a specific healthcare issue through whatever it is, a virus, but it's specifically here in Scotland and it's not happening in the rest of the UK, how does the Scottish Government fund it? I would have to be funded from within a resource. Okay, that answered that question, so I'm well led on. You guys are good. Sorry, there are a couple of other wee bits and pieces, just bear with it. Alec had a question earlier on about the budgets for getting people in. Is it financial that's causing the problem with having enough people in place or is it people just not being available to do the job or wanting to do the job or having moved away from the job? Because I know that there has been a huge churn in people's life and they've said, hospitality for an instrument, I don't want this life of hospitality anymore. Is the same thing happening in the NHS and is that one of the problems that you have in resourcing staff-wise rather than financial? I think that's a hugely complex question again. The answer is very complex because as Dr Foster has said, there will be some behavioural activity in there. The two years of Covid have exhausted our staff, both those at the front line, the very front line, the people who were at the real front line facing of that. But also those people perhaps referred to by Dr Foster as being at back support. So a lot of the digital and IT work that went on that has gone on behind the scenes has really taken its toll in that space. So people are tired. There's no doubt about that. They are reframing not their work-life balance but their life-work balance and actually considering where do they want to work. They are looking, for example, I've had a number of people who have resigned from their roles because they want to move closer to family. Family has become in some ways more important to some people. So it's multifaceted and multifactorial. Colleagues in National Education Scotland and Scottish Government colleagues will be able to answer more questions around the analysis of that. There are other factors at play. So for example pension implications, the implications of pension taxation on whether people retire at an age that they can afford to do so. It is a factor, for example. We've recently had a policy introduced where people can retire and return to the health service to make sure that we have skills retention. And it is in the world of nurses and doctors, the vacancies that Convenier quoted earlier on. But there are also other job families such as biomedical scientists and digital where the market is strong. And actually public sector cannot compete with private sector for some of these areas of work. So it's hugely complex that area of recruitment and retention of staff across the health system. Thank you. First I'll just pick up the back office thing because I just want to be absolutely clear that just to pick up from me, I don't think the NHS has too many back office staff. Just in case anyone thinks that's what I said, I absolutely don't mean that. What I think is we spend far too much time on back office type functions. So we sit in governance committees and audit committees and performance and resources committees and board meetings. And actually we just need to reflect on do we really need to do all of that stuff to the level of depth that we do? Is it necessary for us to have what ever is 32 IGBs and 14 health boards and 33 community planning partnerships and 33 community justice partnerships? And 33 alcohol and drug partnerships? And as a director of public health I could sit on them all and many of them have between 500 and 1,000 pages of print for each meeting. It's an extraordinary industry of bureaucracy and I'm supposed to be a frontline doctor serving patients in the NHS. And at those meetings I'm sitting alongside increasing numbers of senior doctors and nurses who are servicing those meetings. Because we don't have lots of managers and administrators and so on who do that. People think that but we don't. We're actually quite light on that. So all that back office stuff that we do, which is right, you know, we need governance and we need accountability and everything else. But perhaps we just need to take a breath and think if we need quite so much on it because that would be an area of saving. But that and actually in order to free me up I actually need more people to do that, you know, to make sure that pay and rations gets done. Because it seems crazy to me that as a director of public health I'm filling in people's pay and rations stuff as part of my role. That just seems bizarre. That's not what I spent 30 years training to do. But in our current system it's the way we run things because we don't have people to do that for us anymore. But to go on to the actual question, I think there's two big issues. The question was would more money help? And the issue is right now the core of the problem is not that we aren't working flat out, it's that demand is exceeding supply. And it's exceeding supply not just in the health service but in the whole care sector as well. So a huge problem for us is that the care sector is really, really struggling with huge numbers of vacancies. So older frail people who come into hospital have nowhere to go. So our staff are looking after lots and lots of older frail people who are in hospital who don't need hospital care or hospital treatment but need care. And actually it's really, really difficult to get them back into the community because they just aren't the services. There aren't people to do home care visits and there aren't people to staff care homes and that's a real challenge. And it might be partly about money in that sector because if you paid more you might argue that you would get more people. But you might equally just suck them out of other areas of the health and social care sector. So I think there is something about the absolute number of staff. And in terms of the recovery, we don't have any operating theatres that are standing empty that aren't being used. They're being used every day, flat out to try and catch up. So in that respect I'm not sure that we could do a great deal more. We're just behind them. We're running as fast as we can with the available resource that we've got. But the resources, people and buildings and operating theatres and so on, it's not just money. And so there isn't a quick fix here. Is that enough of an answer? I'm going to pressure wee bit on this because something that Mary said earlier on, John talked about the just-in-time supply chain. You talked about beds at their maximum, not their maximum, at their most efficient, at 85 per cent occupancy. There's a question there for me about how much financial value do you put in the ability to have the continuity supply, a resilience supply chain keeping critical mass? Is there a financial value to having that critical mass that you talked about? And that same question could go to bed occupancy. Do you understand what I mean? Yes, yes, I think so. The challenge is that we have driven ourselves to be ever more efficient, more efficient and more efficient and then an extra thing has come along and overloaded the system. And it's really, really hard then to reset the system. I'm very attracted to the idea that we just all need to take a breath and start again. But of course we don't get to do that because the demand, the queues are still outside A&E as we speak. So we don't have that ability, but at some point we need to stop and reflect on what we're doing. And I think part of the issue is we need to find some things that we perhaps don't need to do so much or we could stop doing or do differently. Right, okay. I'm sorry, I'm going off at a tangent. It was something that John had said earlier on. That value of having the stockpile, there's a financial value to having it from a purely financial point of view but also from a qualitative point of view when able to deliver the system at the time it's needed. You see what I mean? It's about your throughput, I think. The key is you can have a bigger stockpile if you have a greater value of turnover because you can justify holding that stockpile and having that initial investment. So what we desperately need is everybody who needs to use PPE, not just the acute sector that we supplied pre-pandemic but also social care, perhaps other parts of the public sector to actually draw their supply from us rather than buying from their other sources so that there's a single supply chain for that product that allows us to then maintain a stockpile at that maximum capacity to get the turnover so we don't have any wastage in the stock because the last thing we want to do is to buy gloves, masks and then they go out of date and we have to... The suppliers are all coming with different methods of production of what have you and some of them drop off, you lose that critical mass at a time when you need it the most. What we had during the pandemic was global supply chain, supply in China, the whole world trying to source its PPE from the same manufacturing plants that were running full-time and countries buying the entire supply production of a plant at a time and then jumbo jets of PPE getting transported. That scenario is not...we want to get away from that, have a local supply chain so in the case where we need it we have secured that supply. That local supply chain is now up and on so there's a huge value for us as a country to be able to make sure that we continue to keep that local supply chain functioning. In a scenario where you have to ramp up then rather than paying a manufacturer in China to ramp up you're paying your locally based Scottish manufacturer to ramp up and it has a huge economic benefit. I felt you were asking about the same application to bed capacity for example and there is inpatients in hospital and acute care. Those hospital acute beds are more expensive than having the same patient cared for in a more homely setting in a care home piece. It is a cyclical piece. It's where you hold your bed stock and what is needed for throughput and how you reduce your length of stay that's very complex. I really don't envy the job that you guys are going to do to try to juggle all of this and not know what's actually coming down the road. I want to come back to you because the actual question I wanted to ask about was long Covid recovery because that's one of the things that we talked about just immediately prior to coming in is their budget going forward to deal with the research, the kind of treatments and everything else that every one of us will have long Covid sufferers coming to us as constituents MSPs and the message that we're getting is that there's not enough being done there's not enough help for them. Is there enough budget research and everything else going into it to be able to deal with the people that have got long Covid? I can't comment on the sort of any global budget that's been put into it but certainly we in Public Health Scotland are working with Glasgow University we have a project where we're looking at people that are presenting with long Covid symptoms so it's not just self-reporting which is what the ONS are basing their statistics on they're basing it on self-reporting of symptoms and so we've studied its on-going and there's a paper due to be published in the next week or so and again I'm happy to provide that to the committee which is really trying to understand are we dealing with one thing or are we actually dealing with multiple things that require different interventions and until we understand that it is actually quite difficult to do anything more than provide supportive care so it is about trying to understand the condition we are involved in looking at that but we need to tie in probably to some of the work that's being done at the UK level in order really to get access to the numbers we might need to understand those questions and also to share the expertise and the knowledge the more people looking at an issue and a problem the more likely you are to come up with a solution so it's very much about us doing some primary research but also trying to link in to other research that's being done elsewhere with regard to funding for services I'm afraid that's not an area I can comment on Just to follow up on that a long Covid strategic network has been established it's formed through national services division which is part of NSS and funds I can't quite remember the exact amount have been distributed through that network to health boards to set up services that are locally responsive to the needs of the people in their area it's not a recurring sum of money so it's not going to go on for a long time because really it is emergent and we need to understand what is better needed but funds have been distributed to assist people experiencing the effects of long Covid so it's effectively we need to try and find out what it is that we need to do before we can actually budget for it is to try and understand what we mean by long Covid it's like 25 years ago we talked about autism as if it was the same syndrome affecting everyone it isn't, we now understand that so it's getting that understanding and it's really only been two years if we, you know, the pandemic is two and a half years now so we've really only been looking at this for two years and for a chronic condition that's not very long so it's really, I know it's difficult but it is taking the time we need to look at this OK, thank you I know we are just on time but Brian, if you could be very brief with your question just one area that I think we need to touch on is the level of funding that the Scottish Government should be allocating to future pandemic preparedness and long-term resilience and obviously the pressure that inflation and supply chain currently is going to put in that and we knew pre-pandemic through Silver Swan that the likelihood is that the biggest threat to our public health was going to be some kind of global pandemic and yet we allowed that to slide so I think my question really is how do we maintain that preparedness and how robust do we need to be to make sure that our preparedness is kept at that level no matter who would like to answer that question Dr Foster Thank you, so I'm just taking a minute I think the important thing is that what you need is you need robust, resilient NHS services that can respond to anything that's what we need and we need to be efficient about how we plan and as we already discussed it's not efficient to take a large chunk of money and put a million masks in a warehouse somewhere and think that's preparedness tick that's not a good way to behave what is necessary is that we design our systems so that they have a little bit of resilience in them so that we can respond when we hit rough water and then ultimately we can deal with any emergency if we can get through the first little phase public services will kick in and we will respond but what we mustn't get is to a situation where our services are so thin that we can't make that initial response who holds back who puts their finger in the dike for the first few months while we all realise what's going on the evidence comes, we understand the disease we learn what's required and then we make the big decisions so we need robust, resilient, well-resourced, basic public health and emergency services so that we can deal with that and just in closing the idea of how much is virtually impossible but the truth of the matter is we don't actually spend very much on prevention out of our entire overall budgets I suspect if we asked you all to make a guess you would be way over what actually we attribute to prevention and so without quoting a number I think as a philosophy we should collectively be seeking to slightly increase the amount of the overall resource we spend on prevention each year going forward because I think as Nick has very ably demonstrated it's so important that we address prevention and keeping people well Thank you, we are out of time I'd like to thank all the witnesses for their evidence today and for giving us your time if witnesses would like to raise any further evidence with the committee they can do so in writing and the clerks will be happy to deal with you and how to do this I will now briefly suspend the meeting to allow the witnesses to leave, thank you I now move to the second agenda item which is consideration of the negative instrument listed on the agenda Members should refer to paper 3 which sets out the background to this instrument The deadline for a motion to annul this instrument is 30 October 2022 Members will see from the paper that a motion to annul the instrument has not been lodged to date Does any member have any comments to make on the instrument? John I note the DPLR comments that the timing was just slightly out I think it's just a few days Personally, I find that acceptable but it's never ideal We will be having the DFM on 29 September if you feel like we need to have evidence on it Are members therefore content that we agree that we have no recommendations to make on this instrument? Agreed Thank you, we're all agreed not to make any recommendations on this instrument and that concludes our consideration of this agenda item The committee's next meeting will be on Thursday 15 September when we will continue our evidence on taking on pre-budget security That concludes the public part of our meeting this morning I now move into the private Thank you