 Y Llywyddyn am iawn, ac hi i. Mae gyrfaen nhw'n cyfrifiadau y ddefnyddio ar gyfer Cofid 19 y Ddefnyddio Pwyllwyllus 2021. Y first agenda item this morning is a decision to take item number four on our approach to the coronavirus discretionary compensation for self-isolation, Scotland bill, in private. Are members agreed? Yes, please. Thank you! We're agreed to take agenda item number four in private. This morning the committee will continue its inquiry into baseline health protection that's taking evidence from stakeholders in health and social care services. I'd like to welcome this morning to the meeting Donald Morrison, member of the Scottish Dental Practice Committee and the British Dental Association Scotland, Dr Andrew Bust, Chair of the British Medical Association GP Committee, and Dr Donald MacAskill, Chief Executive of Scottish Care. Warm welcome. Thank you for giving your time to us this morning. This is the second of our four evidence sessions that we have planned on baseline health protection measures. These measures are the main tools that we are using to respond to Covid-19, which include ventilation, face coverings, social distancing and vaccinations. This morning's session will focus on the role of baseline health protection measures in keeping health and social care services running over the winter period. We will also consider what support might be required longer term to support your sector to recover. I will now turn to questions, and if I may start with a few questions. Could the witnesses briefly outline the ongoing impact on Covid-19 on your sector and whether you think that we are using the right approach to baseline health protection measures to help us get through this winter? Can I start with Donald Morrison, please? Good morning, committee. Just briefly, I'd like to introduce myself. I'm Donald Morrison, I'm a general dental practitioner of over 20 years of experience in the NHS. I currently work in a mixed NHS practice in Ayrshire. We're responsible for around 5000 plus NHS patients. I think that the problem or the issue that you bring here regarding how it's affected the sector statistics or the numbers that we've got just now that we've lost over 4 million appointments at the beginning of the pandemic and a system that was working at 100 per cent capacity and growing at the beginning has now been due to mitigating circumstances to protect patients and clinicians. It means that, with the different baseline measures, even at its best, absolute best, we probably find that surgeries can only work to 40 to 50 per cent of what they were doing before. My definition of a system that wasn't creaking before is absolutely struggling now. I think that we will be a few years if we ever get back to anything like normal. As far as affecting the sector, although there's been a lot of support from Government for the NHS part of the sector, there have been support payments put in place and there's recovery packages to try to keep on running, without which it genuinely would have gone to the... I think that the system is struggling so hard now just to keep up at 50 per cent of what it was. Although we've had help, the most important thing is that, on-going from on end, we need to look very, very carefully at how the sector is going to be affected when things are supposed to try to get back up to the percentages of care that we've offered in the past. That's all I have to say about that. Thank you for your comments. Can I bring in Dr Andrew Buse, please? Thank you, convener. We're like the industry. Our capacity has also been affected by baseline measures. We've dealt with that, as we did from the beginning of the pandemic, by moving to what we call a hybrid method of consulting with a mixture of remote consulting, video or telephone, face-to-face. By doing that, we've managed to maintain the totality of the number of consultations that we offer. We surveyed practices four weeks ago in Scotland and showed that we're providing over 500,000 appointments each week in a mixture of remote and in-person. I doubt that the baseline measures have impacted on how we work, the social distancing, the mask wearing. I find it particularly difficult in terms of consulting. It's probably not as difficult as the industry will do, for obvious reasons. However, when you can see a patient face-to-face, it's such an important part of the consultation, the non-verbal clues, particularly with mental health issues. I've tended to personally cope with that by seating a patient at a two-metre distance and saying, look, can we agree to take our masks off so that we can see each other face-to-face? Overall, it has impacted on the service that we offer, but by providing a hybrid model of consulting, we've managed to maintain overall totality of consultations. However, it has quite a significant cost to the general practice workforce, who, I have to say, are quite fatigued by this and by some of the unfair criticism that has been levelled to general practice. I bring in Dr Dono MacKeskell, please. Thank you, convener, and thank you to members for the invitation. The social care sector has been particularly hard-hit by the different waves of the pandemic. Many of the members will be familiar with that, although I suspect familiarity has prevented us from recognising the very real immediate challenges that we are facing. Undoubtedly, the four measures that we are reflecting on today have significantly helped to make residents in care homes and individuals receiving care and support in their own home much safer. However, as we have gone through the 20 months, we are evidencing real profound impact, not just by those measures but by the whole pandemic itself. Those are probably in three areas. One is workforce. During the first wave of the pandemic, workforce stability was in the high 80 per cent. Very few people left the sector. They were dedicated. They stayed. They were sacrificial in their working. However, we are facing in social care the biggest workforce crisis that the sector has ever experienced. That is having a profound impact on the stability and sustainability of the sector. The second main factor relates to the economic sustainability of the sector, which is of real concern. Given that social care is the fifth contributor to the Scottish economy as a whole, if we fail the social care sector by inadequate resourcing, and if we see more and more providers, given that Scotland has a unique small business social care make-up, if we see more of them going to the wall as we will this winter, that raises profound questions about sustainability. The last factor is a whole set of additional elements that have come in in the last few months. For instance, we are seeing insurance premiums for care homes—absolutely rocketing. Two years ago, 2019, average payment was about £3,000 to £5,000. Last year, that rose to £17,000. This year, providers are being, for the same coverage, charged £30,000 by insurance companies. That makes a small family-run business virtually impossible to sustain. Add to that real challenges with energy cost increases, challenges with transport and all the consequences of instability brought about by the wider workforce. There are the three factors that today are impacting on the sector. The measures, although they keep people safe, are certainly not addressing those significant issues that I have just outlined. If I could just ask this probably question for Donald MacAskill, of course, during the pandemic, the care home visiting was stopped in order to protect the most vulnerable, and that was very difficult for all the families. However, following the petition lodged by the care home relative of Scotland, the Scottish Government is now planning to introduce legislation known as the ANS law, which will define a resident's right to see and spend time with those that are important to them. Can I ask your views on the visibility of balancing visiting in care homes with the need for infection prevention and control measures? Thank you, convener. A Scottish Care supports the broad principles of an individual resident having the right to have family, friends and others visit them. Clearly, the early measures taken by Public Health Scotland to prevent visiting were necessary and undoubtedly saved many lives. Unfortunately, as we all know, the fact that those measures remained for longer than perhaps was necessary has resulted in real psychological, emotional deterioration and loss of life, undoubtedly, on the part of residents and a very negative impact on the whole care home community. As we move forward, what we continue to need to do is first and foremost to remember that our primary duty is to the preservation of life and a life lived to the fullness, not just keeping people alive but keeping them living in a way that they would want to live. What we have as a challenge in the future is a situation where an infectious disease still exists in the community, may increase in its robustness in the community. We know that it is from the community that harm comes to an individual resident that what we will be required to do—and this will involve all of us working together—is to balance the rights of an individual to see family, friends with the rights of other residents and the rights of staff to be protected and safe from harm. I think that we are in a very different position from where we were for instance this time last year. The vast majority of care homes are now trying to be as flexible as possible, even during an infectious outbreak if it is appropriately managed, but we will only move forward to try to restore ourselves to a situation that existed before the pandemic where I could count on a couple of hands the number of instances where there was disagreement about visiting. However, as we move into winter, the threat of community transmission increasing and therefore challenge in our care home community increases. Last week, sadly, we lost 10 residents in our care homes as a result of Covid. That is significantly better than where we have been, but even with all our protective measures—vaccination, PPE, social distancing—we are still losing individuals, so we must never take our eye off that real challenge in the months ahead. I could ask Donald Morrison the next question. To give you a bit of a background, it is one case that has been made aware of in the last 24 hours. One lady was diagnosed with a tooth abscess and a related infection back in September. Her dentist prescribed antibiotics and said that she needed to have root canal surgery, but due to Scottish Government restrictions, she was not able to get an appointment for the surgery until April 2022, so that lady continues to be in a lot of pain. I would like to know your response to claims that private patients are being prioritised at the expense of NHS patients, and if you think that that is true. I think that the big issue in this particular question—I am sorry to hear about that, lady—is certainly at a local level in my practice. Nobody is left in pain. There are facilities in the practice to take pain relief precautions and pain relief measures for patients that can be done without even finishing a definitive surgery. We believe that the system will allow us to treat those patients and any individual patient who is in that situation. I would urge them to contact their local health boards and their local dentists to communicate with them, because communication is one of the big problems. We are finding that the dentists do not always know exactly what they are supposed to do in that situation. There are quite a few patients that, prior to the pandemic, were not registered with the dentist anyway. There is no incentive and there certainly was not a facility during the pandemic for a dentist to take on a new patient who was in that situation. The question of the private sector is slightly more complicated in that each dental practice exists as an individual entity. We are essentially private contractors who work for dental checks, so there are probably 1,1100 practices in Scotland—only a handful, maybe 30, who are completely private. The rest are a combination of the two. We call them mixed practices to do a bit of both. A prior to the pandemic, a small proportion of your work might be carried out privately, but it was the work that would help to subsidise practice. Each business has to run, to function like a hospital, to function like a care home, to function. It just so happens that it is mixed in the one building. What tends to happen is that in the clinicians where that revenue was cut off from the clinicians, there was NHS support and no private revenue, so those practices became all-stun viable. To build back in strength into the sector, we need to continue to work in a joint next fashion to allow all those practices to continue to run or they will fail. Obviously, there has been a funding package that has assisted, and it does help the dentist and me. We would say that there were winners and losers and there are certain practices that have had larger payments that are doing better and others that are doing worse. Obviously, that is something that we are always trying to work our way through. However, the problem with individual cases is that it gets a little bit mixed up with the fact that there are always going to be cases of people who feel that they cannot be seen in the way that they want to be seen. I would urge that person very strongly to contact any dentist in their area. All the professionals, all the dentists, are working really hard to try to deal with these situations for these patients and these people. Nobody wants to be seeing anybody in pain. The private sector, as far as edgentry is concerned, has supported and boiled up the NHS sector for a long, long time. It is not well recognised. Unfortunately, as we come through the pandemic, it may well be that, because we do not know what is happening, because of the communication with the Scottish Government, we do not really know how things are going to go back to the treadmill of the broken system that was being reformed prior to the pandemic. If we go back to that, the clinicians are unaware of how they are supposed to see it, so they must, under all circumstances, make the system, make their practices, be viable for their patients. There will always be people who fall between the gaps. On a personal level, I can only reassure you that that would not happen on 90 per cent of the dentist's watch. We are working very, very hard. However, there will always be a system certainly in medicine where people will pay privately for something to have done faster, to use better materials to do X, Y and Z. In some cases, patients will refuse to have or to just remove, which is a treatment that is a viable option to remove infection, to treat and make the patient well, but that will not be what they want. Therefore, it takes time to get that done for the patient. I am sorry to hear about that. As far as the BDA is concerned, and as far as clinicians in that area, I am sure that any number of clinicians would take a call from a patient and see them. Thanks for the guidance for that. I am sure that all of us as elected members all have these kind of issues in our inbox at the moment, because it is a very challenging time. Last question. I think that it would be irresponsible in the last 18, 19 months if we were not putting measures in place to try and stop this challenging winter ahead, which we all know that we are currently facing. In the last few days on Tuesday, the 9th of November, in Scotland, we had 2,233 new cases of Covid-19 reported. Yesterday, that rose to 3,852 new cases, which is very alarming. Do you believe that the vaccination passports should be extended to other settings? I think that I would be supportive of that. I think that if I am going into cinemas or theatre or something like that, I think that it would be useful to know that the people that I do not know have been vaccinated would give me some comfort. In short, I would be supportive of the proposal to extend it. Thank you. Can I go to Dr MacAskill? Having already said that the relationship between community transmission and what happens in a care home or indeed what happens in somebody's own home is now undeniable, then personally I would be in favour of the extension of the use of vaccination passports. However, I think that we have got to be extremely careful that we do not see that somehow or other as a panacea to address the rising number of cases. I have equal concern about the growing evidence. I live in Ayrshire, I wander around and I see increasing evidence of people being very lacked in wearing masks. Although Scotland thankfully has a policy that is about encouraging mask wearing in public spaces, I think that we need to look at toughening the stance on that and removing the abuses of that very, very important protective measure. I have absolutely no doubt personally as unfortunately not just in terms of Covid but in increasing respiratory conditions such as flu and norovirus, we are likely to see increased restrictions. I hope that those are brought in early enough to be sufficiently protective. Thank you very much. Can I just finish with Mr Morrison, please? Thank you. I think that the big thing for clinicians are certainly in the dental centres that the other baseline measures that we use, social distancing, mask wearing, as far as dealing with our patients is concerned, is to really just go out of the window because you cannot treat somebody, you cannot social distancing, you cannot wear a mask. I think that vaccine passports, as far as I am concerned or we are concerned, would be that we would not necessarily be in something like that, quite supportive of it, but I will be wary of a situation where patients weren't in treatment. Probably the problem with people without a vaccine passport, we worry most about the fact that patients who have benign or have symptomatic oral cancer that we haven't seen for a couple of years, who are the sort of people who generally can be picked up early, we can get these people just laying our eyes upon them, seeing it in the myth and standing on to the right place, is a huge thing and picked up early saves a huge amount of money and effort and time for every, all the patients and all the hospitals, et cetera, et cetera. I would be concerned about a passport stopping these types of patients, we are talking about all their male patients, smokers, drinkers, who would then use it to avoid picking treatment, because for our patients we would be a wee bit one, but that said, I don't think that a vaccine passport, I think that if patients in education programme died out properly, would we educate the patients that, as opposed to having a vaccine passport, they could take part of their clinical records that they've been vaccinated or not vaccinated? We generally treat patients, even ones that are—we assume that everybody has it and treat them accordingly in social distance, whether they can, in their own PPE droplets. It is very difficult working in the PPE, the respiratory masks, quite exhausting and the profession are exhausted back, but as far as actually our patients are concerned, I think that if they are—a passport for us would make a difference, but we are certainly not against something like that. We worry that it would become a barriers treatment for some people. Thank you very much. Thank you, convener. Good morning to the panel. I've got one question for each of the panellists, please. I wonder if I could start with Donald Morrison. It's a follow-up to one of the convener's questions when she relayed an experience of her constituent. I've had a number of constituents raise other issues with me. I think that there's a bit of a theme here that constituents are saying that if they are private patients and they have access to treatments that are not available to them with NHS patients, that's led some to become private patients if they're in the fortunate position where they can afford to pay, but of course there's a danger then that you create a two-tier system. I wonder if you can explain to us why is it that if you're a private patient you can get access to appointments and treatments that you can if you're in NHS payment. Thank you for that question. I would go back to my answer in that the setup, as far as each individual practice is concerned, is set up around an individual practice. Each practice is essentially a small micro hospital in itself. During the course of the pandemic, the clinicians that are running these places need to make the practice viable and that the private part of their income subsidises and supports the practice. Without that, they won't exist. There's no doubt that there are large NHS practices that are running at over 100 per cent compared to previous measurements because they have to go so quickly to generate the income to get the resource into the practice. That might sound a bit strange, but to explain it, the percentage that is paid through the Covid recovery payments or the support payments is 85 per cent of what the growth to the practice would have been and what the building would have brought in. In order to make that work, there are some situations where being able to generate larger income from private treatment is not about the patient being private, it's about the treatment being carried out in a different way in that it's using different materials or taking more time, etc. However, the provision for NHS, which is stipulated by the NHS recovery pact, is that clinicians have to and do work in the NHS centre and provide as much as they possibly can. At the moment, we receive support of PPE to treat up to 10 patients a day. In a practice on the NHS that used to maybe see 40, 50 or 60 patients a day, we're only receiving the resources to treat 10 patients a day. Increased time between patients, fallow time, which basically means that once you have picked up dentistry is unique in the fact that, whilst being in a patient's mouth, put you at high risk or put the clinicians at high risk of catching Covid and other respiratory diseases, we also produce an aerosol in most things that we do, which disperses infection into the air. Fallow time means that you wait for a period after you've done surgery in a room that hasn't got adequate ventilation. That fallow time can be anything up to an hour before you can go back into the room. There are situations where you can increase ventilation and we're working very hard for that to do that, where you can get this fallow time down to 10 minutes with high-speed suction, but the process of doing that is essentially the same generation or immunisation practice. It means that the dental practices have to do more work privately to generate the same income as ever before in order to make the business wider. If you can only see 50 per cent of the patients that you could see before, there will inevitably be some patients that give you or report to you the perception that they couldn't be seen. That doesn't mean that they couldn't be seen. There will be waiting lists. The waiting lists might be four, five, six months. No practice, no clinician will leave a patient in pain, and that won't happen. Our members are very, very careful about the fact that if I have done it in my own practice, where I have had a practice on the road on the NHS, saying they can't see a patient, we've taken them and see them in the NHS, helped them out, passed them back, we work together as clinicians, there will always be some outliers, and I have no doubt there will be some situations where patients will need to fit in with, we still get people who say, I can't come because I'm working or I can't do this or I can't do that, but we have to be able to recognise that somebody who is reporting this to you, and I go back to my previous answer, if there is a problem, then they need to be seen, then they will be seen on the NHS. As to whether or not the treatment is carried out immediately, and we are still in a backlog, I mean having lost four million appointments and working at 50-60 per cent back to definition, we can't be back to where we were, and it certainly isn't business as usual, but pain relief and pain management can be done. As far as the private sector is concerned, there will be dentists out, there will be other clinicians out there who have invested in a huge amount of ventilation systems, buying their own PPE, working as well as they possibly can, and patients who go to those clinicians and pay privately and have the work done. That's the same as any medical sector and has been like that for a long, long time. We'll have to say about that. Right. Thank you. Thank you, Mr Morrison. That's very helpful. Can I maybe turn to Donald McCaskill, please, and ask him a slightly different question? Dr McCaskill, you were talking about some of the issues in the care sector, and you specifically referenced issues with workforce. I've spoken to people in the care sector who say that one of the major issues has been the number of experienced and qualified staff in the care sector who are now leaving the sector to go and get jobs in other sectors, such as retail, for example, because the paying conditions are better. I'm interested to understand from you how much of an issue that is, and if it is an issue, what needs to be done to fix it? How do we make sure that paying conditions in the care sector improve that people are not leaving to get jobs elsewhere? Thank you, Mr Fraser. It is probably the most significant issue facing the care sector. You're undoubtedly right in that we are hemorrhaging experienced, billed staff, nurses and carers who are going elsewhere. There has been a step forward with the announcement by the Scottish Government of an increase in the carer salary to £10.02, taking it above the living wage. That is the first step, but the first step in a long journey towards the destination of parity with the NHS in particular. What we are seeing at the moment is that we carried out a survey with our members over the summer, published in September. Nine out of 10 of them are struggling to recruit. People who are called to interview 40 per cent aren't turning up. People who are appointed 60 per cent leave within the first six months, because care is not for everybody. It is a human, it is an engaging piece of work, it is valuable but it isn't inevitably a career for everybody. The response to what we need to do is multi-fold. We need to increase baseline salaries because £10.02 is good—it's better than what it has been—but the same individual can go and get a job in retail or in hospitality for more money. I'm not dissing those environments, they are extremely important to our society, but they are not demanding of an individual that they be registered, that that individual is regulated and that that individual has to be qualified. All for £10.02, it is simply not sufficient. I'd like to think that the way in which we reward those who care says something about the nature of our society, and at the moment Scotland is failing in that relationship. However, there are other factors, so the NHS and local authorities' partnerships are engaged in a massive recruitment drive at the moment. In this last week, a rural care home in Four Valley reported to me that they have lost three nurses and four carers, all of whom have gone to the NHS in the local area. A care provider in Edinburgh has lost 15 per cent of his home care staff because they have gone to work with the local authority. We are not wanting to stop people from moving on, but if we are paying the same amount of money to somebody who is a domestic member of staff in the NHS as we are to somebody who is delivering professional-skilled care, who is qualified and regulated, that lack of parity means that, no matter how much we give to the social care system, we will always bleed our talent and our skills elsewhere. Undoubtedly, another factor is that those two sectors, retail and hospitality, are dramatically short of staff in no small measure as a result of their inability to recruit internationally. In rural parts of Scotland, our members are saying to us that they are losing care staff to secure less stressful environments that are not able to recruit internationally. There are many steps that we can take. Take home care as an example. We still have home care staff doing 15-minute visits. Seven minutes of that is taken by donning and doffing your PPE safely. The organisation will be penalised by electronic call monitoring systems established by the local authority. The way that we are treating our front-line care workers is appalling and abysmal. Yes, we clacked on a Thursday for several months, but solidarity needs to be seen not just by forgetting the care workforce but by resourcing them and skilling them with adequate training and adequate access to all that they need. Thank you, Dr MacCassel. Just one brief follow-up. You talked about the increase in base salary to £10.02. Have you got a sense of what level it should be at in order to try to make sure that we do not face the issue with staff hemorrhaging out of the sector that you have been talking about? At the very least, what we need to do is to create parity with the NHS. At the moment, a care home manager under the national care home contract, which is the deal with the independent sector, is paid £13.50 an hour. That, as a manager, and all the responsibility compared to a carer at £10.02, we are having real problems with recruiting and holding on to senior staff because of the lack of differentials. I know that the trade union sector has advocated a £15 an hour starting salary. That ultimately is where we need to move to that level of parity. However, we need significant steps in the immediate future. I know that finance experts will say that the cupboard is bare. There is a very real risk of social care collapse this winter unless we intervene with additional resources to retain staff. Unison has suggested retention payments to hold on to existing staff, but I will also start a salary that will properly recognise the amazing skilled job that carers do. You have been talking about challenges with surging demand going into the winter on GPs. The pressure that is on GPs is simply that we do not have enough GPs in Scotland to address the public demand. You cannot just produce a GP out of thin air. It takes six, seven years to train a GP. Are we today facing a legacy of issues that we should have addressed many years ago, and it will take a long time to catch up? We entered the pandemic in not a good situation. We were short of GPs before the pandemic started. That was something that we were trying to address through the 2018 Scottish G contract. We wanted to make general practice more attractive and encourage more young doctors to come in to be a GP and for older GPs to stay on a bit longer. We were trying to build up the multidisciplinary team, the pharmacist, the nurses and physiotherapists, and the mental health workers around the practice to take away some work that the GPs were doing that could be done as well or better by other healthcare workers. However, the pandemic struck and we had not delivered on all of those things. Premises is another big area where we have a legacy of not investing in our infrastructure, and it has caught us out too in terms of the pandemic, small waiting rooms, difficulty in social distancing, difficulty in having one-way systems, ventilation problems. We weren't in a great situation before the pandemic, and it's certainly found us coming up short. Alex Rowley, please. Good morning. I'm going to start with Dr Beust. Before the Covid-19 pandemic, many of these problems existed. In terms of prioritising for this winter, what should the Government be doing that they're not doing in terms of prioritising for this winter, simply to get through this winter? Secondly, should we be looking at system change and should we do that now, or do we have to wait and try to put all our energies into getting through the winter? When I talked about system change, I noted that the previous chief executive, NHS Scotland, had written an article in October. Paul Gray, where he talked about the need for system change, he highlighted, like, a number of systems, the Alaskan system and the system in Sweden, and said that the types of systems in primary care can deliver. Where's the balance for us as politicians, and what should the priorities be, or can we do both? That's a very big question. System change is—we are in the middle of a pandemic—that is something that will be difficult to do for this winter. The Alaskan model is very resource intensive. If the Scottish Government wanted to move to that, we could certainly look to it. One of the biggest problems is that we have not invested sufficiently in community, health and social care. I will bring you back to the David Kerr report of 2005, which ultimately said, that we are not providing the healthcare system that our patients and the Scottish people need. We have far too much focus on acute care, on hospitals, and not enough focus on access to care in the community. The pandemic has absolutely exposed that. It's just the nature of things in this country, like many other countries. The focus is not on community care, but on social care, on the common ground. Earlier, we took many of those things for granted. The media public politicians are focused on what is happening in hospital, what is happening in an accident emergency, when there should be much more investment and focus on the community. We can fix that right now in what we are still in the middle of a pandemic. However, when we come to review and reflect on what has happened in the pandemic, those are the issues that need to be explored. We are short of workforce in the community, our infrastructure is mentioned to murder the premises. 90 per cent of GP premises are more than 10 years old. Some are over 50 years old, but they are not really fit for purpose. We spend very little of the NHS capital on the community buildings. It tends to get put into developing facilities in the hospital. We are still in the pandemic, and we need to learn the lessons for going forward, not just in case there is another pandemic, but in terms of what is most important to the whole of Scotland. Mr McCaskill, you talked about the relationship between private home care providers. It is very much a contract, and it is very much seen as an internal market. Is that part of the problem? When I talk to home carers, they tell me about the 15-minute visits on the clock of the clock. Is there a real disparity between the way that local authorities treat their own workers who are providing care and those workers who are employed by a third sector or private provider? Is there a real disparity between the two? Would the starting point perhaps be to look at where the best practice is and try to get towards that? There is certainly a disparity, and it is a disparity with hypocrisy at its heart. If we take home care as an example, the same electronic monitoring systems that are used on staff in the third and independent sector are very rarely used on staff employed by a local authority. One local authority this week is advertising jobs for home care staff at £14 an hour, which is more than a care home manager gets in the third or independent sector. There is significant disparity. If we take care homes as an example, last week, two independent studies evidenced that a reasonable cost of delivering 24-7 nursing care home provision would be between £1,000 and £1,200 a week. The national care home contract, which is what the state pays for somebody funded by the state in a care home, is only £750. There is a huge gap. The average local authority care home cost is closer to £1,300. Yes, there is a gap, and it is a gap that, unfortunately, those who are self-funders in care homes and those who are increasingly funding their own care in the community, are having to match. That is unfair and it is inequitous, especially for women and men who are unfortunate enough to develop dementia and who, in the later stages of their illness, will have no choice but to receive the 24-7 specialist care in a care home. Where they to have, unfortunately, developed cancer, all that care and treatment substantially through the NHS community and primary and secondary services would be paid for them. So, inequity is like a stick of rock in our health and care system, dependent on condition and dependent on who delivers that care. In the end of the day, Mr Rowley, the worker, the carer, gives the same compassion even if she is not rewarded or recognised in the same way. So, following up on that, and it would also be the Doctor of Use as well, last week the guidance was given, and I think that NHS Tayside was highlighted as good practice, where people approaching an accident emergency are referred to wherever they should have gone, it is suggested. Much of that suggests that those people are going to be referred back to the community, but we seem to have a crisis within the community. Regularly on a daily basis, I have people contact me to tell me the difficulty they have had in securing appointments, either with a GP or a medical practice. The numbers waiting less for social care where people have been assessed as needing social care in the community, home care, is grown. One, is that porn pressure on the accident emergency because that is eventually where people will turn up? Two, is it acceptable that that accident emergency can keep referring them back to the community setting when the community setting cannot cope? We start with Doctor Of Use. I support the principle of redirection that has operated in Tayside for more than 10 years, and the Tayside public broadly know that, if they have a non-A&E type problem, they should not go to the accident emergency if they have had back pain for two months. It is not appropriate to go and take a decision maker will redirect you. I suggested this to Gene Freeman in July last year as a better model to address the four-hour waits than the redesign of urgent care, which I do not support. As a model, it needs to be well communicated and understood by the public and introduced gently. As the point that you are making, there needs to be places for those patients to go. That might be to the community pharmacy and, increasingly, the pharmacy pharmacy as a useful model, or it may well be to the general practitioner. As I mentioned earlier, general practice in Scotland is often over 500,000 appointments every week. That is one person in every 10 in Scotland is having clinical consultation at their general practice each week. However, our capacity is finite and, at some point, very often just now, it is exhausted. I go back to my earlier point. We do not invest sufficiently in our community healthcare capacity. Right now, we are short of general practitioners, short of practice nurses, short of pharlas and physiotherapists working in general practice. We need to continue to deliver the new GP contract, which is about increasing the number of GPs and increasing the number of multidisciplinary team members attached to practices to meet that demand, so that patients do not have a vote when it is not appropriate to do so. I agree with what Andrew has just said. What happens, as you will know, and as other members of the committee will know, is that if somebody cannot be supported in the community because home care services do not have workers who are able to do the job, then those care packages are handed back or they cannot start. A huge pressure is put on our colleagues in community nursing and in general practice. At the other end, if somebody needs to and is ready to be discharged from hospital and care homes do not have staff or capacity or home care, it does not have capacity, then the whole system is blocked. At the moment, it sometimes feels as if we have a 25-year-old car and we have decided to spray paint it, but we are ignoring the fact that the engine is broken down. Part of that means that we have to start working as a whole system. Unfortunately, the way in which we prioritise attention to secondary, particularly acute care means that social care and, to some extent, primary care is left on the sidelines. We need to start talking. For instance, we have not had a strategic national gathering of individuals in the sector of social care and health for some considerable time. It may be that social care partnerships and providers from the public sector are talking to health colleagues, but I know for certain people like me and my colleagues in the third sector who deliver 70 per cent of social care in Scotland are simply at the moment not at the table. That includes the failure to learn from the pandemic to be present in terms of pandemic response. I have found that, when I have raised the NHS Fife around social care, the chief executive has been very quick to tell me that I really need to speak to the chief executive for Fife Council. When I speak to the chief executive for Fife Council, he is quick to refer me to staff three or four levels down and tell me that they will get back to me. Nobody seems to be taking responsibility. Is the health and social care partnerships a joint integrated boards? Are they fit for purpose and do they have the capacity to meet the challenges that we face over the coming months? Dr MacAskill? I think that that is a huge question. Obviously, consultation on the national care services is in part about redesigning the system of governance around health and social care. My primary point at the moment is that, if we are to get through this very challenging winter that we have now started, the whole system, both at local and increasingly national level, needs to start, including the third and in the independent sector. In parts of Scotland, there is tremendous partnership working, but in other parts of Scotland, the NHS tale is wagging the social care dog. I start by asking a very general question. I always think that if we are going to have a working healthcare sector, we need to look at the morale and the health of the healthcare professionals that work in that sector. Can I ask that general question around where we are in terms of the morale and health of the healthcare professionals who are currently working compared to what they were pre-pandemic? I will start with Mr Morrison, if I could. I think that, probably to describe the morale to be at low is a huge understatement. The profession itself is just struggling under the course of the pandemic, but prior to that, I think that we were in a system that had already been recognised as not fit for purpose, so we were in the process of trying to reinvigorate and reinvent. We were told that the process is not going to be addressed any further. To make large changes—to quote the CVO at this point or the health minister—this would be a problem for us to do or try to resolve and change reform of the system. If I go back to Mr McCaskill's analogy of the 25-year-old car again and re-spray, our 60-year-old car, which was due to re-spray, is now not even getting its re-spray. We are probably at a point where, recently told practitioners, 80 per cent of them have suggested that they will reduce their NHS commitment, and 30 per cent of those who said that they would be looking for early retirement and to leave the system. Morale is really low, with the clinicians. It is also particularly low with staff. We are getting stories now, practitioners, who have had maybe three or four staff in a small practice just to around and say that we need to move on. Again, they are getting jobs in hospitals, they can get jobs in test schools and get paid more, and they reduce the problems that they have working in PPE of FFP3, where they are working in a respirator mask for large quantities of the time. We are losing nurses, we are losing dentists, and there does not seem to be much that is bringing anything back in. Morale is particularly low just now, and I think that the question—I cannot really go on any more about that, if I am honest. Dr Boest? Morale is down in general practice. People who work in general practices are tired. I am tired. As well as talking to you guys, I work two days a week in general practice. We have been on the front line of this pandemic since March last year, and it has been unrelenting. It has been constantly changing. We had the early phase, the shielding, the problems of secondary care having longer waiting lists for outpatients, operations. That causes back pressure into general practice, rising levels of mental health, issues, stress, anxiety and depression in our inpatients. That problem lands very much on general practice. Being aware of demand is outstripped, our capacity despite our valiant efforts. The issue of criticism that has been unfairly labelled at general practice by certain sections of the media and certain politicians is very demoralising when you are absolutely doing your best. Unfortunately, in some cases, that has led to verbal abuse from patients towards practices staff. 88 per cent of practices reported that they were aware of verbal abuse in previous months. We are not in a good place just now. I do worry about retention of the workforce. I know that many GPs are looking at whether they are going to stay in the profession or whether they might reduce their time commitment for their personal wellbeing. We are not in a good place just now as we face this acknowledge to be the most difficult winter ahead of us. Moral in social care is just through the floor. A bit similar to what Dr Booth said, social care workers who have been on the front line are still on the front line and they are absolutely exhausted. They are literally running on empty. People have kept going through all the challenges physically and emotionally because they felt that it was their obligation, their responsibility, both to those who they support but also to their colleagues. Part of that ability to keep going was a sense of value. However, as time has gone on, that value has diminished and has depleted. The obscenity in which Operation Copper is for care home staff has directly resulted in numerous staff leaving the sector. We all want answers to the loss of lives but the victimisation, the disproportionate use of power by the Crown Office, is shameful and it shames our nation. We have to draw a line under. We are still having people who, 20 months after initial interview and evidence gathering for people who died in care homes, still do not know what is going to happen with that information. Our care sector, our care workforce in the community and in care homes is feeling hugely demoralised physically and emotionally. I have the privilege of chairing Scotland's working group on our national bereavement charter. The impact of grief and loss on those in the social care sector has been hugely significant during the pandemic. It is now becoming something of very real concern. Individuals are experiencing what clinically is described as prolonged grief syndrome. It is a trauma that they have experienced and which has led and I am absolutely sure will lead more to leave the sector. You address that sense of trauma by appropriate mental health support but you significantly address it also by making a woman or a man, a nurse or a carer feel valued, respected, wanted and appreciated and unfortunately the whole of our society singularly has failed to do that for front-line social care. I thank the panel for your answer. It is certainly a concern. I have always thought that the first step should always be to look after the health and wellbeing of those who look after us. You described a system that was creaking and was not working pre-pandemic and you are suggesting that there is now about half capacity at the moment. Can you catch up while the Covid measures are in place? First and foremost, do we have to accept that under the current conditions it will be nigh on impossible to catch back up to where we were pre-pandemic? What needs to happen to return to that balanced operating system and link to that? Is there an opportunity here to reassess and redesign the system from the learnings from Covid? That is your first question. I do not believe that we can catch up in its current form. Recently, we have been told by the CDO and the Scottish Government that we will return to the previous remuneration method, which is the statement of dental remuneration, the SDR. It is a fee per item process where the clinicians or the practice paid for what they do on the patients. It is a really old system. As I said, it has been around since the 1950s. It is based on getting in patients fast, getting them turned around and getting them out the door and doing any treatment that they need as quickly as possible. It is not nice for patients. It is really difficult to work under. We refer to it as NHS treadmill. Prior to Covid, at the end of 2018-19, we started to talk about the overall health improvement review and we were looking at possibilities. It was not. The negotiations were not going very well, but they were at least being acknowledged that we needed to take more time and we needed to concentrate on prevention. I think that the system that we have just now through the pandemic, I would like to acknowledge the support that the NHS sector has had from Government and the dentists that have continued to work under the recovery package or the maintenance package. They have kept that float. That maintenance package is left in place to be taken away from as we were advised in April that next year will be gone. We are supposed to have turned to paper writing. If you can only go at half the pace, you will not be able to address those, certainly deal with your backlog and you will then be going at half the pace from then on. I think that to realistically deal with the backlog, the answer is quite simple. No, but if we were in a situation where there was more dentists provided, there was better. We have fewer dentists being educated and trained. We do not have patients coming in. We used to have a lot of dentists coming from overseas, Europe, etc, but Brexit is certainly a lot fewer of that. That being addressed may well be a positive thing. Staffing from overseas as well was a thing that the sector benefited from, which we are suffering from now. As far as the baseline measures are concerned, I think that mitigating in general practice is difficult. We have always expected that, certainly from a personal point of view, one of your issues was when you went into the profession that you would be exposed to a lot of respiratory viruses. It is part of the nature of working in a person's mouth and being close to them. The problem that I find interesting is the fact that if you took Covid completely out of the arrangement just now and you went back to what we are waiting for—we have not had the guidance yet—we are waiting for IPC guidance, which is infection prevention control guidance, which was reviewed last year and has still not been published in Scotland down to the professionals. We do not really know what we are going to have to do. At the moment, we currently keep patients outside waiting rooms, when the waiting rooms are small, we keep them waiting in cars, we escort them on and off the premises, we do hand-washing hygiene. That takes a colossal amount of time. There is follow-up, as I have talked about before, if you are working with a patient, you need to allow the time for the droplets to drop so that you can then clean the area. We have tried to look at different options for that, but at the moment we are draping the place in plastic. We have ventilation, which is trying to get 10 airchages in the room to get follow time down, but that also drags all the warm, heated air out of the building, so there is increased heating costs. There is nurses working in PPE, wrapped in plastic at one point and then freezing cold because you cannot heat the room on the other side. God knows what we are doing to the environment. I think that trying to keep the mitigations that we need to protect from Covid is ultimately costing a lot of other problems in other parts of the sector. Having a process for ventilation could be effectively increased. We have had funding from the Government of £5 million to allow us to help with practices, but that is down to about £1,500 per surgery. I have yet to find anyone who can put effective ventilation in for that. Some practices, lots of them are in old buildings. I have had a colleague to put in adequate ventilation costum to the tune of £15,000 to £20,000 to do that. Those things need to be in place to make the environment safer for clinicians and nurses. However, the concept of the redesign of the system is what we have been pushing for pre-pandemic for the past almost as long as I have been in the industry for more than 20 years. The redesign of the system is really important. We have been advised that the redesign at this point would be a poor thing to do. I have been advised that, at the moment, Scottish Government wants us to get back to our backlog. However, if that is never going to happen or not, we need to have some sort of redesign. I think that the system needs to keep its support payments to practice at the moment. If you want to keep the NHS sector alive, it will be lost. With all the things that I have said, the biggest and most important thing that we have just now is that we have a huge, huge lack of communication. As a clinician, I hear certain things through my contact with the British Dental Association earlier, but my colleagues hear things through social media. In fact, we get absolute consultation with many, many decisions have been made to the past 18 months. Communication, even if we all accept that we are in a situation that is almost untenable but we will work really hard together, we would feel as a profession that we are working with Government rather than it feels like it is against Government, the concept of being asked constantly why we are not getting on with things that should be business as usual and that just isn't business as usual. For that to be put out in press, for that to be put into the public domain by our politicians, I suppose. Certainly the media haven't helped, but we are seen as the bad guys and we just desperately are not. We are working very, very hard not to be like that. Ventilation, assistance with that, acknowledgement of the situation. The one thing that is probably very unpopular—I might say that this is not necessarily the best position—but, as far as dentistry is concerned, the two-tier service that nobody really wants to have, all the dentists would love to work in the NHS and do their work in the NHS if it was recognised properly, but I think that a two-tier service would be the thing that would end up clearing backlog of pain and problems in that pain relief, teeth removal, abscess. There's a lot of horrible things in people's mouths that could be helped with a base-level service that I wonder if we can find a way to do that more efficiently, more carefully and more quickly for our patients. Just because I suspect that the next two years is going to be really, really hard, two to three years is going to be very difficult, but I suspect that that might be an unpopular idea. Catch up, no, redesign, yes. Can I turn to Dr Beuce? I think that it's recognised that, pre-pandemic, we were short of some 860 GPs. We were working towards multidisciplinary teams and we were working towards a move towards community care. Of course, a lot of that has been put on hold because of the pandemic, but one of the things in the pandemic is the rapid deployment of technology. I wonder what you think going forward as a recovery from the current crisis, whether the continued deployment of technology would help doctors to cope with the backlog and potentially development of future policy. Before I answer it, I wanted to come back on the previous question in support of what Donald MacAskill was saying. I know that I'm here to speak on behalf of general practice, but one of the clearest messages that we need to the Scottish Parliament is that social care is the top priority to resolve this winter. I joined the health and sport committee on Tuesday and that was the outstanding issue. We must do something to support the workforce. Otherwise, the back priority that that will create in the rest of the system will take down anything else that we try to do. That is one of the top messages that we need to take from here. Regarding technology and helping with catch-up, in general practice, we largely deal with today's work today. If you have to wait a week to see a GP, that's quite a long time. We don't have a six-month waiting list or a 12-month waiting list to see your GP. We're trying to deal with problems right now. The area that has probably most suffered through the pandemic will be long-term condition management, chronic disease management, things like diabetes, health management, heart disease, but adjusting blood pressures and blood sugars and things like that. I think that that's one area that we've not been able to provide as much support to as we normally would. One of the questions that I thought you might ask me today is about the consulting model. We were moving to more remote consulting before the pandemic. Indeed, we were being encouraged to move to video or telephone consulting before the pandemic. When the pandemic struck, we were particularly encouraged to do it because of the benefits of infection control. We're going to continue with a hybrid model of consulting—a mixture of face-to-face or in-person—when that is appropriate to do so. However, when a patient's problem can be managed by telephone, many patients appreciate being able to have the problem dealt with quickly by telephone. They may be at work or they may be away from home. It saves them time. It is efficient for the service and it is also environmentally friendly. I think that technology in terms of remote consulting is here to stay. Other methods of monitoring remotely technology—we need to get the basics right before we can adopt a lot of the ideas that are bubbling around. Right now, the basics are not right. The telephone is fine, video consulting is coming in, other methods could come in, but we need to get our basics sorted before we move on to adopting large-scale technology. I'm sorry, I'm just conscious of time. We've got 14 minutes until we've got two minutes silence at 11 o'clock and we've still got two members to go to, so can we move to John Mason, please? Thank you, convener. I'm disappointed that some members have had considerably longer to ask questions than some of the rest of us. Mr Whittle just had 22 minutes and Jim Fairlie and I now have to share nine between us. I'm also on the finance committee and we've been spending quite a lot of time on preventative spending. That's been going on for quite some years. I think that this is the anniversary of the Christie commission and so on. The point that's been made by Dr Buist this morning is that there might have been a concentration on hospital buildings rather than in the primary care sector, where all three of yourselves are. Have you any suggestions on how we take that forward? Assuming that there's not going to be extra money for anyone in total, should we be trimming a bit of money off the hospital budgets and putting more into primary care? I'll start with you, Mr Buist, if I can. Thank you for that question. Yes, we should. The Government announced a £30 billion programme of investment in the buildings of the health service recently, 10-year plan to deliver that. I've said to whom a use of general practice primary care needs to get their fair share of that. The money tends to be devolved to the health boards for them to decide how to spend that money. They spend a vanishingly small amount on general practice and I suspect dental community services as well. We need to have a fair share of that investment. As I said earlier, more than 90 per cent of the 1,000-odd general practice buildings across Scotland are more than 10 years old. They've been found, in many cases, severely wanting by this pandemic in terms of the ability to manage patients safely in large numbers due to cramped conditions and ventilation being inadequate and waiting areas being too small. There's an absolute desperate need in one of our top priorities for the community to get a fair share of that investment. I think that it's a difficult question to answer, as we're not necessarily privy to the numbers that are kept for health boards. I can think that the Scottish spend in densities is about £400 million. The £775 million of which comes from patient charges that we bring in, the practices that bring in themselves, but all of those practices, almost with a few exceptions, are in privately owned buildings that belong to practices. The system is so stacked in the private sector, working as independent contractors. It's very difficult to imagine that taking budgeting for dentury away from hoffles was the way that I would do it, but I don't know the budgeting side. I have to pass to the others and say that I can't answer that question. I'll just ask one further question in the light of time. We talked about vaccine passports, and the suggestion has been that staff in certain settings, for example, some care home companies, I believe, are making it compulsory to have their staff vaccinated. I just wonder if you all feel that would be the right way to go, Dr MacAskill? As a national organisation, taking the stance that what we need to do is to convince, persuade, answer the questions, give assurance to staff. In Scotland, our figures are astonishingly high, both in terms of the first dose and second dose of vaccination. What we want to do is continue to address any anti-vaccination messaging, which has become fairly dominant in social media. I don't think that it is an issue in Scotland at the moment, and I would like to hope that, as we move forward, we are able to continue to build confidence amongst the workforce. I am very aware that colleagues in England are talking in the last 24 hours of losing 50,000 care staff and, potentially, 120,000 in the extension of vaccination requirement into the NHS. It is not a step, either, in terms of workforce management, or to give assurance to both staff and residents in a care home that we are contemplating at the moment. In the interests of time, I would like to say on a personal role that I would like to give the healthcare my personal thanks, because my family is currently using various methods of the national health service and are working in the national health service. I have given us a huge amount to think about today. To be perfectly honest, we have only got four minutes left. Any one of the members of the committee today could have taken the full 85 minutes, because there is a massive amount to get through. I am not going to ask any wee pointed questions. The biggest issue that I had was the fact that there were the national health service in England bringing in the compulsory vaccination system. That was the biggest issue for me. Is that something that would be accepted here in Scotland, and how do you feel about it? I know that Mr MacAskill, you have just answered it. How do you feel about that same question, Mr Morrison and Mr Bewist? If I can come in there, I think that we feel that messaging in the same way that Dr MacAskill was saying, public messaging is really, really important to try to get anti-vax, because we are very strongly with the vaccination programme. I would have to say right at this current moment that anything that is likely to cause staff to leave or have to stop is terrifying for most clinicians, and most clinicians would say that I would not do anything that will affect my staffing at this moment in time. I am quite happy to promote it, and I feel that we feel that it is a very positive and important thing. I have full uptake in my practice. I cannot overemphasise how important that is. However, we do not support compulsory vaccination. That in mind, we have always been compulsory vaccinated with hep B for years and years and years, and it has never been a problem, but anything that would affect the workforce just now, I think that I would be really concerned about it. Dr Beust I endorse my two colleagues here in terms of what they said. Education and persuasion are the best ways to encourage staff members to take up the vaccine. I would be seriously concerned about the impact that they will have on workforce. As we have already said, they are very vulnerable just now. We will see what happens in England. I think that we should think very carefully before we institute a similar requirement. I will leave it there, convener. In the interest of time, there is no danger of getting in any substantive. Once again, my thanks for the service that we have had. I know that it has been a hellish difficult time for me all, and it is not a platitude. I mean it quite sincerely. I would like to thank all the witnesses for their evidence today and giving us an insight to all the challenges that you are currently facing. 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 liaise with you about how to do that. The committee's next meeting will be on 18 November, when we will continue to take evidence on baseline health protection measures. That concludes the public part of our meeting this morning. I suspend the meeting to allow the witnesses to leave and to move the meeting into the private for the next agenda item.