 Rhaid fawr iawn i'w gweithio ag oedau'r newidol y Caisine Covid-19 ym 19 ym 19 y intertwod gyda yw mewn cyfle yn 2022, ac yma yw'r gweithio'r ymerthdeithasol yn ei wneud i defnyddiant a'w amser i'r ysgolPLAN fel y pd小ol. Rhaid fawr i'w gweithio'r gweldai,嗎 ? Prof. Andrew Elder, y prifesioedd y Roedd Llyfrgell yw llwyfedd enbryu. Yr Ymddydd John Thomson, y Prifesioedd y Llyfrgell of the Royal College of Emergency Medicine, Dr David Shackles, joint chair of the Royal College of General Practitioners Scotland and Dr Barbara Miles, president of the Scottish Intensive Care Society. Thank you for giving your time this morning and also for providing the written evidence for the committee. The session will be the first of two evidence sessions with stakeholders on this inquiry before we hear from the Cabinet Secretary for Health and Social Care and Public Health Scotland on 17 March. Each member will approximately have 12 minutes to speak to the panel and to ask their questions. We should be okay for time this morning, however, I apologise in advance if time runs on too much. I may have to interrupt members or witnesses in the interests of brevity. First of all, can I please ask our witnesses to introduce themselves and just say a few words? Can we start with Dr Thompson, please? Good morning. My name is John Thompson. I am a consultant in emergency medicine in Aberdeen and I am chair of the Royal College of Emergency Medicine Scotland and vice-president for Scotland. Good morning, everybody. Thank you very much for the opportunity to participate in this. My name is Andrew Elder, as you have heard. I am representing the Royal College of Positions of Edinburgh, which is a wide range of specialties, but I myself am a consultant geriatrician in practice. Dr David Shackles, I am a general practitioner in Perth, and I am also one of the joint chairs of the Royal College of General Practitioners in Scotland, a membership organisation that promotes quality and excellence in general practice throughout Scotland. We are allied and work closely with our colleagues in England at the Royal College of General Practitioners. Good morning. My name is Barbara Miles. I am a consultant in intensive care and anaesthesia in Glasgow, and I am here as the president of the Scottish intensive care society. We represent professionals working in Scottish intensive care units throughout Scotland. First, I would like to thank everyone, as I said previously, for your intermission, but everybody else who responded to the committee's call for evidence. I will start with my first question. The first thing that stands out to me is that, when the committee launched its inquiry, data from the Scottish Government showed that deaths in Scotland were 11 per cent above the average for that time of year and had been for the average of the last 26 weeks, which I think caused us to be alarmed and that this was going to be a growing trend. Although, when we look at the recent data that was published on 14 February this year, it shows that deaths in Scotland are currently 6 per cent below average. Can I ask if anybody has any insight or explanation for this trend? I do not know if anyone wants to put their hand up or come in here. Professor Elder, sorry, my eyesight is failing. Thanks very much. I think that your question highlights one of the main issues here, and that is over what time period will we make or be able to make conclusive judgments about the impact of the pandemic on total mortality and on what we are allocating as non-Covid mortality, which is much more difficult. We will see, as you have highlighted, short-term fluctuations, and that is in part due to a phenomenon that some people describe as mortality displacement, that some individuals, particularly perhaps the frail and vulnerable, who may have died in a given time period, died a little earlier because of the arrival, in this case, of a new condition. That could explain, in part, a decline in the mortality that you have highlighted at the moment. I think that that fact that over short periods of time we will see these kinds of fluctuations that you have highlighted and the additional fact that some of the potential impact of the pandemic and the way that we have had to manage it will be only apparent over a longer period of time. There is going to be a lag effect, myself and many of my colleagues believe. We really should be very careful not to draw quick conclusions from this data. We are going to have to wait a considerable period of time—years, probably—to gauge the full impact of the pandemic on mortality and morbidity. Professor Elder, I am not sure if anybody else wanted to come in on that question. I agree with Professor Elder. I think that the effects on the population of the pandemic and the effects on the health service of the pandemic are long-term rather than short-term, and it is going to take some time to see the full effect. Thank you very much. I will move on to my second question, and this is a question that one of my colleagues brought up in the private briefing that we had before this morning. A majority of our respondents who answered our call for evidence did not think that there was enough strategic focus on non-Covid conditions and suggested increasing staff and bed numbers. I think that we all appreciate and understand the pressure on the NHS over the past two years and you cannot just magic up staff and beds overnight. Is there anything that you think that could be done in the short term to address the backlog when we have so many of the capacity challenges still exist? Is there anything that the Government could be doing in the short term to bolster the health and social care workforce? I think that you are correct that the key to recovery is capacity, and that is both workforce and facility-related. We cannot magic up either more beds or more or a bigger workforce. We could and we are already doing that to some extent with the suggestion of the national treatment centres. Attempt to separate elective and emergency care better, because one of the factors that contributes to the waiting list issue in elective surgery is the fact that, not just during the pandemic but in our usual winters in Scotland, we have the unwanted impact of the increase in emergency care, the demands in emergency care, impacting on elective care. As you know, it has been suggested that if we could find ways of separating elective from urgent care, that might help. The second thing, and I would highlight that particularly as a geriatrician, is that recovery is a whole system issue. I am interested primarily in the efficiency of our hospitals, but they can only operate at maximum efficiency for either elective or urgent care if we can get people out of hospital quickly. We have a substantial problem in Scotland. It is not you—we have had it for a while—that we have a problem with what is often called exit block or delayed discharge, enabling people who do not wish to be in hospital to get home more quickly. The solution to that, though, is not simple, in my opinion, because it comes down primarily now to the workforce available for social care, particularly in the delivery of don silvery care in patients going home. Those are two issues that could have been considered already to help me to get rid of the problems. I will follow on from Professor Elder's point and expand on it slightly. I agree with everything that he says. We know that there is a clear relationship between particularly long waits for beds, so patients waiting greater than 12 hours in emergency departments for beds, and subsequent cancellation of elective activity. It is very pertinent that any future strategy of elective care involves unscheduled care that cannot be looked at in isolation. In terms of the workforce that would be required to separate elective and emergency care, that is going to be, as Professor Elder said, one of the greatest challenges. We have a single workforce and to separate elective and emergency care. Within Scotland, we do not have the workforce currently to do that, despite the desire to do so. I wholeheartedly agree with Professor Elder's comments about the capacity of the workforce in community care, particularly in the care home sector, which has been a particular problem throughout the pandemic. Any community care is absolutely necessary. We have had even pre-pandemic significant workforce issues in general practice and in primary care throughout, and the pandemic has really just shone a spotlight on that. We need to be absolutely certain and look at a good workforce strategy, along with the Government, to try and rectify that. I see that that has been highlighted in this morning's Audit Scotland report, making exactly that point that we need to be looking at care in the community, rather than relying on sending people into more hospitals the capacity in which we do not have. When you are looking for solutions for this in the short term, absolutely, it takes 10 years to train a general practitioner, so that is going to be a struggle present. What we have got to be looking at is adequate retention of the workforce, and that is in all sectors. We cannot afford to be losing anybody to the workforce. We have got to be trying to keep them working in a reasonable level to the skills that they can deliver. Retention is absolutely critical. The other thing that has got to be a good way of winning is that rather than having to work more or harder, it is to work smarter. We believe that improving the interfaces of care, particularly the interfaces between primary and secondary care, where we can get better pathways for patients that are smoother and more effective and more efficient, can make things better. We can smooth patients' journey, make them more effective, use less resources and get people treated in a more timely manner. I will echo my colleagues. There is a finite workforce in the NHS and healthcare, so health and social care in Scotland. It is very difficult to open centres without denuding staff from the existing workforce in other places, much as that might be desired. I would agree with Dr Shackles that we need to retain the staff that we have already got. The pressures of the pandemic have resulted in a large volume of experienced staff either seeking work elsewhere or seeking early retirement. We lose a lot of experience and skills within the workforce when that occurs. In the short term, measures to retain those staff in the workforce would help with some of the challenges that we face ahead. I move on to Murdo Fraser. Thank you, convener, and good morning to the panel. I wonder if I could start with a question to Dr Thomson in relation to the written submission that you have made on behalf of the Royal College of Emergency and Medicine. I was very struck in that by the comments that you make on the impact of the delays in patients being admitted to emergency departments. You highlight the issues of ambulance stacking. We know that there are delays with ambulances being able to attend and also ambulances queuing up outside emergency departments. You go on to say that, in your estimate, in 2021, the delays in admissions equated to over 500 excess deaths in Scotland. That is an extraordinary and extremely worrying statistic. It is saying that there are 10 people a week dying because they cannot get treatment in time. Can you tell us a little bit more about how you arrived at that figure and what the impact of that is? Yes, thank you very much for that question. There has been evidence published in the emergency medicine general last month and subsequently last year that getting it right first time emergency medicine report in England that was published in September showed a clear correlation between long waits for beds, essentially patients waiting in emergency departments to the appropriate clinical area and mortality. Patients waiting longer than six hours in an emergency department, the number needed to harm, is one in 77. For every 77 patients waiting longer than six hours, one will die within 30 days as a result of that wait. For patients waiting greater than eight hours, it is one in 67. There is a clear association with long waits in the emergency department and mortality. What the studies were not able to clarify, but clearly is a much greater problem, is the harm that is not resulting in death that results from those long waits. In 2021, we had almost 13,000 patients waiting greater than 12 hours, which was a greater number than the previous three years combined. 2021 saw our second lowest annual attendance ever to our emergency departments nationally. That comes down to a point that Professor Elder mentioned earlier with exit block. There is exit block of patients leaving the hospital, which impacts on the capacity, and exit block of patients leaving a crowded emergency department. It is the weight of the patients that then impact on ambulances that have been able to unload, because there is no safe clinical space within our emergency departments to receive those undifferentiated unwell patients, unfortunately, because of the issues that we have with patient flow within our hospitals. Thank you very much, Dr Thomson. That is a very helpful response. A couple of things I would like to follow up on if I may in terms of what you have said. Clearly, there has been a major issue with this. We have had a big problem over the past two years with ICU beds being taken up with Covid patients. It would seem to be the case that that is now on the downward trend, which is very positive. What have you picked up just over the last few weeks in terms of future trends, and would you expect this issue with delayed admission to start to work itself through, or is it with us for the longer term? My second question—I will just ask it at the same time—is an issue with workforce. That was part of the earlier discussion in response to the convener's question. You make the point in your submission that, even before Covid, emergency departments were understaffed and underresourced. How do we solve that in the short term? It takes 10 years, Dr Shackle said, to train the GP. I imagine that for those who are doing emergency medicine, it is a similar time. Even if we started ramping up recruitment, now that is going to take a long time to work through the system. We probably cannot recruit from other countries because they will face exactly the same challenges that we do, apart from the ethical issues around taking medical staff who have been trained in other poorer countries. What more can be done to address the staffing issue that will help us without having to wait for 10 years for more medical staff to be trained? Thank you for those questions. To answer your first question, the issue with prolonged patient waits in the emergency department is not a Covid phenomenon. That has existed for many, many years. In fact, in the first wave, when there was a step down from all other scheduled activity, patients did not wait at all to move from the emergency department because there was available capacity within the hospitals. That is a chronic problem, and the majority of patients that we see in our emergency departments are non-Covid issues. The college estimates that we are approximately 1,000 acute beds short across the country, and that exacerbates the problem. The issue of long waits within emergency departments is not a new problem. Ambulances waiting to off-load is a relatively new problem, and the reason for that is specifically that, during Covid, there were quite significant infection prevention and control measures put in, not just in emergency departments but throughout hospitals, which meant that patients had been offloaded to a corridor, which is what would have happened previously. Thankfully, it was no longer deemed acceptable. Pre-Covid, the patients that we now see in ambulances waiting outside emergency departments to be offloaded, were lying in corridors in emergency departments, which was neither desirable nor acceptable in terms of a level of care. It is really just a spotlight on what was happening previously, but with patients waiting to be seen for many hours in emergency department corridors. In terms of the workforce, again, I do not have any quick solutions to mitigate the issues with our workforce. We undertook a census last year that showed that we are approximately 130 whole-time equivalent consultants short in emergency medicine in Scotland to provide the appropriate level of care and to have enough consultants for the number of patients that the department sees. You are correct in terms of the time that it takes to train a consultant, and there is no quick solution for that. As Professor Elder highlighted, retention is the key. Our census showed, unfortunately, that one in five consultant colleagues plan to take earlier retirement in the next five years, and one in two, so 50 per cent plan to reduce their hours within the next four years. We have significant workforce challenges currently, and they are only going to increase over the next few years, unfortunately. Thank you, Dr Thomson. I am happy to open it up to other members of the panel to get their perspectives on that. You talked about the importance of retention of staff. Anecdotally, we hear that there is a huge issue right across the NHS with burnout with those who have lived through the last two years with Covid, and that has probably accelerated the trend of those seeking to take earlier retirement, for example. Would that be your perspective on it? What practical steps can be taken by the Scottish Government and the NHS to ensure that people are encouraged to stay on? I can come in first before my colleagues. Although I have not seen a significant number of colleagues leave the specialty over the past two years because of the pressures, I think that not just in emergency services, but throughout the whole health and social care system, everyone is under the same pressure and feeling the same degree of stress and intensity in terms of what has happened over the past few years, which has opened up to everyone's knowledge the issues that the NHS was dealing with prior to the pandemic. Professor Elder, I think that you were hoping to come in. I thank you. My microphone was muted there. I thank you very much. If I may make a couple of points in relation to your first question, the first is that although the focus of our discussion today is primarily around mortality, the impact that the pandemic has had on mortality, in considering the impact of weight at the front doors of our hospitals, we must bear in mind the huge impact that that has on other aspects of the quality of the care that we deliver. It is alarming, as you have pointed out, that it leads to excess deaths, but it is also tremendously detrimental to the overall well-being of patients and, indeed, their families have to get in the way that they are seen properly into the hospital. In fact, in our whole discussion, although we are focusing on mortality and the impact of the pandemic, we have to be seeing it in lots of different ways. The second issue that I wanted to comment on was the whole issue of international recruitment as a potential short-term supportive measure. I do not believe that we should disregard that for a number of reasons. You are correct that the medical workforce issue is a global problem. You are correct that there can be so-called ethical concerns about a relatively wealthy country like Scotland absorbing doctors from other countries that may not be so well placed. We have to remember that training and experience in Scotland is still very highly regarded by international colleagues. Our college is an international college and I hear that all the time from colleagues. There are a number of systems available that can be developed to enable, particularly trainees who have a role in service delivery to come to Scotland to work for short periods of time and then to return home to their own countries, because it is worth bearing in mind that many trainees in many large countries around the world—for example, India—cannot access high-quality training. I do not think that we should give up or disregard international recruitment at all. The second point is about retention of staff. I think that anecdotally speaking to many colleges is a great worry. The point that I wanted to make is that it is not just about colleagues who are more senior and who have the option of taking early retirement. As international travel opens up again, I worry that some of our trainees may start to say that they are going to look elsewhere myself and go and work there. From many of their point of view, it is about things like respect and value of them in the workplace and the messaging that they get in the media and from politicians indeed about how much they are respected and valued. It is about things like access to somewhere to rest when you are on call to hot food. We have had the story in the media lately about the accessibility or otherwise of period products in Scottish hospitals. There are some quite basic things across all our hospitals that we need to focus on more, that make our trainees, as much as our consultants, feel that they truly are valued and therefore will be more likely to remain a part of our workforce. I begin by asking a question about data and the availability of data. Earlier this week we learned that there are waiting times for people who are on NHS waiting lists. There are 680,000 people, so 108 Scots are on an NHS waiting time. Is it possible to determine any relationship between a person's cause of death and whether they were on a waiting list and whether that related to it? If we want to understand excess deaths, how do we understand the impact of people being on those waiting lists that are unacceptably high? Could I perhaps ask Dr Mills if you were able to comment on that? It is not precisely our society's area of purview, but some of the people on waiting lists are for long-term chronic conditions and some are for more acute. Teasing out that difficulty in life would be quite... Teasing out whether there is excess mortality related to all of the people on waiting lists would be quite difficult, but one of my surgical colleagues would probably comment on that in relation to certain kinds of surgical procedures and the physicians in regards to long-term health conditions. Professor Elder, would you be able to comment on that about being able to collect data and understand the impact to those large, massive waiting lists? First and foremost, I would agree with Dr Mills that trying to connect a period of time on a waiting list with what we will call excess mortality would be very, very difficult. Particularly in the context of the pandemic, and as I said at the beginning there, I would suggest that we do not jump to quick conclusions about it. The other point that I would make is that, although it is important to consider what you are asking, which is whether a prolonged wait for an investigation or procedure increases mortality, those prolonged waits have impacts other than on mortality. I think that we all understand that, if you are waiting for, let us say, a knee replacement, it is unlikely that that will lead to your premature death. It is possible, but it is unlikely. However, you have the burden of the disability and dependency that goes along with having advanced arthritis of your knee and the pain and suffering that may go with it, so there are drivers other than excess mortality to make us push to reduce waiting lists. I will turn to Dr Shackles. I noticed in the written submission that there is a recommendation here in terms of general practices to increase the support and care that GPs and their teams can provide for those patients with mental health clinicians should be made available to all GP practices. One of the outcomes of the lockdowns in two years of Covid has certainly been reported as increases in people's mental health, and no doubt GPs will be seeing that. What is the current position on the question of integrated joint social care boards? Is that integration leading right down to the medical practices where you have mental health services, social work services? Are we seeing that level of integration across Scotland, or is it patchy? I think that that has interesting questions about all those topics, and I think that it is patchy. Unfortunately, during the pandemic, it became more patchy. The provision of those services started off with good intentions, and then, during the pandemic, some of those services ended up being withdrawn. Certainly in my own practice, we have a mental health worker who is very well used, but I am aware that other practices do not have that service. That is great to the disadvantage of the patients, but also to the GPs themselves. We need to increase that provision, make sure that it is embedded within the practices, and make sure that patients know how to access those services as well. That is one of the other difficulties that we have, because sometimes patients are navigating the route into those services effectively so that they can get them in a timely manner. We absolutely need to see that improved. I do not yet believe that we have got good enough integration at the health and social care level, and we need to work harder with that, both with our social work colleagues. That is one of the things that we hope to gain from GP cluster working, which was, again, starting to become more effective as GPs and their teams could integrate and work better with social care and local authority colleagues. Unfortunately, the pressures of the pandemic are rather poor, and that can be brought back and returned. As a matter of fact, I might comment on the previous point about waiting lists. One of the difficulties that we have in general practices with the increased number of people on waiting lists, we end up seeing people again and again either returning because their condition has been worsening, either the pain of their authority condition or because clinically they have been deteriorating, putting increased pressure on ourselves and trying to work out how best to prioritise patients. If they need expediting and putting up the waiting list, that becomes very difficult and getting back into the system. What we do not want to do is create a revolving door when we are just seeing people who are on the waiting list when we have got their new people with new conditions coming in as well. There is increased burden on all of the services. That is the point that I am trying to get to in terms of the waiting list. It is trying to understand what the impact is and how you measure that. The example that you give, I certainly know somebody who is on a waiting list to get a hip replacement and they are in absolute agony. That has a wider impact on their health and makes it worse because one of their friends who was able to put together £15,000 was able to go away and get their hip replacement like that. You can see that that is what I am trying to get to. How do we as politicians and as policy makers understand the impacts of one in eight people in Scotland being on a NHS waiting list? I do not know if anybody would... I might just come back on that as well. One of the things that we need to absolutely understand is that the data that we have in primary care about the type of people we are seeing, the appointments that we have, the workload and the workforce that is available is not good enough. We need much more data about what we are seeing, who we are seeing, and the number of people who have repeat consultations and what they are for. We need to have that to be able to understand it. Some of the data that we have from England is that it used to be that patients would consult their GP three or four times a year at maximum, but now that is going up and up. We have multiple people attending over the year, putting an increased strain on primary care. Not only is the population increasing, but people are attending more often. To the extent that might be becoming unsustainable, we need to get data about that to see if we can help to reduce the need for attendances so that we can get people treated more effectively and not having to come back to us all the time. At the moment, we absolutely understand that people are in pain, people are concerned about their health, they come back to us and we try to deal with them as best we can, but we need more and better data. Can I quickly return to the point that Murdo was speaking about, Dr Thomson? My understanding is that it takes 11 years to train an emergency department consultant. I took the point that Professor MacDonald made about continuing to recruit fair abroad. Given the pressures that are there right now and the massive staffing shortages that are there right now, is there any type of short-term activity that the Government should be undertaking to try to bridge that gap between the lengthy time that it takes to train a consultant and the problems that we have right now? I think that that is a very difficult problem. I echo some of the points that were made by colleagues earlier about widening the net and making it easier to recruit internationally. It is a large marketplace for doctors to work in, so it needs to be attractive to come and work in Scotland, not just financially but in terms of working conditions. We spoke about wellbeing and burnout. From an emergency medicine perspective, one of the things that would improve the wellbeing of our colleagues is reducing the weights for patients in emergency departments. By improving the system and improving the care that we are delivering to patients, that was the main point that would improve our wellbeing, not financial remuneration, not improving conditions, but seeing that the care that we are delivering is improving for our patients. That is a very important point to make and to hear. It is not solvable just from a front door, from an emergency medicine perspective, that it is part of a whole system. We see the patient at the start of that journey in terms of secondary care, but it is a whole system that is impacting on the delays that the patients are facing. Professor Elder, you want to respond as well. I think that an additional angle on the workforce issue would be to consider the role of the consultant. Quite rightly, I believe, we have aimed to have a consultant delivered rather than a consultant-led service. I have already said that trainees contribute a lot to service, but that has been an aspiration that very well-trained doctors—and that means that a long time of training—will be heavily involved in service delivery. I do not think that it would be correct to move away from that philosophy, but we have to consider what aspects of both the hospital and community doctor can be delivered by other healthcare professionals. That is already well established and is happening. To specifically answer your question, in the context of my own physicianly background, the physician assistant movement and the development of that profession will help to bolster the medical workforce and deliver some of the services that have traditionally been delivered by consultants. Dr Muzz, would you like to come in? Thank you. To go back to some of the points that Professor Elder and Dr Tons have made, I think that making Scotland an attractive place to work is not all about remuneration. It is about feeling valued in the workforce. There has been quite a lot of work looking at wellbeing, of what affords wellbeing in staff, and some of those points could potentially be addressed in the short term. What makes a staff member feel valued in the workplace and will aid their retention? It is not always difficult things, simple rest areas, better transport links, parking, food and hot food are helpful to staff to make them feel that they are a workplace value. Developing allied health professionals to fulfil some of the roles that medical staff do will be helpful, but often denudes other parts of the workforce. Many allied health professionals come from the nursing workforce, and when you train allied health professionals to be advanced nurse practitioners, they denude the nursing workforce of a skilled, experienced nursing staff. That would help one area of the workforce to potentially cause issues in the other, but we would all find it helpful to expand medical working and reduce the workload on the consultant staff. Dr Shekels would like to come in as well, and then we will move on to Jim Fairlie. Thank you. It is just to concur with Dr Miles's points about workforce wellbeing. We think that that is absolutely essential to retain the workforce and to make it an attractive place to work in Scotland. We are very pleased to see the workforce specialist service available for healthcare workers to look after their wellbeing and their mental health. However, we are doing our part to have great concerns about the level of abuse that has been levelled at both GPs and their staff at the end of last year. About 88 per cent of practices reported verbal or physical abuse directed either to GPs or members of staff in the previous month, and that is unacceptable. Our staff do their best for the patients and the public. We cannot magic up appointments and resources where we do not have them, but having the staff being abused is just unacceptable. We feel that those sorts of events are having a significant impact on people's retention. People say, I just do not want to do this any more if that is what I am going to be subject to. We feel that some of the narratives that have been propelled both in the media and occasionally by politicians do not help that. In particular, we feel that the narrative that was circulating throughout the pandemic, that general practice was closed, was not helpful, and despite media activity by Kerry Lun and one of our previous chairs, that narrative seemed to continue to persist. The abuse that we got from ourselves and our staff really sucked morale and had a big impact on how we work and what people are looking to do for the future, and we need to change that narrative. I just want to bring in Dr John Thompson, who has asked to speak as well. Thank you, convener. Yes, it was just to echo the points that colleagues have made around making it attractive to work. One of the colleagues mentioned earlier about hot food, there are a number of hospitals throughout Scotland that, if you are working overnight, you have no access to hot food or hot drinks, and I think that that is absolutely unacceptable in terms of wellbeing of colleagues. Thank you, convener. I thank the panel for coming along to speak to us today. I will come back to the staff morale thing in a minute or two, but I want to start at the beginning from my own thinking. This is an inquiry into excess deaths. What do you feel the value of this inquiry is for you as a profession? Nobody wants to answer that one. Just put your hand up. Anyone can jump in. Okay. Can we start with David Shackles, please? Thank you. I think that that is a very good question at this time, when we all, as professionals and as members of the public, have been through a once-in-a-generation event. One of the things that we value as doctors and medics is evidence and looking at what has happened to us, making conclusions, and seeing if we can make changes and choices for the future. Looking at that in depth is really important. As Professor Elder said, it may take some time before we can learn all the lessons and look at all the data, but it is absolutely crucial that we do that, though that should future events happen, better prepared and know how better to deal with it, and to open up that conversation with politicians, media and absolutely with the public about how best our health service should go forward in the future, about where we put our resources, where we concentrate both on conditions that will cause mortality, morbidity, how we manage our elderly, how we manage our care home population and how we put our resources either into hospital-based services or whether we look actually into community-based resources, particularly if we can increase the focus on prevention as a way of trying to manage our health going forward in the future, particularly with our very ageing population and some of the really significant things that we have seen with dips in longevity. I think that it is important that we have these conversations, and that is why inquiries like this are very important to open up these topics. Let me just come back to you, Professor Elder. I welcome back to you in a second or two. From your point of view, Dr Shackles, is the purpose and the value of this inquiry going to be that it shines a light on the deficiencies that we already had? I think that that would be rather negative. We know a lot of what the deficiencies were. Just going over old bones is not going to be helpful. I think that we do have to make sure that we look for the future for this and where we can best look at things. Just criticising what has happened in the past is not going to be helpful to our patients, not going to be helpful to us and to our morale. We might have to look and see if we can learn from the past, absolutely, but just going over it without any thought for the future is not going to be productive in my view. Professor Elder. I think that we should remember that this pandemic is not over. The lessons learned from the last couple of years could be ones that we have to apply within the next couple of years if we get another variant that has a higher mortality rate than Omicron appears to have had. I would be wary of suggesting—I am sure that that was not your intention—that the pandemic is over. We are looking way into the future with this. In terms of the value to the profession now, I have said already that the metrics that we choose dictate our policy. Maybe looking at just mortality is not the best way to go about it. It is very easy to measure mortality, but, as you know, the things that can be counted do not always count and all that. Bureosity is fundamental to clinical practice and science, so it is entirely appropriate that everybody is asking questions about this. However, this has been an extraordinary two years, a major event, and I think that it is entirely appropriate that we look at it now. My final point—I have mentioned it already—was that I sincerely hope that we have, as a society, as a political community, as a medical community, the real capacity to learn whatever lessons this does tell us and take them forward, because that is not always the case. And some of the lessons from the last pandemic or the one of 1918-19 that were writ large there, we did not actually apply as well as we might of now. Thank you for your answer. Your point there about saying that you hope that I was not implying that it was over, I am quite the opposite. I am probably one of the more cautious people given what my background is. In terms of learning the lessons, would it be fair to say that, had we had elective clinics already in place, we would have had less excess deaths? Sorry, is that to me? Anybody that wants to answer that, you guys are the experts? I think that the amount of excess capacity that we would have had to have to cope with what was coming just wouldn't be practical, wouldn't have been in no healthcare system in the world, had the excess capacity available for its elective work or none that I know of to take away the displacement of activity that occurs with the kind of surge that you see from a virulent virus. In theory, yes, but in practice, no. I think that, as I said earlier, you have said that it is spotlighting things that we knew already. Every Scottish winter for the last 10 years, we have seen the displacement of elective activity because of winter surges in urgent activity. That lesson can be carried forward into the idea of better separation of elective and urgent care. Okay, so let me just pursue that a wee bit further. There is a plan to build a 33 bed elective care centre in Perth. Had that been up and running and established, the people in my constituency would have had access to that, so we may have not reduced the excess death numbers because we were losing people to Covid and then related diseases, but would it have meant that we would have been able to treat people with those earlier stage diagnoses of cancers, rather than them getting, for want of a better phrase, bumps down the line? Well, as Dr Thompson and John Thompson said earlier, any new facility needs staff. Remember, we were redeploying staff to support the front door of our hospitals, so had the facility existed, no, it wouldn't have been able to do what you might be hoped to would because we wouldn't have had the staff. Sorry, can I just bring in Dr Miles, who would like to come in on your question, Mr Fairlie? Yes, thank you. I was just going to agree with much of what was already being said. I think that the point of this original question, the point of this inquiry, the value to profession is to learn. I would hope that we can apply that learning to try and have a slightly more resilient health service that we can never respond to the peaks of activity that the first wave and subsequent waves have had, but peaks of winter activity, we might be able to manage more effectively from what we've learned through this pandemic. I would also agree that we do not have excess capacity to manage peaks that we have seen previously. We don't have the workforce. The only place where there is activity that can be stood down is generally elective activity, and that's where people were mobilised from theatres, outpatient departments to help with the acute demands in inpatient facilities. That service is always going to be vulnerable if we have these on-going peaks, as Professor Eldiff says. This happens to some extent, but not in frequently every winter. I am sure that it wouldn't be viable for us to have that level of staffing at all times to cope with a potential peak. No, it's not viable, and neither are the staff out there to employ. Sorry, Jim is just really conscious of time. I have to move on to Brian Wood's case. I want to construct quite a lot in the evidence that was given around the potential that patients are now presenting with more acute conditions than they were pre-pandemic. Can I start by asking that question? I suppose that I could ask anybody that question, but can I start with Dr Miles, please? I don't have any… As a society, we don't have actual data on this, but there are certainly anecdotal reports that people are presenting with conditions, chronically comorbid conditions that have not been managed, perhaps as efficiently as they could have been under normal NHS working conditions, and so they present with decompensated disease to hospital more frequently. There are some conditions that, if they are not managed under the elective programme, will present, as people have said before, to service GP or to hospital frequently as those conditions clear up. There may be some data coming through on cancer presentations, but that may take some time to be interpretable. Don't know if there's any of the other… Okay, Professor Elder, everybody wants him, Professor Elder. So quickly, thanks. Since our written submission, I've been made aware of one paper in Scotland that I can forward to the clerk. If you wish, it does look at what we call the acuity of presentation in patients in three centres across Scotland, and they gauge the judged acuity based on the extent of damage to the kidneys and some other changes in the chemistry of the blood, and also early inpatient mortality. So that paper is relatively small, but it's the only peer-reviewed evidence that I'm aware of at the moment, and I say that I can make that available. The strong anecdotal clinical impression is that this is the case, particularly amongst colleagues, I would say, who work in the specialities of diabetes and cardiology and oncology. If we mean by acute how unwell you are when you come to the hospital, you can also separate that out into how advanced your disease is, particularly when we're thinking about cancer, when you present to the hospital. There is, again, I would say, quite a strong, but still anecdotal impression from clinicians, and from some pathologists that I'm aware of, that disease cancer is more advanced when it presents, but we're going to have to wait more time to get more information on that. Thank you. Dr Thomson. Thank you very much. Yes, I was just going to first of all make the point that Professor Elder made that there's very little in the way of published data around this. However, within the emergency medicine community, although it's anecdotal, there's a clear consensus that our emergency departments were dealing with patients who were of higher acuity. Although it's normal for patients to be diagnosed with cancer by presenting to emergency departments, a number of patients had a significantly more advanced disease, as Professor Elder said, so there's no data, but there's a unanimity in terms of the clinical professional opinion, in terms of the acutive patients over the last two years. I don't know if Dr Shackles has anything he wants to add. Unfortunately, like the others, we don't have the absolute data to give, but anecdotally, within general practice, in my own practice, I would agree that, yes, we have been seeing patients who have been presenting at later stages, either with their cancers, because they didn't present to us, or for other reasons. As Professor Elder pointed out, we have an ageing population with multi-morbidity, and because we have not been able to do a lot of the routine chronic disease surveillance and monitoring, those patients have potentially had deteriorations that, when they have developed some other condition, have made them present in a more acute manner. We can see some of those elements, as Professor Elder alluded to. Dr Bernie Crowell from the Royal College of Pathology has got some good data that is buying to publish about the use of laboratory services down to actual GP levels. We can see that there was a big drop in the use of laboratory services at the start of the pandemic, and we are just now starting to see the chronic disease, bloods and surveillance getting back to a more normal level, which is obviously going to be helpful as we can monitor our patients more effectively now. Yes, anecdotal evidence, but nothing we can give definitively from general practice. I think that that is very helpful to set us up for the direction of travel. We wanted to go in here, and I think that it is around the collection and analysis of data. We did a lot of work in the Health and Sport Committee last term, pre-Covid, around the fact that, in Scotland, we are behind the curve in terms of our ability to collect data. If we would approach a challenge, we would really need to be able to quantify what the challenge is in the first place. Are the Scottish Government collecting or establishing indicators adequate to establish the extent of the health impacts that are not directly related to Covid-19? Is this perhaps one of the learnings that we need to take from Covid in that we need to be better at gathering and quantifying that data? I will ask Dr Shackles to start on that one, please. I think that it is a very good question. We do need to be collecting more data. We need new systems to be able to do that. We in general practice have been waiting some years for IT reprovisioning or systems that would give us more ability to collect that data. We hold the re-coding system that we use in general practice that is outdated. We need to move to SNOMED. That has happened in England and it has not happened in Scotland yet, and that would give us better ability to code the medical conditions that we are seeing and to track conditions for that. For all of that, for data collection, we still need workforce to be able to do that. Data collection in primary care in general practice has been poor for a whole number of years. We are working with the Scottish Government and other colleagues to try to improve that, but it is a slow process and it needs to be accelerated. Are there any other of the panelists who would like to comment on that? Professor Elder. I think that doctors and general scientists will always want more data. Data requires resource to collect it. That is a fundamental decision that has to be made to direct resource to the collection of data or other parts of our health service. It is a moot point whether we need more data. From the clinician on the ground's perspective, I would suggest that what would be more helpful is the ability to join up the different data sets that we have, to access it and to be able to apply it to our own clinical practice. We are living in an age of fantastic IT but still within the NHS we are not always as well served as we might be with that IT to enable us to use the data that already exists. I will finish the question. I was hoping to get to Professor Elder in that the IT system that we currently have—this is not just Covid, it was pre-Covid. We discussed this Health and Sport Committee. The IT system that underpins the health service and the directs of the health service is outdated. Given that this is the Covid recovery committee, one of the things that I would like to explore is whether we should be investing in the IT system that overlays the whole of the NHS and the clinical system. In the future, it will give us an ability to better respond to a pandemic like this and, in general, to understand what is happening in non-Covid conditions that Dr Thomson on your hand was up quickly. In terms of Covid recovery, we spoke about workforce for data collection. From an emergency perspective, there are three different systems used nationally in different hospitals, none of which speak to each other. There is a large problem with primary care systems not speaking to secondary care systems, so we can see patients in amounts of medicine and are unable to access primary care data, which then impacts on our ability to treat patients appropriately. The amount of clinicians or physician associates or advanced nurse practitioners, but the clinical team spent inputting data into the systems because it is so clunky and dated, is phenomenal. The amount of clinical time that is lost to poor IT systems that, if it was improved, would increase the amount of clinical time available for patients. Not just for Covid recovery, but for the NHS moving forward, that IT has to be a huge focus. I have written down the interface between primary and secondary care here as part of that solution. You also highlighted, Dr Thomson, that there is not a universal system for the whole of the NHS to access. Presumably, what you would be asking for is exactly that system that clinic clinicians can even multi-layered access, and that would have a positive impact on the ability to care? It is a huge patient frustration when we continue to ask them questions. The patient's perspective is that when they see a doctor be that in primary care or secondary care, we have complete access to their medical records, and nothing further could be from the truth. In terms of improving how we look after our patients, having some seamless access to the patient's medical records, which is becoming increasingly electronic, if not purely electronic, is absolutely necessary. Dr Miles would like to come in on that question, and then we will move to John Mason. Yes, I have echoed many of the points that Dr Thomson just made. It is frustrating when you cannot get access to information either in other health boards or in other parts of the health service when you are dealing with a patient in front of you. I think that more data is always useful, but we have to be careful that volume of data is not always the issue that is collecting the right data and using it in the right way. If collecting lots and lots of data is very workforce intensive, but sometimes not all that data is required, so the choice of the data that you are going to collect and then having the ability to analyse it and implement it is very important, so we have to be, I think, more smart about this than we have maybe been in the past. I have forgotten the other point. The data that we use—I know that this panel is looking at excess mortality—to go back to the points that we have made before is that morbidity is very important, and we do not—mortalities are easy to measure and morbidity is harder, but lots of patients living with excess morbidity is very important to them and also very important to their families and affects the way they live their life and how they function within society, so I think that that is also useful data to collect. Thank you very much, convener. I ties in my first question quite well with what Dr Miles just said about mortality and morbidity. I was going to ask Professor Elder first in his written paper, its 5D, in the paper. I just wasn't sure I quite understood what you were saying. Consideration should be given to the relative priority of treatment for high morbidity, low mortality conditions brackets, for example joint replacement for degenerative joint disease, closed brackets, and treatments for conditions with higher mortality. You are saying that consideration should be given. Are you saying that we should put more emphasis on morbidity than on mortality? I am saying that consideration should be given, and I think that amidst all the various choices that we make about priorities, one quite clearly is whether—and this is what this discussion is getting at as well—mortality should be the main driver to our policy, or how do you balance that against what we call morbidity just now, waiting a long time with a very painful hip or knee? I am not suggesting one is more important than the other. I am suggesting that we should be—if we have to take such steps to accelerate recovery, that one option is for policy makers to make a call on that. Do you think that we as a society put too much emphasis on avoiding death? I think that a case could be made with an ageing population that a time comes in an individual patient's life, and it is for them to determine—and not for us—on the basis of their own age. But some individuals, definitely in my experience, begin to hope and wish for a style of treatment that focuses more on their comfort, wellbeing and quality of life than their longevity. I think that that is an individual decision that we—through initiatives like realistic medicine in Scotland—we need to enable patients and their families and their caregivers and doctors to discuss. I can take another quote from your paper, although I think that other panellists might want to come in on this point. You referred to the United States in 1B about around one-third of excess deaths may relate to non-Covid causes. It was a more general question. I just wondered whether lessons we can learn from the United States or from some of our closer neighbours in France, Germany and the Netherlands about how they have dealt with Covid and whether they dealt differently with non-Covid cases during the pandemic. Do you want to start, Professor Elder, and then I will move to the others? The analysis and question there are huge in the States, and that is what it points to. It points to the fact that there is excess in a very common non-Covid mortality, and the conditions that are noted there are those most likely to feature there. Can we learn lessons from the United States? I think that the approach has been so different in many states in the United States and in much more difficulty than we are due to varying rates of vaccination in particular. Of course, the fragmented style of healthcare between public and private makes it very difficult to draw conclusions. I would say that there is nothing in particular right now that I am aware of for the way that the United States went about it that we can learn from. I do not know about European neighbours or anything that we made particular in that. I wonder if any of the other panellists know about other European countries that we could particularly learn from or have done anything particularly well compared to us. I am seeing shaking heads from everyone, so that is okay. Dr Shackles did want to come in on your previous point. Thank you very much for that. I just want to come in and echo Professor Elder's comments about the realistic medicine and the utility of that. I want to make some of the data-sharing comments as well. At the beginning of the pandemic, we spent a great deal of time working with our patients contacting them and constructing advanced care plans. At the start of the pandemic, the number of care plans went up fourfold compared to pre-pandemic. That is very useful for the data-sharing, but it also has the ability to have conversations with individual patients about what their wants are about their care going forward. One of the things that we are starting to see in general practice is emerging evidence and some public evidence about the importance of continuity of care in general practice. The continuity of care, seeing the same general practitioner, the same nurse each time, can have a significant effect and improvement on both morbidity and mortality. The only way that we can manage this continuity of care is making sure that we have the workforce able to do that. We see continuity as being one of the things that underpins what we do as general practitioners. Some of the ways of working because of workforce, because of the need for rapid access to general practice has been eroded away to the detriment of patient care. The continuity is absolutely necessary, and we need to build on that as much as we can to work on some of these things like the morbidity of patients and also to give us time to have these really important conversations about what patients want about their care. Are they going to be somebody who wants to be treated at all costs or are they somebody who values just being kept comfortable and looked after and actually additional treatment isn't in their interest? Those are difficult conversations to have and we need to be able to share those conversations across the interface as well to make sure that we all know what the patient's wishes are. Okay, that's helpful. I mean, I certainly remember when I was younger we saw the same GP every single time when we went to the GP. To move on to a slightly different area, Dr Miles, in your paper you talk about resources and I think that gets touched on in other papers as well, but specifically you say the health service budget is finite and was under-resourced given the demands before the pandemic, so I'm kind of wondering, I mean, we've already mentioned preventative spend, so I wonder if you're arguing that we need to, as a society, we need to spend more on health and assuming we're not going to cut that off universities or schools, that probably means higher taxes, so is that kind of what you're arguing? Or would you argue more that we should be using money differently within the health service and better within the health service? I think the tax question is potentially, and the decision about where resources are allocated and how much tax is raised by the government is generally a political one rather than a medical one, but I think how we utilise the resource that we are allocated also has some degree of political will behind it and societal will, so going back to the points that Dr Shackle made, what is important to society to focus on? Even if we raise more money, we will always have a finite resource. It's never going to be, you could spend, the America spends more on healthcare per head of population than we do and still has not been able to deliver the healthcare to all of its population that it would want to or that population would demand, so money is not the only answer. What we decide to spend it on is important and it's possible that we may over subsequent years decide to refocus that on preventative care more than acute care, but those are conversations to be had with society and the political parties as well as the health service. I wasn't surprised that you said it was a political question, although I have to say that if people state that the health service is under-resourced, I think that that is a political statement and therefore one of my jobs is to ask where the money is coming from. Dr Thompson, kind of in the same area for yourself, your paper talks about needing extra beds, and yet at the same time the concept of preventative spend and a lot of people would say that we should give the GPs more money and chop it off the hospitals. How do we get that tension right? In terms of the beds, that's what we feel is required for the demands that are currently placed upon second care. I think that we need to be looking at different options to hospital admission. We need to be looking at how we can treat the patients differently. Colleys, again, I have spoken earlier about community-delivered care and whether that is direction. We need to look at using the resources effectively and not admitting patients to hospital who can be managed in different ways, ideally when you look at the University of Scotland, particularly closer to home. Okay, and maybe from a final point then, Dr Shackles, would you like to come in this one, does there need to be a shift to primary care and away from the hospitals? I would say so, yes. Throughout my career, every high-level report that has been issued has said that there needs to be more of a focus on care in the community, care closer to people's home and less of a focus on secondary care, but all we tend to see is money gravitated towards hospital services, either building hospitals or increasing consultant numbers and less delivered in the primary care sector. There are GP estates or GP surgeries and practices. Currently, one of the biggest problems that we had was delivering care in a Covid-safe way, because GP surgeries were not in many cases fit for practice. They did not have the space or the workflow to be able to deliver it effectively, and that was a big strain because of potential underinvestment, I would say, in the GP premises estate. Yes, we need to have a rebalancing, but equally, I am also going to agree with Dr Thomson that the number of acute beds available to us probably is not sufficient. It is how we square that circle. Over my career, when I started up for every general practitioner that was 0.7 of a consultant, now it is the other way round, we have an inverse pyramid of the number of doctors working in the secondary care sector, and that seems to me to be strange when all the policy makers say that we should be having the care closer to the patient's home. If we are trying to look after more people at home, then we are going to need more people working in the community. There are initiatives like hospital at home where hospital consultants and hospital staff will be involved in that. That is well and good, but other resources are required for that as well, particularly our district nursing colleagues or social service carers, where we need to provide nursing care and looking after potential carer numbers in the community. It is complex. I do not think that it is just one thing or the other. I think that that would be massively oversimplifying a health service that relies on all of us to be working to the highest level to make it work. Okay, that is helpful. Thank you very much. Thank you very much. I am going to bring in Jim Felly, because I knew I cut you short and I shouldn't have, because we have more time than we thought we were now, short of time. I will be very brief, and this is directed to Dr Shackles. We all stood outside our doors, clapped for the NHS, clapped for the nurses and all the rest of it, but there seems to me to have been a massive turnaround in that you guys have now become the flipping boys in terms of the appalling abuse that GP surgeries have had. I guess that some of that will be the practices of a GP are changing, the fact that you are now seeing people online as opposed to in-person. Where do you feel the GP system is at the moment, is it going to go back to being all-in-person, and how do we make it easier for you as an individual profession within a wider profession? How do we make it better? I very much take on board your tracing of patients' information, and I think that that is something that we should look at in making sure that the IT system works for you guys, but what else do you need in order to turn that around where you are no longer have taken the abuse that you've been getting, which I have to say has been utterly appalling. Thank you very much for the question. It is very much on our mind all of those topics that you've raised. General practice and general practitioners and all our staff, all we did throughout the pandemic was what we asked. We applied the guidance that came down centrally, the principle guidance sent out from the chief medical officer from the Scottish Government and from other agencies about public health and the way that we should be working. We haven't made anything up ourselves, we've applied the guidance that has been given, we've been very agile, very good about switching quickly to the remote method of working that we were asked to do, while still making sure that we could see, that we could visit those who were vulnerable who needed face-to-face appointments. That never stopped. What did stop was that the message didn't get through. Partly the message didn't get through is because so many patients are absolutely used to over their entire lives, over many, many years of just walking into their GP's surgery. Very good access. The access that we have to general practice in Scotland has been unbelievable over years. When it was suddenly told that it couldn't have it, it stopped, you got a reaction, understandably for that. Particularly during the lockdown phases where patients couldn't go out, if you can't see somebody working, you don't think they're working. When they can't see us, they don't know what we're doing. However, our members have been working incredibly hard, as I said, making up the advanced care plans, phoning our most vulnerable patients, working out the shielding lists, then starting to do remote consultation by video, telephone, also doing home visits to care homes as well. That never stopped. And then as we start to open up a little bit more as patients come up and the demand went up, of course, inevitably demand exceeded supply. So patients were told they couldn't speak to us or see us. We're still having to have initial conversations on the telephone, which uses up time, reducing the potential number of face-to-face consultations that we have, still trying to make sure that we ask respiratory questions so that we're not bringing down people who may potentially infect other people with Covid who are attending the surgery, so still working to the winter pathways as much as we can. That's despite Carrie Lunan and others fronting up public information films about the changes that we're having. We don't believe that there will be a complete reversion to how general practice worked before. We always did use some video consultations. We always used the telephone. There will probably be a rebalancing. We see it will probably go out in the college to maybe somewhere around 65 per cent face-to-face 35 remote consultations. That might be appropriate for that, but there will be some areas where it's different, particularly in remote and rural, if patients find it much more convenient to use some of these new technologies as they get used to them. Patients still value the face-to-face consultations as do the doctors. It's what gave us a lot of job satisfaction, and that's one of the difficulties that we're seeing in retention, where older doctors, particularly, are not enjoying the new ways of working. They don't get the same satisfaction from seeing their patients, and they're saying, you know what, if that's what it's going to be, we don't want it, so we've got to be very careful about that recruitment-wise and retention-wise, because that's what makes us work well. Absolutely. We've been calling for better public messaging, public conversations for a long time, well into the pre-pandemic. We absolutely needed it now. The problem is some of the damage has been done. People are feeling undervalued, feeling abused, and we've got to regain some of that trust. That's not that we don't undervalue some of the comments made by other organisations, patient organisations, the Alliance. We understand some of the concern that patients have had, because they haven't been able to access the GP at the time they wanted or face-to-face. We understand a lot of their distress. We feel we need to work with our patient groups better and to get better understanding for that, because we can make sure that patients can get seen when appropriate. A lot of those points are about resourcing, as well as the way we work. Thank you very much. That is very helpful. Thank you very much. I know others did want to come in, but unfortunately we have run out of time. I would like to thank all the witnesses for their evidence and giving us their time this morning. If witnesses would like to raise any further evidence with the committee, they can do so in writing and the clerks would be happy to liaise with you. I will briefly suspend this meeting to allow a changeover of witnesses. Thank you. Good morning. We will now move to agenda item number two. The committee will take evidence from the Scottish Government on the ministerial statement of Covid-19, two monthly reports and subordinate legislation. I welcome to the meeting our witnesses from the Scottish Government John Swinney, Deputy First Minister and Cabinet Secretary for Covid Recovery, Professor Jason Leitch and National Clinical Director, who is joining us remotely this morning, and Dominic Munro, director of Covid-19 exit strategy and Elizabeth Blair, unit head of Covid coordination. Thank you all for your attendance this morning. Deputy First Minister, would you like to make any remarks before we move to questions? Thank you, convener. I am grateful for the opportunity to meet with the committee and I will make a brief opening statement. On Tuesday, the First Minister set out the revised strategic framework to Parliament. This document details the Scottish Government's approach to achieving a sustainable return to a more normal way of life while remaining prepared for potential future threats from Covid. This approach will support us to manage Covid effectively through sensible adaptations in public health measures that will strengthen our resilience and support our recovery as we build a better future. In time, we will seek to rely much less on legally imposed measures and instead rely more on vaccines, treatments and good public health behaviours. We will continue to ensure the maximum possible availability and update of vaccination in line with expert advice. Indeed, from mid-March, we will start issuing vaccination appointments to all five to 11-year-olds. We will also begin providing additional booster to care home residents aged over 75 and over 12 who are immunosuppressed. Similarly, testing has been and will continue to be a vital part of our management of Covid. Over time and in a careful and phased manner, it is reasonable to move away from mass population-wide asymptomatic testing towards a more targeted system that is focused on specific priorities. We will publish a detailed transition plan for testing protect in March, by which time we will hopefully have much needed clarity from the United Kingdom Government on testing infrastructure and funding. From Monday 28 February, the guidance on how often to take a lateral flow test will change. We will revert to the advice to test at least twice a week, particularly if going to a crowded place on meeting anyone who is clinically vulnerable. Further, the updated strategic framework sets out a number of additional proposed changes to public health protections over the coming weeks. Firstly, from Monday 28 February, the Covid certification scheme requiring certain venues to check vaccine status will end, although the app that supports the scheme will remain operational for businesses who want to use it voluntarily to reassure customers. Secondly, from Monday 21 March, assuming that there are no significant adverse developments, the legal requirement to wear face coverings in certain indoor settings and on public transport will end. From the 21 March, we also expect to lift the legal requirement for businesses, places of worship and service providers to have regard to Scottish Government guidance on Covid and end the requirement to retain customer contact details. The strategic framework details the kinds of behaviours and adaptations that will be encouraged in different circumstances. Those include enhanced hygiene, improved ventilation, increased hybrid inflexible working and face coverings in some indoor places. It is now less likely that the measures will be legally imposed in the future, but we will advise their use for as long as they help to control the virus and protect those who are the most vulnerable. The approach that is set out in the strategic framework will support us all to return to normality and ensure a safe and sustainable recovery. I am very happy to answer any questions that the committee may have. Thank you, Deputy First Minister. I will turn to questions now. If I may begin by asking the first question, first of all, I think that I would like to thank the Scottish Government for this strategic framework announcement this week. I think that it is very welcome news for many of the lifting of restrictions later next month. I know that there is currently uncertainty regarding the future of testing, but as our framework identifies three broad threat levels being low, medium and high, if testing is reduced in considerable capacity, how will it be possible to monitor the outbreaks of new variants to determine which threat level we should be at? I think that I will bring in my officials to provide some further detail on this, but this is a very material issue, convener. It will involve an on-going level of testing infrastructure. That is the key point that I would want to reassure the committee about this morning. We simply cannot turn off testing and it would be a mistake to do so. There has to be a mix, and this is what we will consider as part of the testing plan, a mix between measures such as the ONS infection survey, which is absolutely critical for intelligence purposes on the prevalence of the virus, and levels of testing that enable us to reliably gather the basic information that enables genomic sequencing to be undertaken so that we can identify any new strains and new variants. There has to be a degree of on-going intelligence about the prevalence of the virus within our society to enable some of the judgments to be made about at what stage are we operating. There will be more detailed testing required to enable us to form a picture of what, if any, new strains are emerging within our society. There are almost two different elements and requirements that are necessary in that process to inform our judgments about the state of the pandemic and to be able to contribute to the international effort to identify any new strains and variants, which is our absolute duty and obligation to participate in. Indeed, if there had not been good international co-operation with the authorities in South Africa and good testing infrastructure, we would have had a less early warning of the Omicron variant than we actually had. I invite Professor Leitch to add anything to that, and perhaps Dominic Minow on the judgments that will be made. Professor Leitch, I do not know if you can hear me, but I think that you are on mute. I am not. Can you hear me now? Somebody turned me up. I just said good morning. That was all. Thank you for allowing me to come in virtually. It helped logistically significantly this morning, so I appreciate that. DFM covered it very well. You need testing for four reasons. You need to surveil, you need to treat, so you need to know what disease it is that you are treating, so you have to test before you treat. You need to know what is happening in high-risk institutions, prisons, social care homes and hospitals, and you need to know how to manage outbreaks, whether that is a chicken factory or a school or wherever else. The question is how you do that. The end point for all Western European countries is the same. We will test less. You do not test for flu in your own home, but we do test for flu in hospitals, and that is where we are all headed. We hope to be headed there relatively soon, but we do not know if we are going there. That is why our advice to the Deputy First Minister and the First Minister was to maintain the testing regime as it is presently with one principle change, which is the removal of daily or every time you have a social event asymptomatic testing, to move that to twice weekly, which is what we did before Omicron. We will continue to monitor the pandemic, but one in 25 cases in the population just now, so every 100 people, there are four positives. We think that it is too early to remove that level of protection where you might put others at risk. I just heard this morning of a wedding of 120 people with 30 positives within a few days of that 120. Keeping the positives out of those events and out of cinemas, care homes and public transport is still a crucial part of our protection. However, as prevalence falls, you can adjust your testing regime, and that is exactly the advice that we will give as we hope prevalence falls, but it is not showing the things of doing that. I am afraid very quickly. I suggest not much more to add to what the Deputy First Minister and Professor Leitch have said, but, coming back to your question and putting it in the context of future threats, the two key parameters that we will need to know with any new variant are how much more severe it is than the current strains that are dominating Scotland and how much more transmissible it is. Whatever the arrangements for testing that we have in place going forward, and both the Deputy First Minister and Professor Leitch have set them out, we need to be able to ascertain those two things quickly. We need to ensure that the infrastructure that we have going forward—and that could be in the form of targeted PCR testing, wastewater sampling and a sufficient ONS infection survey—enables us to get that kind of data to be able to ascertain severity and transmissibility quickly. I will move on to my next question. I think that the announcement of some of the restrictions in March, as I have already said, is very welcome, but there will be a lot of people that have concerns, particularly our most vulnerable, perhaps, that have been on the high risk list during the pandemic. What measures will the Government take to ensure that our most vulnerable people on the high risk still feel supported as we move on to the next stage? I think that this is a vital issue, convener, because I quite understand the appetite on the part of individuals to return to something like normal life, but there are some in our society who are frankly terrified by that prospect in the light of Covid. The first thing that we have to do is be respectful of their views and their concerns and to understand the anxiety that they face. That is why we have taken the gradual approach that we have taken. We have tried to do that in a measured way to ensure that we try to build as much resilience as we can within the population. Vaccination is critical to help us in that journey. Of course, there are some people who are vulnerable who cannot get vaccinated for entirely understandable clinical reasons, which increase their anxiety further. Vaccination is critical to building resilience. There are routine measures where, although on 21 March, we may remove the legal obligation to wear face coverings on public transport, we will still be saying to people that it would be advantageous for that to be the case and to be a good civic gesture to undertake to protect other people. For those who are very vulnerable, we want to make sure that they have access to the clinical support that they will require. Individuals who, for example, are immunosuppressed have had communication from the chief medical officer that there are antivirals that would be available to them because of their clinical vulnerability that they should access. There is mental health support that we want to make available to people to support them in their anxiety. In general, we want to make sure that people have the support that they require, which recognises the fact that the relaxation of restrictions is not universally welcomed within our society and that we ignore the anxieties and the fears of individuals in our society at our peril. Thank you, convener. Good morning, Deputy First Minister and colleagues. I suppose that my first question is a very neat follow-on from the question that the convener has just asked. We have seen a move now from the Scottish Government, which was announced by the First Minister on Tuesday, to move away from legal restrictions towards a situation in which we are relying increasingly on personal responsibility and individuals complying with public health guidance. That is very much in tune with what has happened elsewhere in the United Kingdom. First of all, the Welsh Government announced that, then the Northern Irish Government and the Prime Minister announced the same for England on Monday, albeit on slightly different timescales. Is it now the assessment of the Scottish Government that the public are in a place where they will, in the main, comply with public health guidance, without it being required to be set in law, where they behave in a particular way? That will be our general assumption in relation to the management of the pandemic, but we have to make sure that we have the legal capacity in place and the statutory capacity in place to be able to respond to a deteriorating situation. Should that be the situation that we face? We have seen, for example, with the discussions that have been around the rules on self-isolation this week, that the Scottish public have complied very well with the public health guidance. When the Prime Minister announced that the self-isolation rules for England would be dropped, there was a lot of criticism of him being made in some quarters. Some people seemed oblivious to the fact that, in Scotland, there has never been a legal requirement to self-isolate following a positive test, except in the very limited circumstances of international travellers. I think that we are in a good place in terms of the public. The reason that I ask the question, as you can imagine, is that we have an instrument to consider shortly on extending the extraordinary powers that the Scottish Government has for a further six months. Given that we know that the Scottish public responds very well to public health advice, why can't we just trust people to follow the advice, because we know that they will do that, rather than having those legal powers continuing? We may face a deteriorating situation, and we may have to take some more severe action. I hope that we do not have to, but we may have to. I have rehearsed with the committee before that, on one Tuesday morning in November, the Cabinet thought that the pandemic was pretty stable and that we could look forward to a pretty straightforward Christmas. 48 hours later, Michael Matheson was on a call with the United Kingdom Government applying travel restrictions on South Africa and various other African countries, because Omicron had descended upon us and bluntly Omicron was the variant of the virus that came closest to tipping over Scotland's national health service, and it came very close. That all happened in the space of 48 hours, so I cannot predict what lies ahead, but I have sat in Parliament in Parliaments for now nearly 25 years, and I have listened to members of Parliament rightly and demand that the statute book is capable of dealing with situations that we face. At this moment, with all the history that we have had in the past two years, I simply want to make sure that Scotland has a statute book that can be used if it needs to be used to protect the public. I stress that the word can be used, not must be or will be, but can be used, because I suspect that I might be exposed to a good amount of criticism for not foreseeing this and not foreseeing that. In this particular situation, I and the Government are deciding to try to foresee some of the difficulties that we might face and put in place a statute book that gives us the ability to respond in a way that we hope we do not have to respond but may have to respond. I suspect that we may have to just agree to disagree on this particular point. I suspect that on this particular theme, Mr Fraser, we may just have to. I have a time for one more question. I was looking at the ONS statistics this morning, which are suggesting that although there is a downward trend in terms of infections across the rest of the UK, in Scotland that is not the case. The latest figures seem to show that we have an infection rate of one in 20 in Scotland, one in 25 in England and one in 30 in Wales. That would seem to suggest that, despite the fact that we have had more legal restrictions in Scotland over the past few months compared to other parts of the UK, England in particular, that has not had a beneficial impact on the case rate. I am sure that you saw that there was a study in the Financial Times two weeks ago that analysed the figures for the last six months. We suggested that, again, despite the fact that there were more restrictions in place in Scotland, including wearing face masks in certain settings, the fact was that there was no beneficial outcome. In fact, the Financial Times was suggesting that the rate of death in Scotland from coronavirus was higher than the rest of the UK. Does that not suggest that the Scottish Government's approach in having more restrictions has not delivered better outcomes than elsewhere? No. I am obviously aware of the ONS infection survey detail this morning. If my memory says me right and I stand to be corrected in this, this is the first week of the survey, certainly since the onset of Omicron, in which the incidence ratio in Scotland has been at a poorer level than the rest of England and other parts, but, certainly against the English comparison, it may be different in relation to some parts of Wales where, of course, there have been other restrictions. I think that this is the first occasion on which that has been the case. The Financial Times assessment, I think, raises a lot of questions because, essentially, the death rate in Scotland—I hate to talk in this kind of language, but it has been put to me, so I have to do it—the death rate in Scotland has been comparatively lower than the death rate in England throughout the pandemic. I am not quite sure where the Financial Times gets its conclusions from. What is important is that we take measures that we consider to be proportionate and appropriate. The Scottish Government has done that throughout with the objective of protecting the public. If the position in Scotland had been any more serious than it has already been, then I am quite sure that there will be many people queuing up to demand that the Scottish Government take stronger action. Indeed, some people have demanded that the Scottish Government take even stronger action than it has taken. The European Union will be free, obviously, to make those arguments, but we have to make a balanced set of judgments and to protect the public that has been at the heart of those judgments. Thank you. I would love to pursue those issues further, but I feel that we are out of time. Thank you. I am going to go this way this time to John Mason, please. Thank you very much, convener. We continue to have a problem with misinformation and people who are either Covid sceptic or vaccine sceptic. I understand that some of the data that has been produced has been misused or misquoted and twisted. As a result, Public Health Scotland is not going to continue publishing some of the figures. There was an interesting article by Helen McArdal in Saturday's Herald, which I, frankly, struggled to understand. Can you clarify what the problem was? I think that it may have been to do with the unvaccinated population and how they are counted. Can you clarify why that data is not solid and why it is not being published? To come in on this particular point, or we may have to write to the committee on this point? I am not entirely clear what that is, so I think that writing might be the best idea. My best—I was going to say guess, never say guess, in front of the Deputy First Minister or a parliamentary committee. My best thinking here is that one of the translational challenges in the vaccinated and hospitalisation data is why, does it look as though more vaccinated people are in hospital than unvaccinated people are in hospital? That is a good question. The reason why is the vast majority of the country are vaccinated. Therefore, you still end up with more vaccinated people in hospital because your denominator is so huge compared to the unvaccinated small numbers of people. However, if you look at it proportionately, the proportion of people who are vaccinated who end up in hospital compared to the proportion of unvaccinated people who end up in hospital, you see a stark difference. That shows globally that vaccinations stop hospital admissions, they stop ICU, and they stop deaths. Not in their tracks, of course, they do not reduce it to zero, but they reduce it significantly. Therefore, when you go to intensive care, as I did this week in the Queen Elizabeth hospital, then you are much more likely to see unvaccinated people proportionately in that intensive care. I will look at Helen Macadol's article and we will get back to you on the specifics, but I imagine that that is what it was. I think that that was the area that it was touching on. There was also mention of ghost patients, if I understand that the population who are registered with the GP is actually higher than the population. That seems to be another part of it. If Mr Mason will understand that I try my best to keep across all newspaper articles, I do not read every one of them. If that was the case, I would be doing nothing else in life. If the committee will forgive me, we will write to the convener with a response at that point. Professor Leitch's answer did deal with the actual problem, so that is helpful to get that on the record. The second area that I wanted to touch on was vaccines. We are obviously expanding that slightly, and some people are getting a fourth or second booster vaccine. Can you give us an indication of where that might be going? Are we going to go right through the population from the oldest to the youngest again, or would annual boosters wait until the autumn for the under-75s? Again, I am going into territory here where I am speculating. What we do know is that the JCVI advice that we have received will result in assisting vaccination appointments to all five to 11-year-olds very shortly. We will start that in mid-March to issue, and we will do most of that around about Easter holidays. An additional booster will be provided to care home residents, those over 75 and those over 12 who are immunosuppressed. That will dominate the spring and the period towards the summer. I think that that probably makes it likely that we are heading towards a booster programme in the autumn, but we will await JCVI advice on that particular question. I think that we will be moving into a period assuming that there is no substantive deterioration in the situation in which we will be relying upon vaccination to provide us with effective resilience. My next one was just on testing, which has been mentioned already. If we do not get funding from the UK or if the UK does not fund the testing kits, is that going to seriously curtail what we can do? Obviously, we have judgments to make about what will be the nature of the testing programme that we can take forward. It is informed by the decisions that are taken by the United Kingdom Government, because, clearly, the financial arrangements support an expansive testing programme if curtailed will have an effect on our ability to deliver such a programme. We have to pursue the detail of the United Kingdom Government announcement that was made earlier this week. It was pretty obvious that it was a tense set of discussions within the UK Government—some might call it chaotic—that led to the announcements on Monday. That has not provided us with particular clarity about their intentions. We are now seeking that, and that will inform the testing programme that will come out. However, I assure Mr Mason and the committee about the points that Professor Leitch and I put on the record and the responses to the convener will very much inform the formulation of the plan that the Government puts in place to enable that to be the case. My final point, if I may, is looking at the strategic framework going forward. I think that there is a little bit of mention of Malawi, Zambia and Rwanda, and what we can maybe do for them. Can you just say anything about what we might do for them? Obviously, we are working closely with the long-standing relationships that we have with these countries to play our part responsibly to support the vaccination programmes that are under way there. We accept, as a Government, the importance of ensuring that we fulfil our international obligations to ensure that the whole world is protected from Covid, because only by the whole world has been protected from Covid do we have as much assurance and security as we possibly can do. Our co-operation will be to that end to achieve that objective. I'm going to take the opportunity here, if I could, to extend the conversation that we had with our previous panel, around looking at lessons learned and what we can do in the future. I think that some of the submissions, or most of the submissions that we had from the experts or the word anecdotal in terms of collection of data and what's happening out there, appeared a lot within the submissions, especially around what's happening around non-Covid-related conditions and death from other conditions that may have increased, but they're not aware of any data to support this. I think that this really extends work that was done in the Health and Sport Committee in the last term around collection of data. Then, very fortunately, one of the experts this morning raised the issue of the IT system that's currently available within the NHS. The words clunky came out. There were three different systems that the NHS worked with just now, and it would be beneficial if one of the investments that was made was delivering an IT system that allowed proper collection of appropriate data and deployment of that data. Covid has taught us that data is incredibly important. Is the Government looking at that in the previous term? I wonder where we are with the development of a new IT system, potentially for the NHS. The first observation that I'd make on Mr Whittle's question is that, in a sense, Mr Whittle makes one of the fundamental points that I was making in my response to Mr Fraser, that it is important to deduce lessons from the pandemic and apply them and learn them where we believe there are important lessons to be learnt. I happen to take that view about the statutory framework, and Mr Whittle has put into me an entirely legitimate point in relation to data and IT. Fundamentally, Scotland has been very well served by some critical decisions that were made a long time ago about the unique identifier of the Ki number, which has essentially acted as the foundation for the administration of healthcare within Scotland, based around the individual, enabling the information and the records of individuals to be accessed appropriately to ensure the delivery of quality healthcare for that individual. That has been a really strong foundation of our systems, but, of course, with every development that comes along, there are extra pressures put on that core system. Covid has put many data demands on to the system, particularly on vaccination records and all that has gone with issues of that type. The Government has been taking active steps to ensure that the approach to the delivery of digital care has been strong within Scotland. It has got ever stronger during the course of the pandemic, and the development of appropriate information technology capability to ensure that we can meet the needs of individuals, identify those needs and meet those needs lies at the heart of the system. The Government will be working closely with health boards on that question to ensure that the foundations of our IT system are kept up-to-date to ensure that we meet the needs of individuals. I thank you, First Minister, but I think that there was definitely frustration vented this morning with healthcare professions around things like the interface between primary and secondary care, secondary care being unable to access primary care data when a patient presents. To me, this is an area that I worked in pre-parliament, and it is something that interests me—this ability to port that kind of information, that kind of data. What Covid has done is exacerbated the issue and highlighted the issue. Looking ahead, as we need the lessons learned, as you said, Deputy First Minister, there is a very good opportunity to look at what data is collected and how that is accessed. It does fundamentally require an IT system that is universally applicable across the whole of the country, but that is not the case at the moment. I am just wondering where we are with the development of that kind of structure. I would like to have a look at the circumstances that the clinicians were raising with the committee this morning. My understanding is that, throughout the national health service, there is the capacity and capability to access critical information about the healthcare of each individual. That is why I made reference to the kind number, because that is what underpins and drives the system. I would want to understand a bit better some of the deficiencies that have been highlighted. In principle, the availability of data and the necessity to collect the appropriate data within our healthcare systems is something that, with which I agree with the points that Mr Whittle put to me. To have a system that can be accessed in all different spheres of the health service is an important provision. I am very happy to look at those issues, to look at the particular points raised by the clinicians this morning. I will encourage the health secretary to look at those questions and to determine what further action it requires to be taken. I think that this definition and that particular point that I will finish here is that, if you look back, I would encourage the First Minister and the health secretary to look back at the work that was done by the Health and Sport Committee in the last term. I will again listen to the evidence this morning. The situation that you described there is that this sort of universality of access is not the case in Scotland. If you input your data in Glasgow, somebody in Edinburgh cannot access it. If you have to be over here, you have to re-input that. We are getting into an area here, but I think that this is a criticism, but I think that there is an opportunity here to look at a system-wide change that would be to the huge benefit of our population and our NHS workers. The characterisation that Mr Whittle puts to me is not my understanding of the situation, but I will go and look at it again. I think that there is accessibility for critical information—perhaps not all information, except that—but I will certainly look at the issues that Mr Whittle raises and encourage the health secretary to do so. Thank you, convener. I will reiterate what Mr Whittle has just said. Clearly, the message that came across from this morning is that you cannot follow a patient regardless. If it goes from one department to another, that information is not following them, so it is just to look at it, because my understanding was that it could run across the country from what we are getting this morning. That is not the case. There are so many things that I would like to talk to you about. What is the WHO advice on testing at this stage, given where we are in the pandemic? I will come specifically to Professor Leitch on that point, but the World Health Organization advice to us at this stage in the pandemic in general is to take care and not to consider that everything is over and done with. The position that the Scottish Government has taken on, for example, continued use of face coverings as a mandatory provision is an approach in line with the guidance from the World Health Organization. The World Health Organization will encourage us to maintain a testing infrastructure that enables us to identify what is the prevalence of the virus in our own society and what can we contribute to an international understanding of the virus by virtue of the information that we collect and the experience that we have. When it comes to specific measures and restrictions, the World Health Organization may set out what they think to be desirable. We as a Government have to judge whether that is proportionate because we have to be satisfied that we can withstand the legal challenge to any of the decisions that we take. Generally, the advice from the World Health Organization is to take care at this rather pivotal moment in the pandemic, but I will come to Professor Leitch for that on the specific point on WHO advice on testing. I will not go down the digital health tunnel, but I commend to the committee the October update to NHS Scotland's digital health and care strategy, which sets out both the present position and the plans for the future. They may want to consider that in deeper detail, and the Health and Sport Committee certainly will. My four categories come directly from the WHO's advice. Mr Swinney is correct that the fundamentals are that you should take it cautiously. The next variant, of which there will be one, will either come from a highly vaccinated country with a high prevalence, which is what we have, or an unvaccinated country. The virus will either find a way through vaccines, and if it has high prevalence it gets more opportunity to do that, or it will find a way of transmitting in an unvaccinated community. Vaccines squeeze what the virologists call it, so the virus will find a way to get new people. That means that you need to do surveillance, and that requires genetic surveillance, so you need PCR testing for that, and you need to do that if you can randomly across the country, like the ONS survey, but also for those with symptoms. You need to do high-risk locations, you need to have capability to manage outbreaks, and you need to know who to treat, because as the therapeutics improve, you need to know who to give the therapeutics to. It's a fairly basic clinical formula. Does this person have Covid, so should I give them Covid medication, or does this person have something else for which they would have different medication? In order to make that decision, clinicians need testing. Traditionally, we do that once they reach healthcare. The challenge with this disease is that, because of the great therapeutics that we are now developing, many of them are helpful before you reach healthcare, before you are sick enough to need traditional medication. It may be that antivirals could stop the heart transplant patient or the 85-year-old reaching healthcare at all. Therefore, you have to move testing up the chain, do it earlier, and then you get treatment options coming from that. That's what the WHO says you should do, and that's the advice that we're giving to the Scottish Government. The point that I'm trying to get to is how we surveil in order to make sure that if there is something moving about in our community that we catch it as early as possible, is the current system we have in place that we know is sufficient is what we are moving to going to be sufficient? That's essentially the discussions that we are taking forward as part of the formulation of the testing transition plan. I think that it has to be accepted that we cannot sustain the level of testing infrastructure that we have had in place for most of the last two years, but we cannot have none in place. It's one of the lessons of the start of the outbreak. Indeed, there's a really interesting global point on this. Many of the Asian countries have been able to withstand Covid to a greater extent because of their experience on the SARS-related viruses over the past. They have always maintained a much greater testing capacity and capability than ordinarily was the case in western countries. We might not go to those levels, but we certainly have to go some way towards them to maintain surveillance. The debate that we've got to have is on the question of sufficiency. We believe that a sufficiently credible and capable ONS survey is vital to enable us to be able to be properly prepared. We have got to have a level of testing infrastructure that enables us to detect and identify any new strains, and we have got to have a capacity to be able to identify any emerging issues within individual populations. For example, Dominique Monroe made the point about wastewater sampling. That is a very good way of determining the parts of the country where there may be, comparatively speaking, more incidents in the presence of the virus that can be undertaken through wastewater sampling. That will be sustained by the Scottish Government on a non-going basis. There is not a definitive answer today to Mr Fairlie's question. It is a very important and legitimate question, but over the course of the next few months we will have to answer that question satisfactorily as to what should be the level of capacity that we retain in place. I am sorry, Mr Fairlie, but we are running out of time. Alex Rowley, please. There is a political balance, isn't there? I do not think that it is unreasonable to look for an extension of powers for another period of time, given where we are. If you were saying that you wanted these powers forever more, that would be a different matter. Given where we are right now, that is why I welcomed the announcement this week that there is work now going to be done on future pandemics. Professor Leitch talks about possible variants. I worry that we are starting to get to a point where everybody thinks that this is over and we can get back to some kind of normality. However, in terms of the work and the reports that are coming in the spring, are you looking at a proposal for how we prepare and plan Scotland-wide? Or, when you say that you are talking to local authorities, are we looking at regional approaches across Scotland so that, at a regional level, they are prepared? The evidence that we had this morning, part of that for the Royal College of GPs, was that seven years on for the incorporation of health and social care into the IJBs, it is a hit or a miss at the local level as to whether you have joined up services, mental health services, social work services, all working at a GP level. It is fine to have big central plans, but we do not seem to be able to get that through on to the ground and have a decentralised system of governance in place to deliver. First of all, I am grateful to hear that Mr Rowley has taken his usual rational and considered approach to the regulatory infrastructure, which I am very much welcome to. I look forward to that being shared universally across the committee. On the substantive point of Mr Rowley's question, I also very much agree with his sentiment that there is a danger that people think that this is all over in Dunbarth, and it is not. I know that I sound like a broken record about my Omicron example, but those things can happen really quite quickly and we do not know the extent to which, as international travel takes off again to a greater extent, how quickly those variants may be able to spread across the world. There are absolute legitimate points here. On the preparedness question, Mr Rowley is correct that we are now undertaking further work on future pandemic preparation. That has to be an all-Scotland approach. It is not an argument to say that it has just got to be done at national level, it is an all-Scotland approach. It has got to involve our resilience partnerships in every part of the country. Mr Rowley will be familiar from his long experience in Fife of the role of the local authority as a key part of the resilience partnership at local level, working with the health board, the police, fan rescue service and various other players, who we turn to and rely upon, as we have relied upon during the pandemic, to be able to deliver an appropriate response. Indeed, we have been relying on them very much about stormy weather as well. Those local resilience arrangements have got to be effective, so we have got to engage them. I meet regularly with the Scottish resilience partnership, which brings together the local resilience partnerships, where we reflect on what are the current threats, what are the challenges that we face, how do we respond to them and what is the learning that we can deduce in every part of the country. All of that is undertaken and valid, and we should be focused on pandemic preparation. If I was to reflect on the last number of years, when we have looked at an annual stocktake of what are the resilience threats that we face Scotland, a pandemic has always been right up there, but you sit there waiting for it to happen. Stormy weather comes very frequently, as we know, and flooding comes frequently and various other things. It is important that we have that foresighting capability. Mr Rowley goes on to raise a fundamental issue, and it is relevant to the debate around the national care service. He is absolutely correct, and I think that he and I will be able to agree on that point. There are variations in the quality of the delivery of care around the country. The question is what we do about that. Currently, I contend that the arrangements that we have in place do not provide the assurance that, in every part of the country, every individual member of the public who needs care services is able to get the sufficient quality and extent of those services. The Government's views came from the research undertaken by the Feeley review, which would be best addressed by the establishment of a national care service. That is an issue that Parliament will obviously have extensive discussions on in the foreseeable future. However, I think that the point that I want to emphasise clearly to the committee is that I acknowledge the importance of every member of the public regardless of where they live to be able to rely on quality care service and quality care experience. We have saw this week that we have got one in eight people in Scotland that are on an NHS waiting list. I was asking the health professionals earlier about what data is available. In fact, I think that Professor Leitch told me a few weeks ago that most of the data should be available on this. However, to understand the knock-on effect—the example that I gave this morning is two constituents who both need a hip replacement—they both suffer from that. One is able to get £15,500 together and get it done privately, and that is the same sorted. The other cannot afford that. The knock-on effect that is having on that person's mental health and the knock-on effect that is having elsewhere. In terms of those waiting lists, what we are going to do as a regional planning going on, and how we are going to get those waiting lists down, and how we are going to address the knock-on effect that those unacceptable waiting times are having on people's health and wellbeing? We have had discussions in this committee and across Parliament on countless occasions. Mr Whittle has consistently questioned me on the question of the impact on people from non-Covid health harms. Those are absolutely legitimate questions. I would be the first to acknowledge that waiting lists are larger and longer than they were before the pandemic, but that is a direct result of the pandemic. There is no health board in the country that wants to get into a position as early as possible to be able to tackle those waiting lists. There is no health board in the country that wants to put off tackling those waiting lists. Obviously, we have to be mindful of the presence and prevalence of Covid. Although we have seen a fall in Covid admissions to hospitals in general in the course of the past few weeks, to our unease, Covid admissions are rising again, and the number of people in hospital with Covid is rising again, unfortunately. I assure the committee that the NHS recovery plan is also inherent in the investment that the Government is making in the elective treatment centres. We are anxious to expand the capacity to address the issue that Mr Rowley fairly puts to me. Members of the public who are suffering pain and need a hip replacement can, within a reasonable timescale, expect that they can have that treatment undertaken. Should we not be saying to each health board that they need to identify exactly what the demands are in their area and start to bring forward some kind of proposal on how they are going to do that? That is why I would contend the NHS recovery plan because it focuses entirely on that issue of making up for the treatment that has been lost because of Covid. Each health board is under an obligation with a plan that they have had to submit to the health secretary about how they are going to go about doing that. Obviously, we are keen to make sure that we make as swift and early progress as we possibly can do on advancing that treatment. That concludes our consideration of this agenda item, and I would like to thank the Deputy First Minister and his officials for their evidence today. I now move on to the third agenda item, which is consideration of the motion for the Health Protection Coronavirus Requirements Scotland Act No. 4, Regulations 2022. Members will be aware that we will take the motion on the other two instruments listed under agenda item 2 at a future meeting once the Delegated Powers and Law Reform Committee has reported on them. Deputy First Minister, would you like to make any further remarks on this SSI before we take the motion? I think it would help if I put some comments on the record about those regulations. The committee has on its agenda three SSIs and a motion to improve the number four amendment regulations. Those three instruments all put back the date in which the key coronavirus provisions would have expired by default, and thus act to protect our ability to have in place any measures that are considered necessary. The Health Protection Coronavirus Requirements Scotland amendment No. 4, Regulations 2022, amend the date on which the Health Protection Coronavirus Requirements Scotland regulations 2021 expire from 28 February 2022 to 24 September 2022. If that expiry date has not changed, the baseline measures will automatically cease on 28 February 2022. Although we are starting to take steps to remove the baseline measures, regulations shared with the committee yesterday will remove the Covid certification scheme from the regulations. It is important that the other baseline measures can remain in place after 28 February to support our review of the baseline measures on the basis of the latest data. We do expect that the other legal requirements will be converted to guidance on 21 March, but as the First Minister said on Tuesday, this is subject to there being no significant adverse developments in the course of the virus. The health protection coronavirus restrictions directions by local authorities Scotland amendments regulations 2022 amend the date on which the health protection coronavirus restrictions directions by local authorities Scotland regulations 2020 expire from 25 March 2022 to 24 September 2022. The directions regulations will continue to be reviewed every 42 days as is required by the regulations. Keeping those regulations in place for a longer period of time will support local outbreak management of coronavirus. Local action to control our close premises or businesses at the centre of an outbreak can in many cases be the most effective and proportionate response. The Coronavirus Act 2020, alteration of expiry date Scotland regulations 2022, extend the expiry date of five provisions within the UK coronavirus act for a further six months until 24 September. Without those regulations, those provisions would otherwise expire automatically on 24 March, alongside the majority of the act's provisions. Those provisions being retained for a full six months relate to the remote registration of deaths and stillbirths, removing the requirement for vaccinations and immunisations to be delivered by or under the direction of a medical practitioner. Powers for Scottish ministers to give either boarding or student accommodation directions, which restrict either access or confined occupants. Power for ministers to deliver to give educational continuity directions and enable education and childcare provision to continue. Powers for ministers to make health protection regulations such as the health protection coronavirus requirements Scotland regulations 2021 that were mentioned earlier. All those provisions are in the coronavirus recovery and reform Scotland bill, which is undergoing scrutiny by this and other relevant committees. The Government thinks that those particular provisions should be legislated for permanently from September 2022, should the Parliament agree to the alteration of expiry date regulations. That is of course a matter for separate determination by Parliament. The alteration of expiry date regulations have been made under the made affirmative procedure. At the time of laying, our understanding was that that was the only procedure available to us for those regulations. It has since come to our attention, after discussion among lawyers, that we could have used the affirmative procedure. However, even with that understanding, we are sure that Parliament would have 40 days for scrutiny prior to the regulations coming into force on 24 March 2022. I now invite you to move motion S6M-03168. I will comment very briefly, given the time and given that we have already rehearsed the arguments in the committee. The instrument before us seeks to extend the extraordinary emergency powers for a period of six months. As I outlined earlier, I think that we are now in a place—I think that the Scottish Government—a more or less conceited point where we will be relying in future, increasingly upon the good sense of people to follow public health guidance, rather than be required to act in particular ways by the law. I believe that the experience that we have had over the past two years shows that people have responded very well to public health guidance. I suggest that it is not appropriate for those powers to be extended. I believe that we should test the good judgment of the Scottish people who have demonstrated in spades thus far their willingness to comply with public health guidance. For those reasons, I would oppose the instrument before us. Thank you, Mr Fraser. Mr Rowley, would you like to go? Yes, just briefly, I would say that, at this point in time, I do believe that it is proportionate and reasonable for the Government to have this extension. We should not take our eye off the fact that we are not through that by any means. For the longer term, that is a different issue, and it is one of this committee and other committees' world debates. However, I do not think that it is unreasonable for a six-month extension. Thank you very much. Deputy First Minister, would you like to come in? Deputy First Minister, I think that I remember vividly bringing the emergency powers to the chamber. Quite rightly, you had universal support across the chamber for those emergency powers for the situation that you faced at the time, but yourself and the First Minister have also said that those powers would only be appropriate and kept for the minimum amount of time possible, and that they would go back to parliamentary scrutiny as quickly as possible. I remember how quickly the emergency powers were brought into being and how they were brought in front of the Parliament and voted on. As my colleague Murdo Fraser said, we are in a different time now, and I think that the Governments should not hold those powers unless absolutely necessary. Given that they could be brought in front of the Parliament, and given that those emergency powers could be reinstated very quickly if required, I have to say that along with my colleague, I am going to have to oppose. Just briefly to respond to that, I think that there is in people's thinking a little bit of a difference between what is legal and what is just guidance, despite what Murdo Fraser says about people's good sense. I was down in England last week, where it tends to be more guidance, and people were not really adhering to a lot of the guidance. It is just too early to lift this. I agree that we do not want legislation in place any longer than it needs to be, but we are just a little bit too early to change direction. Just in terms of the ability to be able to say, no, this is what is going to happen, because sometimes people just put their hands up and say, no, no, we are not doing it anymore. I think that the Government has to have the ability to be able to say, no, this is going to happen because of whatever the circumstances should be. We are far, far away from being out of this, and I know that I may be one of the more cautious ones on this committee, but as far as I am concerned, until we are through it, we are through it, we are not through it, and therefore it is utterly essential that the Government has the powers to be able to take proportion to action. I acknowledge that there is a difference of opinion among members on the issue here. The point that I made in my earlier response is that I believe that there is a duty in the Government to have in place a statute book that can enable us to respond to the circumstances that we face. Colleagues have indicated that there are challenges likely to be ahead for us. I think that the measures that are in place are measures that have appropriate safeguards. There is no obligation to use those measures. The obligation, I think, for us as parliamentarians is to have a statute book in place that can respond to the challenges that we face. To Mr Whittle's point, I would say that there is a criticism of Parliament. Indeed, I have heard that criticism being made that we did not have the necessary legislation in place to deal with a pandemic scenario. If we are going to prepare properly for those things, we have to make sure that we have the legislation in place with the appropriate safeguards. I reiterate that, although the provisions will extend the regulatory infrastructure in place, it does not oblige the Government to use them in all circumstances. In relation to the number 4 regulations, there is a necessity if we want to continue the legal obligation to wear face coverings in public transport and public places to 21 March. That has to be put into place today or that would fall on 28 February. Certainly, in that short time, I would appeal to colleagues to support the regulations that will be the subject of a vote today, but there are obviously two other instruments that will be subject to discussion in due course. Members are not agreed, so there will be a division. We will now move to a vote on motion S6M-03168. Can I ask those members who agree with the motion to raise their hand? Alex Rowley, Jim Fairlie, John Mason and myself, and can I ask members who are not agreed to the motion to raise their hands? The result is 4 for yes and 2 for no, therefore the motion is agreed to. The committee will publish a report to the Parliament setting out our decision on the statutory instrument considered in this agenda item in due course. That concludes our consideration of this agenda item.