 Tre quietly on patient safety in the NHS in Scotland. The cabinet secretary will take questions at the end of her statement. I would encourage all members who wish to ask a question to press their requested to speak button as soon as possible. The recently lost of life where a healthcare-associated infection was a contributory factor is a stark reminder of how vital infection prevention and control measures are. I am sure that I speak byddwyd yn lle'l rylech â gyntafu cynedl wedi ddolningu i gweld yn y s flavour? Jówr gyrus peth n tokol yn gwylliadol melunolw � o'i gyd, siddio dylunio hyn adהurd ar brim geeket I will be grateful to the members of the chamber for the vital role that they play and the responsibilities that they take. The step change in the approach to managing infections in Scotland stems from the sea diff Oseal outbreak in 2007-8, at the Vale of Leven hospital. By then, sea diff and MRSA were the biggest infection threats to patients, but identification of the outbreak did not happen quickly enough to stop the spread of infection, and many of the cases were only identified as being part of a major outbreak through retrospective analysis. The subsequent inquiry and efforts of the Scottish Government and the NHS led to the introduction of a national inspection and scrutiny programme of healthcare facilities and developed a national infection prevention and control manual with clear and wide-ranging procedures for healthcare professionals to follow. It also set up the world-leading Scottish patient safety programme, which has contributed to significant and sustained improvement in a range of areas, including healthcare-associated infection. Those approaches have delivered real results. In people who are most at risk those over age 65, C-diff infections were reduced by 85 per cent from 6,325 cases in 2008 to 917 cases in 2017. Although infection incidents are on the scale of the veil of leaven and are now markedly rarer, it remains vitally important that we continue to learn from them and take whatever further steps are necessary to make sure that our NHS is as safe as it possibly can be. Last year, there was a water contamination incident within the Royal Hospital for Children in Glasgow. The previous Cabinet Secretary asked Health Protection Scotland to examine those issues, and I published a report from HPS on Friday. The HPS report makes a number of recommendations, and members have my commitment today that they will be addressed. The report will also be passed to the independent review group to consider, as part of its work, to review the design, commissioning, construction, handover and maintenance of the Queen Elizabeth University hospital and how those matters contribute to effective infection prevention and control. My officials are in the concluding stage of appointing two co-chairs of this review. The potential co-chairs have asked for time to consider what would be required of them in order to ensure that they could fulfil their responsibilities. I fully appreciate that members will be keen to see this work begin as a matter of urgency. I am too, but I am also adamant that we take the time we need to appoint the right clinical experts to lead this critically important work. The focus is on the Queen Elizabeth University hospital, but the lessons are for NHS Scotland. We need to ensure that our physical infrastructure is designed, built and maintained to maximise infection prevention and control. I expect to be able to advise Parliament shortly on the review chairs and then the remit and membership, all in line with the recommendations of Professor Britton. Since the water contamination incident, NHS Greater Glasgow and Clyde has also notified a number of other infection outbreaks. Those notifications happen as a result of the clear procedures agreed after the veil of leave and tragedy and set out in the national infection control and prevention manual. Evidence of a monitoring and control system that acts much earlier to identify and control infection and protect patient safety. Some infections, such as Tafelococcus aureus bloodstream infections at the Princess Royal maternity unit, are common in the general population but can impact acutely on patients who are very unwell and likely to have a lower immunity. Other infections, such as Steno-Trofomonas multifilia at the Royal Alexandra hospital, are rare. However, no matter whether the infection is rare or not, it is crucial that staff identify early, deal with it and prevent its spreading. In all infection outbreaks, immediate additional measures are put in place to ensure that hygiene and infection prevention is absolutely as good as we need it to be. Given the serious nature of those incidents, my officials have daily phone calls with Health Protection Scotland so that I can be updated and the healthcare incident infection assessment tool, HIAT, those reports are delivered following multidisciplinary incident management team updates. Following the cryptococcus infection at Queen Elizabeth university hospital, as members know, I asked healthcare environment inspectorate to undertake an unannounced inspection of the Queen Elizabeth university hospital. The report of this inspection will be published by his on 8 March. We will publish our response to it at that time and it too will feed into the work of the expert review. Presiding Officer, all those steps are important. It matters that, while the independent review undertakes its work, we make any immediate improvements necessary and identified by those reports. I want to make sure that the clinical voice is heard with regard to their work environment so that they can continue to deliver safe, effective and person-centred care to their patients. The health and care staffing Scotland bill, which will come to stage 3 in this chamber in the coming months, follows Lord McLean's recommendation from the Vale of Leven inquiry that we should act to ensure that staffing and skill mix is appropriate for each ward and where that is not the case, an escalation process is in place to respond. The bill provides an opportunity to enable a rigorous evidence-based approach to decision making on staffing, taking account of service users' health needs, including in infection prevention and control. It is important, too, that we recognise the role and voice of all our front-line staff in NHS Scotland. Porters, domestic and housekeeping staff, catering, reception and maintenance all have a critical role to play in effective patient safety. I will be giving further thought to how we can ensure that across all our health boards, those voices and expertise are integral to the work on infection prevention and control. Scotland's response to healthcare-associated infections is wide-ranging and a number of expert agencies are involved. Health Protection Scotland is responsible for undertaken surveillance and horizon scanning for emerging threats and seeking advice from UK and international organisations where required. When HIP, when HPS are made aware of threats, they produce guidance for NHS Scotland to prevent on-going transmission of infections. Healthcare environment inspectorate leads on independent inspections of every NHS acute and community hospital in Scotland. Since 2009, HEI has published 261 hospital inspections, as well as thematic inspections of theatres and invasive devices. The Scottish Government has underpinned those efforts by launching the mandatory national infection prevention and control manual in 2012, using a once-for-scotland approach and providing a framework for staff to apply effective prevention, infection prevention and control practice. It sets out the process that health boards must follow to manage incidents and outbreaks. We have led the world with the national infection prevention and control approach. It has been adopted by NHS Wales and there are calls for it to be adopted across Scotland. In conclusion, Scotland has made significant progress in the last decade on infection prevention and control. Sperd by the tragedy of the loss of 34 lives in the Vale of Leven, where C. diff was a contributory factor, NHS Scotland is now in a position to identify incidents and outbreaks much earlier and take immediate action. Infections are present in everyday life. We cannot avoid all infections, but we must ensure that our systems include horizon scanning for emerging infection threats and ensuring preparedness and resilience. I want to assure Parliament and through members of the public that a culture of improvement and safety is woven through our national health service and that I am committed to ensuring that our hospitals remain some of the safest healthcare facilities in the world. I thank the cabinet secretary for advance sight of her statement and also give our thoughts to the families on those benches. Public confidence has been shaken in light of recent events in Glasgow. What is now critical is that we see leadership and action to make sure that our hospital estate is safe and all measures are put in place to meet the best standards of infection control. I agree that, clearly going forward, the review will suggest lessons and recommendations for other hospitals, including the new Edinburgh SIP kids here in Edinburgh, around infection control measures and building standards above and beyond those currently in place. How will ministers make sure that any and all recommendations are taken forward by health boards? Will the cabinet secretary commit to the publication of any interim findings and recommendations? I understand that public confidence has been shaken, which is in part why I made the statement that I made, just to remind us all of the significant improvements that have been made in terms of infection prevention and control across Scotland and the steps that already exist so that we do not repeat what happened at the Vale where we do not see an outbreak until it has progressed quite considerably. That said, I am not by any stretch of the imagination suggesting that everything therefore is fine. Where we have infection outbreaks, that suggests to me that there is more that we need to do. I completely commit that, if there are interim recommendations, we will make those public, as well as our response that we will make public not only publish the AHEI report but also my response to that and the actions that I will take on that particular Cryptococcus matter and what AHEI tell us from that inspectorate report and the overarching review. Until we appoint the co-chairs, I cannot say because it will be for them to determine how long they might think that will be, but I will hope that they will agree a remit and a timeframe and an approach that we can publish. Within that, we can see where there might be milestones, where there will be recommendations coming forward that we can act on. I will certainly share that with the health and sport committee, but I am happy to share it more widely with members when we get to that point. I hope that that is helpful. Monica Lennon, to be followed by Alison Johnstone. Thank you, Presiding Officer, and I thank the Cabinet Secretary for Advanced Sites of her statement. The thoughts of Scottish Labour remain with the families of those patients who have died. What has occurred is no reflection on the hardworking staff working in the hospitals affected by those infections, but it is clear that NHS Greater Glasgow and Clyde have suffered reputational damage. A culture of secrecy has clouded the health board's communication, and we all agree that it has had an impact on public confidence. Staff and patients who raised concerns about cleanliness, infection control, building maintenance, workforce pressures and more have felt that their concerns were not acted on, and that is bitterly disappointing. In the interests of transparency, can I ask the Cabinet Secretary to update Parliament on how many patients have been affected by the infections referred to in her statement or any other rare infections, including how many patients have died, how many have received treatment and how many cases relating to hospital-associated infections have been referred to the Procurator Fiscal in the last 12 months? Cabinet Secretary? I am grateful to Ms Lennon for that question in terms of the detail that she is asking for in order to be absolutely certain that I provide the accurate detail. If the member is content and other members, I will write to you later on today with the answer to all those specifics, including the PF question, as far as we know that, and make sure that that is shared with the other party spokespersons on health, so that they too have that information. Ms Lennon knows that I have in previous statements in this Parliament recognised that our health board communications across NHS Scotland are at times not as good as I would want them to be. I personally take the view that if you have information, you should give it to people that there is nothing worse than a vacuum in which people fill with their understandable worries and anxieties. That is not an approach that I want to see our health boards adopting. We are working with them to ensure that communications are as transparent and detailed as it is possible for them to make, bearing in mind that they have an absolute duty in terms of the cauldicott guardian and other responsibilities, not to release any information that could lead to an individual patient being identified. That curtailes them to some extent, but perhaps not always across our boards to the extent to which they believe themselves to be curtailed. I am also aware of concerns that have been raised in the past in Greater Glasgow and Clyde. Some of those now are information that I have, and I will ensure that that information is passed to that independent review. I know that the individuals raising that information or raising those matters with me will make sure of that too, but that information in my hands I have given them the commitment that I will make sure that it is passed on so that that review has the benefit of historic information as well as current information and evidence that it may choose to take. Alison Johnstone is followed by Alex Cole-Hamilton. The cabinet secretary recognises in her statement that all NHS staff from clinicians to those involved in catering and maintenance have a critical role to play in effective patient safety. I appreciate that the cabinet secretary has said that she will give thought to how we can make sure that all those voices are heard, but given the pressure on staff who work in the NHS, what assurances can the cabinet secretary provide that staff will be given sufficient time for the expert training that they need, for the mentoring that they need, so that we can ensure patient safety? Part of that comes through the staffing bill that is currently working its way through this Parliament. That is why we are so keen to ensure that that legislation is also applicable in our social care settings, where, of course, safety, infection control and prevention and safety are as important as it is in our acute settings. Part of what I am thinking about is making sure that, in the standard committees and work that a board should undertake, as part of all those processes that I outlined, on what needs to be done in terms of infection prevention and control, that we are assured that maintenance and housekeeping and catering and those other important voices, if you like, are integral in the overall approach that a board takes in a hospital setting and elsewhere to infection prevention and control, and not seen as additional, but as central as the involvement of nursing and medical staff. That is simply about making sure that the individuals who would then be part of those discussions do have that time to add their particular expertise from the role that they play. Where there is additional training or support that is needed, I will expect boards to make that available. As Ms Johnson knows, I meet regularly with the chairs of our health boards to seek their assurance on those areas that I consider of utmost importance and patient safety. There can be nothing higher than that. In addition, the chief executive of NHS Scotland meets regularly with chief executives, and all those discussions are aligned to the key priorities that the Government has. We have that regular opportunity to get that assurance and to act where we believe that what we need to be done is not being done. Alex Cole-Hamilton, to be full by Emma Harper. The investigation into the water contamination incident at the Royal Hospital for Sick Kids in Glasgow was instructed by the cabinet secretary's predecessor on 20 March last year in answer to a question by Anna Sawa. That report was concluded in December and was given to the Government, but the Government only released that report this weekend. What was the reason for the delay? Why did that investigation take so long? And why did the Government choose to not release that information to Parliament and the general public until two months after they received it? Surely, if there are learning points for all of us, if we are all to work to combat the infection control, then time is of the essence. Cabinet secretary. Thank you. I am grateful to Mr Cole-Hamilton. As I am sure he will understand, having read the report, identifying exactly what was the source of the water contamination issue and taking the necessary steps to try and address that as an ever-changing situation inside that hospital is a large part of why it took the time for the work to be undertaken by HPS in order that they could produce conclusions and recommendations that they were confident of and that they also were assured that they had looked more widely for expert advice and support to allow them to get to that point. In terms of why we received the report, I was made aware of the report on the 21st of December and why it was published last week. I took the view, two parts to my view, I took the view that publishing it in the week before Christmas was not necessarily the most helpful thing to do and would be considered in a critical light. I also took the view that I had to be sure how it would fit and that HPS could see it fit into the work of the wider independent review. There was no intention to not publish, it was about making sure that we could align it with the independent review. I had hoped to be able today to say who would lead the independent expert review into Queen Elizabeth university hospital for the reasons that I have outlined. I am not able to do that. All of that was in part why we took longer than we would otherwise have wanted to do before we published the report itself. However, there was absolutely no intention, as evidenced by the fact that we have published the report and that I have given a commitment to implement the recommendations of that report, notwithstanding the independent review, to conceal anything. It is important that that information is available, understood and then acted on. I am quite interested that the minister is giving detailed answers, which I am welcome, but there are 10 more questioners to get through. Emma Harper is to be followed by Brian Whittle. Could the cabinet secretary confirm how the Scottish Government's approach to safe staffing will help to ensure patient safety as well as the delivery of high-quality and safe care across our hospitals and emergency services? The legislation on safe staffing is designed to ensure that there is a consistent approach across Scotland to understand the workload demands of any particular patient cohort at any particular time in terms of their healthcare needs, the workload demands and then the skill mix that is required to address those demands. Inside that is, of course, infection prevention and control, which, as Ms Harper will know from her own experience, varies between different patient cohorts, depending on what their presenting healthcare need is. That is a piece of legislation, notwithstanding that other colleagues will have ways by which they think that it could be improved. I think that we are all in agreement that it will provide that consistency of assuring and a methodology to ensure that workloads are understood in the context of presenting healthcare needs by patients. The skill mix is then understood, we have the right staff in the right place and we have a way of escalating if staff feel that they require additional support and that that is not being delivered to them. Brian Whittle, to be followed by Sandra White. Health and Sport Scotland has no regulatory powers to enforce the implementation of recommendations. For the confidence of staff and patients given in the seriousness of the situation, will the cabinet secretary commit the Scottish Government to implementing all of the HIS recommendations when they publish the health environment inspectorate report? Yes, I will. I also believe that the question of regulatory powers and the various bodies involved—Health Facility Scotland, Health Protection Scotland, Health Environment Inspectorate—will be part of that review. As I said, the focus is on Queen Elizabeth, but there are lessons for NHS Scotland about what more might we do in order to ensure a more joined-up approach to what needs to happen and where regulatory powers will be for the review to determine if they think that that is needed, then I am sure that they will produce those recommendations too. Sandra White, to be followed by David Stewart. The cabinet secretary mentioned in her statement the Scottish patient safety programme, which is helping to significantly reduce hospital mortality and, I believe, reducing avoidable harm at every stage of the care. Can the cabinet secretary provide an update on the hospital standardised mortality ratio figures for Scotland? Cabinet secretary? Yes, I can. The hospital standardised mortality ratio has shown a significant decline. It has decreased by 13.2 per cent in the four-year period January to March 2014 to July to September 2018. Of course, the Scottish patient safety programme helps to be one of the key drivers of that reduction, and we need to continue to see that improvement, which has been a steady decline since the introduction of some of the measures that I have outlined earlier. David Stewart, to be followed by Rona Mackay. Thank you, Presiding Officer. What lessons have been learned about patient safety in relation to new-build hospitals, specifically handover and maintenance of buildings? Cabinet secretary? There are some immediate lessons. There are some lessons in that HPS report, which was published last week. Some of those have already been picked up by NHS Lothian in terms of the new children's hospital for Lothian. There are other lessons that our directors of estates are working through with the chief executive of NHS Scotland in order to see—and with Health Protection Scotland and Health Facilities Scotland—what more can be drawn at this point from the HPS report in particular, but they will also look at the HGI report as well and see if there is anything further. That is what I meant when I said that, although the independent review is very important and its work will be of significance, there are recommendations that we can take forward at this point. I am happy once the HGI report is published to set those out specifically in terms of buildings and let members see what we are acting to do on those. Rona Mackay to be followed by Annie Wells. The Scottish patient safety programme has clearly contributed to a significant reduction in harm and mortality in our NHS. Can the cabinet secretary outline how this internationally renowned programme can continue to provide public assurance about the quality and safety of care that the public expect? Healthcare Improvement Scotland is the primary driver of the Scottish patient safety programme. It provides assurance in terms of its inspections and reviews and reporting of those, and those are published and can be used and seen by others. Some of the data that we produce in terms of overall general infection rates is also another area of assurance in terms of the continuing decline of C. difficile, MRSA and so on. Some of the other work that we will discuss with Healthcare Improvement Scotland, for example, on surgical site infections and other aspects of the Scottish patient safety programme, which members can see for their individual health boards, but there may be some merit in pulling some of that together for the health service across Scotland. Again, I am happy to have a look at whether that is something that is worth doing. Annie Wells to be followed by Ruth Maguire. As the cabinet secretary points out, front-line staff have a critical role to play in patient safety. Despite that, figures show that there was another 1.5 per cent cut in maintenance and estate workers across Scotland in the two years since September 2018. In NHS Greater Glasgow and Clyde, the numbers have reduced by nearly 19 per cent since 2009. What action will be taken to address that drastic reduction? Ms Wells is correct in the level of vacancies being carried in maintenance and, indeed, in some instances in domestic staff. I am very alert to that and have already asked for explanations from boards about exactly what they are doing. In addition, you will know that there is an annual operating plan that boards are required to produce, which shows how they are going to use the resource that they have. This year, it will be within an overall three-year financial planning cycle, but there will be more detail in the first year. We have been really clear about how we sign off that annual operating plan, and I will ensure that capacity—by capacity, I mean that staffing—is not being reduced in areas that are critical to infection prevention and control, and I include all those areas in that. Those plans, once signed off, will be published, so the member will be able to see what action we are specifically taking in those areas. Ruth Maguire, to be followed by Mary Fee. I am sure that across the chamber we agree that all staff are essential to ensuring patient safety. Can I ask the cabinet secretary to outline what impact a no-deal Brexit could have on NHS staffing levels and patient safety? The member will know that our current estimate is that, in terms of health and social care, just under 6 per cent of the current workforce are non-UK EU nationals, and that we have a significant number of non-UK EU nationals specifically in our health service. That figure is greater in different parts of the country and in different job roles. In our planning, in terms of our workforce needs, in some of the areas that Ms Wells identified and in other areas, it has to take account of the fact that we may not be able to retain all that workforce in the current climate of uncertainty. There are practical steps that we can take, and we hope to be able to set those out for the chamber soon in order to make good on our words, which are genuinely intended, that all of those staff are very valued by us and we want them to stay. However, there is an additional element to that, and that is how we attract into our health service some of those from EU countries that have traditionally come to work here. The member will be aware of the 80 per cent reduction at UK level of the number of nurses from the European Union and non-UK EU nationals not registering this year compared to last year to come to work in the UK. There are serious issues in terms of Brexit and serious uncertainty and anxiety being experienced by those who work in our health and social care services. We are trying to do what we can to reassure them that they continue to be welcomed and valued in our service. Last week, the cabinet secretary responded to my colleague Neil Bibby's question on infection control at the RAH in Paisley, saying that she shared his concerns about gaps in the domestic cleaning rotas. In light of that and other tragic cases in NHS Greater Glasgow and Clyde, does the cabinet secretary have any plans to review and update the national infection and control manual, which was launched in 2012? If so, when? That will be part of what the independent review considers. It will consider our existing measures, including that mandatory manual. In addition, I have asked our national clinical director and his to review what we currently have to see whether there are other improvements that we can make in the light of current knowledge to some of those particular steps. I do not know the answer to that yet. I am very mindful of the point that you make about domestic staff that Mr Bibby made and Ms Wells has made again. I do not think that I need anything reviewed before I can act to make it clear to boards that I do not think that it is acceptable to carry those levels of vacancy and maintenance and domestic and housekeeping staff. I do not think that that is acceptable. They are central to infection prevention and control. As central as any other bit of the workforce. We can act on that now, whilst we look at whether our current procedures require any updating and review as a consequence of our recent experience. David Torrance is to be followed by Anas Sarwar. Can the cabinet secretary confirm if there are measures in place to ensure that health boards promptly and effectively implement any recommendations made by independent reviews? Where a review is undertaken by Healthcare Improvement Scotland, it has a process in place for going back and checking that its recommendations and associated actions are completed. Indeed, it takes a view on whether the action board is suggesting that it should take our adequate to meet the recommendations that it has made. Where a review is external and the recommendations are to the Scottish Government, members have a means by which they can check that we as a Government are at what our responses to those recommendations are and how we are taking them forward. In addition, as I have said earlier, we have regular meetings with board chief executives, with directors of estates, directors of HR, directors of finance and me with the chair of health boards in order to pursue specific recommendations on a board-by-board basis or across the whole of the health service. I welcome the comments of the cabinet secretary today, but there have been clinicians and patients who have expressed concerns about the Greater Glasgow and Clyde statement that was issued on Friday, in which it seemed to imply that there was a limited scope to the cabinet secretary's independent review and also announced through reviews of their own. Can the cabinet secretary please take this opportunity to confirm that the review that she has announced has a broad scope that includes the maintenance and upkeep of the hospital since it was opened, and can she also outline what the three reviews that Greater Glasgow and Clyde are proposing to do, what they are, and that they guarantee that that will not undercut her independent reviews at work? Cabinet secretary, I am grateful to Mr Sarwar for raising that. It is disappointing that the board does not appear to have understood what I have said exceptionally clearly. Let me say it again. I absolutely can confirm that the scope of the independent review that I have commissioned is exactly as it is in the answer to the question that was laid and answered. It goes back to the design and takes us right through. Therefore, it will be because it complies with the Britain reports recommendations, it will be for the independent chairs to then take that scope, which is my commissioning, work that into a remit, decide for themselves where they will bring in expert advice, where they will seek evidence from, how they will seek that evidence, how long they think that will take them, what will be the opportunity for interim recommendations based on their work plan, if you like, and I would be asking them to permit that all of that is made public and I have no doubt that they would be happy to ensure that that is the case and that I would take that responsibility. In terms of Greater Glasgow and Clyde's reviews, my understanding, although I will make a point of double-checking this in order to confirm it to Mr Sarwar and to others if they are interested, is that one of their immediate reviews is on their current estate at Queen Elizabeth University hospital to look at whether there are additional maintenance and infection prevention and control measures that they should be taking now. There is another review in terms of flow through the hospital to ensure that they have infection prevention and control steps in the right place, if you like, as people flow through that hospital. However, as I said, I will make sure that we have the clear detail of that and make sure that Mr Sarwar and others—I will pass it to other Opposition spokespersons to make sure that they are clear on that. That, in my view, absolutely does not undercut the independent review but should feed into it. The independent review can take a view on those reviews and their conclusions. I note that that ends our statement. We are going to move on shortly to the next item of business on the human tissue authorisation bill. We will just take a few moments for members and the minister to change seats.