ON 16 MARCH, a few days after abandoning ‘contact, trace and isolate’, the UK and Scottish governments introduced three new measures to reduce the spread of Covid-19 and protect people. These have since become part of everyday language: self-isolation of those with symptoms; ‘social distancing’, particularly of the vulnerable; and shielding of those with suppressed immune systems.
Thirteen weeks later these measures, which had sounded re-assuring and sensible at the time, had failed to prevent 4,070 deaths involving Covid-19. Of those dying 77 per cent were over 75 and 50 per cent lived in care homes. This disaster can be explained by a failure to appreciate the importance of planning, as opposed to policy.
Two weeks ago, the Scottish Government released information on Silver Swan, the desktop influenza pandemic planning exercise for Scotland held in 2015. A review event took place a year later, a month after Cygnus, the UK’s influenza pandemic exercise. Both the report and the review are banal documents, but worth reading to understand just how poorly prepared Scotland was.
While both acknowledged that “pandemic Influenza remains the highest risk faced in the UK and it is recognised as the single most disruptive event facing Scotland”,neither display any sense of fear for viruses and the havoc that a pandemic might reap, nor, any sense of urgency.
Participants in the events did however raise a number of issues that have bitten government in the last three months: How to ensure adequate Personal Protective Equipment, how to bring retired staff back into service and how to preserve business continuity in social care services when “the back-up capacity in the public sector (particularly for care homes and day care providers) no longer exists” were all highlighted as areas needing action. The Scottish Government could and should have been better prepared.
The PPE failures of the first few weeks of the crisis, which continue for services like dentistry, are well known. Had mechanisms been put in place to enable health and social staff to remain on their professional registers after retirement, many more than the 247 reported so far might have so far been brought back into service. I know, I might have been one of them.
I left the Social Work Register last September because I objected to paying fees when no longer working. I raised the issues of what might happen in an emergency with the Scottish Social Services Council (SSC), copying in my MSP, who happens to be Nicola Sturgeon. My views were noted.
Similarly, there were no mechanisms in place to fast track the recruitment and training of new staff, a missed opportunity given the thousands of people who have been made unemployed. Mechanisms have now been developed, only to become operational after the peak of the crisis was over.
The reason these and other recommendations from Silver Swan weren’t actioned was because proper planning takes time and resources. Participants raised this at the events: “Many delegates made the point that resource pressures and competing priorities were having a significant impact on the ability to properly plan and prepare for a pandemic”. Instead of a national plan arising out of the event, local partnerships were left to produce their own “pandemic influenza plans or review existing plans to reflect the outcomes from this exercise.
Locally, it is key to agree how the pandemic response will be managed – whether by Public Health Incident Management Teams or LRPs (local Resilience Partnerships). There wasn’t even any agreement who should lead on pandemic planning locally.
There was no list of action points for national organisations like the SSSC, the Care Inspectorate or NHS procurement and no central co-ordination, although participants had identified this as crucial. Many participants said that the Scottish Government had a key role in setting the framework “to provide national direction, coordination and to optimise information gathering processes” as recommended by the World Health Organisation. Silver Swan is important, because the Scottish Government cannot claim it wasn’t warned. It is little wonder it was reluctant to release the reports until forced to do so under Freedom of Information.
The Silver Swan reports reveal a second strategic planning failure, which arguably had even worse consequences. The scenario discussed was 6 weeks into a pandemic and assumed flu had spread everywhere, with up to 50 per cent of people off work. Participants were asked to consider how to mitigate the impact of a pandemic at this stage, not how to prevent it spreading or how to protect vulnerable. Body disposal was prioritised over transmission. In over 40 pages, there is not a single reference to ‘social distancing’, ‘isolation’, ‘lockdown’, or any equivalent concepts. The possibility of controlling a respiratory virus, the measures needed to do this and their consequences, was never even considered. When the Scottish and UK governments launched their proposals for self-isolation, social distancing and shielding in mid-March, these were effectively new policies without a plan.
The explanation for this massive planning failure appears to lie in the run down and side-lining of public health. Their expertise is in controlling diseases and protecting people from infection, hence ‘Health Protection Scotland’. The idea that by scaling up contact tracing, testing and isolation we might have to able to limit the spread of a virus or stamp it out was never considered. Hence the lack of checks and controls at airports and why the UK and the Scottish Government have just spent 10 weeks re-inventing contacting tracing.
Last week, the Scottish Government responded to two questions from Green MSP Andy Wightman about pandemic planning. Asked when the Regional Resilience Partnerships, responsible for emergency planning, last ran a pandemic planning exercise, John Swinney, the minister responsible, replied: “All three Regional Resilience Partnerships (North, East and West) participated in the Scottish Government Exercise Silver Swan in 2015”. Asked when it last tested its local response arrangements as identified by the report on Exercise Cygnus, John Swinney obfuscated: “Scottish Government local response arrangements were tested throughout 2019, ensuring all SGoRR (Scottish Government Resilience Room) response team members were exercised”.
The conclusion appears clear: there had been no further attempts to prepare for an influenza pandemic since 2015, and most of the limited recommendations of the Silver Swan Report were never acted on.
While Scotland had no influenza pandemic plan in place at the start of 2020, on 12 February the World Health Organisation (WHO) published guidance about “the priority steps and actions” countries needed to take to prepare for Covid-19. Scotland’s membership of WHO is through the UK, but there is no reason the Scottish Government could not have acted on the advice to their staff “to use this unique window of opportunity to act immediately to assist all countries to rapidly detect, diagnose, and prevent the further spread of the virus”. Early communication of risk to the public, contact tracing, control of entry into the country and testing facilities – it’s all there.
Pillar 6 of the WHO guidance is on planning for infection prevention and control (IPC). Had even this been implemented, it might have prevented the deaths of large numbers of older people in Scotland, particularly in our care homes: “Assess IPC capacity at all levels of healthcare system, including public, private, traditional practices and pharmacies. Minimum requirements include functional triage system and isolation rooms, trained staff (for early detection and standard principles for IPC); and sufficient IPC materials, including personal protective equipment (PPE) and WASH services/hand hygiene stations”.
Instead of checking in February whether care home staff were trained, had the right PPE and had rooms available where they could isolate older people from other residents and staff, the Scottish Government left everything to the care home providers. Again, they can’t claim they weren’t warned.
This leads to what was arguably the Scottish Government’s single worst mistake during the pandemic. In mid-March they decided to discharge hundreds of older people into care homes from hospital without testing.
There were no checks made to ascertain whether care homes had effective isolation measures in place that could have served to quarantine these people. This mass discharge took place at the same time that the Scottish Government was promoting self-isolation for infected people (as if older people with dementia would necessarily be able to understand and describe any symptoms), social distancing and shielding, i.e. was ostensibly trying to protect the rest of the population. There was no consideration given as to whether it might not be best to shield the entire population of care homes, the most vulnerable in the country.
Last week, further evidence emerged that whatever the risks of discharging untested and asymptomatic older people to care homes, discharging them to poor quality homes was particularly reckless. Asked by Labour MSP Jackie Baillie “how many deaths from (a) confirmed and (b) suspected Covid-19 there have been in care homes that had a Care Inspectorate report score of (i) adequate and (ii) weak, and how this compares with the total number of deaths”, Jeane Freeman, the Health Minister replied:
“From 27 May, the Care Inspectorate began reporting on deaths in care homes, as provided for under schedule 1, part 9 of the Coronavirus (Scotland) (No2) Act 2020. In the week ending 31 May 2020, 213 care homes notified the Care Inspectorate of 289 deaths. This included a total of 76 suspected or confirmed cases attributable to Covid-19 across 44 services. Of those 44 services, 21 had at least one grade of weak or adequate at their last inspection”.
At the end of February there were 59 out of c700 care homes for older people in Scotland that had grades of 2 or less. They are disproportionately represented among those care homes where people are still dying from Covid-19, confirming that poor quality of care has been a major contributor to the number of deaths in care homes. However ill-prepared Scotland was, that element of the disaster for older people was still preventable mid-March. It should, as I argued last week, been central to the Care Inspectorate’s response.
Three months on, it is still not clear that the Scottish Government has appreciated the importance planning to protect older people in receipt of social care services, whether in care homes or the community.
At least on 22 June, the Care Inspectorate also informed care home providers that the NHS has set up a facility for every care home to have an NHS email address. This will enable secure communication and transfer of information between care homes and health staff. What that says is that very little information has been exchanged between the NHS and care homes during the crisis to date. There have been two separate systems without any effective mechanisms for working together; a proper plan might have addressed the issues years ago.
None of this inspires confidence that the care sector is prepared to protect older people in a second wave of the pandemic. Based on what has gone wrong, a plan to prevent the virus being brought into care homes by residents, staff or visitors is needed and there is now a lot of evidence in the public realm about how to do this. Unfortunately, the work of the Care Home Rapid Action Group “set up to monitor developments in the care home sector, reacting swiftly to developing issues and coordinating our wider package of support to the sector” is not yet public.
The Scottish Government also now need to consider what could have been done to protect the other 2,000 people who have died and prevent further unnecessary recurring in future. A significant number of those who died acquired the infection in hospital, although data on the scale of the issue is not yet public. What we don’t know is how many were in receipt of social care services in the community and what role these may have played in spreading infections. Nor do we know how many may have died for other reasons, the so-called excess deaths, after all but ‘essential’ services were withdrawn at the start of the crisis.
As the number of Covid-19 cases and deaths thankfully drop, it is more important than ever that pressure is kept on government to account for what has gone wrong and use this to inform a proper plan to protect older and other vulnerable people should Covid-19 return. Instead of policy and advice, we need firm plans and actions built around public health. That requires the Scottish Government to invest resources in planning across government and to assign public health the lead responsibility for pandemic planning.