Health, Social Care and Sport Committee

Meeting date: Tuesday, May 30, 2023

Official Report 693KB pdf

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Scrutiny of NHS Boards (State Hospitals Board for Scotland)

Our next agenda item is further scrutiny of NHS boards. Today, we will take evidence from the State Hospitals Board for Scotland. I welcome Robin McNaught, director of finance and e-health at the State Hospitals Board for Scotland, who joins us remotely.

We will move straight to questions. Sandesh Gulhane will ask the first questions.

I thank Robin McNaught for joining us. My first question is about translators. When it comes to mental health, being able to talk to a doctor, a psychiatrist or a nurse is obviously vital, but if someone does not speak the language, that is almost impossible. The Mental Welfare Commission for Scotland has said that access to translators might not be as good as we hope for. How are you addressing that issue?

We are moving forward with that through two separate streams. First, we are looking to increase availability of recognised translators for the languages with which we currently have issues in relation to patients on site. That is to ensure that we are not reliant solely on one translator and that we have back-up options available if somebody happens to be unavailable.

The second element that we are looking at relates to information technology systems. That is part of a broader exercise, but we have had some early success in our initial work in relation to automatic written or verbal translation through screens. That is part of a much more extensive digital inclusion programme, which is in the early stages of evaluation. We expect that the project could run for between three and five years overall, but an early element of it will involve providing a translation facility through a tablet or mobile device, because we have seen that that works successfully elsewhere. The technology is still developing—it is developing rapidly—but we want to be able to take advantage of it.

That is fantastic. That system could be used throughout the NHS once it has been developed appropriately.

I want to ask about patients who are told that they can move to less secure units. A number of patients are eligible to be transferred, but those transfers have been delayed. What barriers do you face in moving patients to less secure areas?

The main barrier is simply the availability of beds in medium-secure areas. If patients are held in our premises for longer than we would like them to be, that restricts the potential movement of other patients. Staff resources need to be focused on dealing with those patients when, given the other staffing pressures, we would perhaps like those staff resources to be spread more widely or prioritised elsewhere. The main obstruction is the availability of beds.

Is the issue that there is a lack of physical beds, or is it that there is a lack of staff to staff those areas?

My understanding is that the issue is the availability of physical beds in other sites.

My final question is about patients who are with you but have no real need to be with you. They are there because they have been for an assessment or review and there is no indication of how long they will be with you. What are you doing to move those patients along? Is it about the availability of beds and the ability to move people into different areas?

10:45  

The clinical teams work extensively with the other facilities daily to assess and forecast availability and when transfers can take place. Neither ourselves nor the other sites wish to be in a situation in which patients are not able to move on when they ideally would, so it is key that we make sure that the time that is spent with patients, the facilities that are available to them and the activities that can be undertaken when they are moving around our site are tailored appropriately so that they do not find themselves excessively restricted compared to patients who are with us on a longer-term basis.

One of the other recommendations in the Mental Welfare Commission’s report, which Sandesh Gulhane talked about, was that managers should ensure that patients and carers have the opportunity to attend or participate in MDT meetings. Can you update the committee on the progress that the state hospital has made on that recommendation?

Yes. It is and has always been recognised that it is important for the patient to be at the multidisciplinary team meetings. There was inevitably a slight issue with patients attending physically as we came through the Covid period. When Covid struck we made quick progress, compared to some other places, in bringing in automated ways of communicating internally and with the outside world, but there was still a bit of a delay with patients being able to engage with their clinical teams remotely if they could not meet in person on site. There was a bit of a dip in attendance during that time.

The Mental Welfare Commission’s visits to us were in November 2021 and, later on, in September or October 2022.

They were actually in August 2020 and November 2021.

Okay. Attendance at those meetings has been improving since then. One important aspect is that extensive targets and measures are controlled through what we call our performance workbook, and one of those targets is attendance at the care programme approach meetings. That has shown an improvement in recent months and we will continue to focus closely on it. The performance workbook effectively links our corporate objectives to our delivery plan, key performance indicators and equality outcomes, and through all of those aspects we will make sure that that—

I am sorry, but can I drag you back to the answer that I was looking for? You have explained what has happened with in-patients, but I am asking about participation of carers at MDT meetings.

Similarly, carers’ participation and attendance are much improved since the restrictions of Covid have been opened up. We worked with carers and provided some of them with remote facilities when we were encouraging engagement at that time. One or two of those carers continue to engage remotely, and there is continuing focus on managing travel to in-person meetings effectively. We are, however, moving towards more in-person meetings in this area and across all areas, and attendance at those has also been improving in the past six months.

Thank you very much. I pass to Evelyn Tweed.

Good morning, Robin. Will you update the committee on the progress that is being made towards opening a high-secure service for women at the state hospital?

Yes. A meeting is due to be held fairly shortly with, I believe, our chief executive and our medical director, who are meeting the Minister for Social Care, Mental Wellbeing and Sport and the mental health directorate to discuss the direction of that.

A multidisciplinary team from the state hospital undertook a two-day site visit to the national female high-secure service at the Rampton hospital in England. A small number of patients from Scotland—currently two—are at Rampton. The number has tended to be between none and three over recent years, and the current average stay is seven years.

The progress in relation to the state hospital is that there are clinical aspects that would need to be addressed on the individual treatment of those patients and a capital aspect. It has been estimated that the revenue cost for the state hospital to manage the clinical side—the teams that would be required and the location of the patients on the site—would be around £2 million, but significant capital investment would be required for us to ensure that the area in which the female patients were held on site was suitably restricted from the remainder of the site.

That is where some of the staffing cost comes for patient movement around the site. When the state hospital was built, just over 10 years ago, it was built on the understanding that it was an all-male facility. Because of the ward structure, capital expenditure would be required to place the female patients in a location that was safe for them, because of the nature of some of our male patients.

How does it work with the women who are at the facility in England seeing their family and friends?

I believe that support is given for families and friends to encourage physical visiting where possible, but I also understand that Rampton hospital has facilities similar to the one that we have to enable our patients to communicate remotely.

Do you foresee the opening of the new Cornton Vale prison having any impact on the high-secure treatment services for women?

It is hard to say, because the future needs are unpredictable. If the facility is deemed to be appropriate from a clinical point of view for any future female patients who require a certain level of treatment, that could assist. However, equally, without a dedicated female high-secure service, which has been initially costed and discussed further for the state hospital, it is likely that a facility such as Rampton would be required for certain female patients. Unfortunately, it is very much down to the individual case. The future service demand in that area is difficult to forecast.

I will pass to Sue Webber for questions.

Sorry, but I am a bit lost, convener.

You were going to ask about financial sustainability.

Thank you very much for drawing my attention to my contribution.

Robin, with the increasing cost pressures to which you alluded in terms of development, how can the State Hospitals Board ensure that it is financially sustainable in the medium and long terms while maintaining patient safety?

That is a good question. It is an area in which we feel quite pressured.

In recent years, we have managed our budget sustainably. We have achieved the levels of savings required and we have been able to take forward new spend and new initiatives where the support has been available. However, it is an on-going cycle. As we get the end of the current year, we are about to approach the sign-off of our year-end accounts, where we will have met our targets for the year. However, as soon as one year is complete, we are already working with budget holders on how to better control next year.

Our current forecast for next year is that we are within the 1 per cent that is permitted, but we are looking at a potential slight overspend in 2023-24, which we would then bring back in the following year. That arises from some one-off costs that we are looking to incur next year, potentially with one or two areas of uncertainty, particularly with regard to energy costs, which are of significant concern not only to ourselves but, I am sure, to many of the other boards.

At this point, we can only estimate what those costs might be, subject to possible price fluctuations and uncertain levels of usage—we do not know how things will be come next winter in terms of needs and the demands on energy. That is a significant cost pressure that we will be looking to manage within our budgets for next year.

The pressure on us is because of that and the resultant level of savings that we will require to achieve in the year, which is quite a bit up on the current year. In contrast to a number of the territorial boards and the other national boards, the specific pressure that we have is that our staff costs are significantly higher as a percentage of our total costs. With that being more than 80 per cent—around 84 per cent—of our costs, it does not leave a huge number of other costs where we can look to make further efficiencies beyond what we have already been doing in recent years.

There has been support in the past two or three years. In the context of national budgets, the level of costs that we are talking about—for example, on the energy side, we are saying that it might be a pressure of an additional £500,000 for us next year—is not a significant amount, but it is a significant element in the context of our total budget. Where certain individual pressures have arisen, we have been successful in getting additional support through. However, the strong feeling that we are getting from budgetary discussions for 2023-24 is that the national pressures in the coming year will be significantly more than last year, which puts additional pressures on us, including on the infrastructure side of things, where there is a significant amount of work on, such as the backlog maintenance of the site. As I mentioned, the site is more than 10 years old now and it is at the stage where a rolling programme of maintenance is required, which is not insignificant.

We got an additional level of support—just over £400,000—last year, when there was some funding available, and that was of a lot of use to us. However, ironically, not long after that funding was made available, there was a communication asking whether, if the spend was not yet committed, it could be paused because some of the national moneys were being pulled back a little.

To ensure sustainability—we do discuss this at our quarterly meetings with our liaison team—when we know that there are areas of additional pressure coming that have not been highlighted before, our main focus is on bringing those up at the earliest stage possible and discussing any additional funding routes that might be available.

As I said, in some areas, we are looking at sums that are important to us but that are not significant in the context of national budgets. For example, as I mentioned to your colleague a minute ago, a lot of work is required on the digital side of things. There is a significant amount of development that we want to do, particularly for the patient side and digital inclusion. However, we need to set out perhaps a five-year programme to say what funding will be required, because we are looking at spending hundreds of thousands of pounds on IT equipment and additional staffing to manage that side of things.

Our main focus will be on engaging very strongly with individual budget holders and ensuring that all the budget holders are very aware of the pressures and are coming to us with initiatives to take matters forward.

Robin, with 84 per cent of your budget being used for staffing and workforce costs, you have a very small envelope to try and find efficiency savings. Given the backlog of maintenance that you talked about, will you have to put on hold some of those projects, and what risks does that present to your facility?

11:00  

I would say that none of the projects that we would be putting on hold at the moment is a priority that would put anything at risk. Those that we were able to bring in towards the end of last year—with the additional £400,000 that I mentioned—were such that we were able to bring some areas through. It tends to be more about looking a year or two ahead, when certain things are coming to end of life or, if it is the IT side of things, to end-of-life support. We would then make sure that we brought those to the attention of the funding teams.

We have a strong programme through which we prioritise matters in relation to patient safety and risk as the essential spends. Other spend will then flow as funding permits.

I will ask another quick question. The “Independent Review into the Delivery of Forensic Mental Health Services” recommended

“that the State Hospital introduces charges for the care and treatment of people from Northern Ireland.”

Given the small number of patients from Northern Ireland in the state hospital, will that generate much income? Can you estimate it?

At the moment I would say that it will not, on the basis that although we had initial discussions with our colleagues in Northern Ireland, the stage of those discussions is such that our chief exec is referring the matter back to St Andrew’s House for further discussion. We got quite well into discussing matters with them, but they are reverting to what they see as the position when the hospital was established, which was before the time of any of us who are now in management. They state that there was an understanding between Northern Ireland and Scotland that that support would be given without charge. Our chief exec is now picking up with the minister on that position to try and take things forward. That discussion will now need to be taken to a higher level than between our board and our Northern Ireland colleagues. We are making no assumptions of income at the moment.

When was that discussion reverted to the Scottish Government and ministers?

I am afraid that I do not know the exact time. Our chief exec discussed it at one of our quarterly liaison meetings, which would have been during 2022, but I am afraid that I do not know the exact date.

It would be helpful for the committee to have that information, if you would not mind writing to us with it. We would probably look to pursue an update on that.

Good morning, Robin. I am interested in some of the key performance indicators that the State Hospitals Board for Scotland publishes. When I was on the health committee in the previous parliamentary session, we talked about patients being offered an annual physical health review. It looks as if the target is 90 per cent but that only 51.78 per cent is being achieved. What actions have been taken to address that specific key performance indicator in relation to the annual physical health review?

That has been a strong focus through the clinical teams. I am looking at our current KPIs as reported to the board and I am pleased to see that our last update on the annual physical health review now has it showing up as green in our red, amber and green status indicator. The level has therefore now reached the required target for the teams. Our board expressed concern about that and there was then a focus from the clinical teams to ensure that those reviews were taking place. Again, it was somewhat affected by Covid, but that is now back on track.

When Professor Lindsay Thomson came to the committee, I asked her about the challenge of overweight and increased body mass index in patients and how to support them to have a healthier weight. Professor Thomson’s said that the on-site hospital shop had made a decision to have 80 per cent healthy foods and 40 per cent unhealthy foods, whereas other places were doing 50:50. That was a goal. At the moment, I am reading about ultra-high processed foods in a book by Chris van Tulleken, in which he talks about the correlation between UHP foods and obesity. How do you support people when activity might not be easy to achieve and groceries are brought in by family members? That issue was highlighted the last time a state hospital representative was here.

It is true that that is an issue, and perhaps it has two aspects. There is the on-site shop and families and visitors bringing items in, and there is availability of and participation in activities on site.

With regard to the shop, that policy has continued and the proportion of unhealthy items there is significantly down. We have a supporting healthy choices working group that works closely with patients and the shop to monitor those changes and take the policy forward. The changes have been welcomed and have not caused us any issue at all. Patients have been quite pleased with the new options and the new ranges that are available on site.

The group is also working far more closely with visitors in terms of giving feedback to ensure that what is brought in is more compliant with those changes and that quantities of anything that is perceived to be on the less healthy side are reduced. In most cases, the group is trying to eliminate the high-sugar drinks and so on that some people were trying to bring in.

That team also has a strong focus on the on-site physical activity programme. In fact, about a month ago we had a week with annual sports awards for patients, where we rewarded patients for participating in sporting activities on site. Taking forward things like that is seen as important to get the patients to engage with the trainers and the team in the sports area and to get them participating in as many sports as possible, some of which are new to the patients. They get fairly simple awards, such as certificates, but the patients really got engaged with that and participation levels were up on the previous year, so the awards will form a key part of the programme in the future.

That cannot take away from the fact that BMI is a significant challenge, which is shared with other high-security settings. It is certainly a challenge that we cannot take our eye off.

Do you measure the activity of individual patients in the state hospital?

Yes.

Okay. I will ask another wee question. We have asked other boards how they will achieve net zero. I am interested to hear what the state hospital is doing to take forward net zero activities.

I am pleased to report that we are well on target with that. Over recent years, our estates team has been looking very closely at all the requirements for net zero and building towards it. We are already well ahead of where we intended to be with regard to our targets and have no significant concerns about failing to meet them.

Recently, we have done quite a lot on electric vehicles, with new charging points on site and new electric vehicles in our fleet—moving to electric those vehicles that we use externally and those that just move around the site to deliver goods to various areas.

We had been looking at the potential for installing a wind turbine on land close by. In recent years, that was dismissed on economic grounds, but we are revisiting it because circumstances have changed and some of the costs that were there before are now more manageable—so we will potentially look at that too, although it is much further down the line.

Our estate team reports that the initiatives that it is currently taking forward are on track for what is in our net zero targets. We are very pleased with that performance.

I will ask one final wee quick question. If someone is transferred to the state hospital and is then relocated to another less secure facility, do you measure that as part of performance measurement? Is that part of tracking patients’ movements?

I am sorry—I do not quite understand. Do you mean, as a performance indicator?

Yes. I assume that, once someone is admitted to the state hospital, there is the potential for them to be transferred to a less secure facility, as part of their progress. Is that monitored?

It is. I am sorry. I did not quite pick up on that at first. I apologise for that.

We also measure whether certain processes are followed each time patients are transferred and whether we have made sure that everything is in place before, during and after those transfers—for example, that appropriate concerns are discussed and that everything is in place with the receiving facility before a transfer takes place.

Before I call Sandesh Gulhane, as I asked you a question about it, I put on record that, when I was Minister for Mental Health, I commissioned the independent review of the delivery of forensic mental health services.

Emma Harper asked about healthy weight. I am keen to ask about smoking and vaping. What are your rates of those? I ask because rates are very high for people who have mental health issues. In addition, what are you doing to reduce them?

We have no smoking or vaping. It is a closed site for patients and staff.

It looks as though the state hospital having done so well in that regard has come as a surprise to you.

It has.

We move to Gillian Mackay for the next theme, on staffing, culture and governance.

Good morning. I imagine that working at the state hospital can differ greatly from working in other health boards. In your opinion, what particular pressures do staff at the state hospital face, how is that likely to affect their wellbeing, and what steps is the board taking to address that?

That is a good question. Inevitably, particularly for the nursing and medical staff who work closely with the patients, and given the unpredictable nature of a number of our patients, a significant element of stress can impact on our staff. That is reflected when we monitor the reasons for staff absences. Stress features in those.

Sometimes, regrettably, staff get into incidents with patients—for example when restraint is involved—and occasionally get hurt. Obviously, that is of concern to us. We focus very much on patient wellbeing but also on staff wellbeing. In such instances, there is strong support working with those members of staff during their absence and when they return to work—whether they come back directly into patient contact or into other areas of work first.

11:15  

During the Covid period, we set up a dedicated staff wellbeing centre, with a number of staff dealing with that specifically. Although, at the time, there was a feeling that that was being brought in for the Covid period and would not necessarily remain thereafter, we decided to keep it in place and take it forward. That staff wellbeing centre is now a dedicated area where staff can go during certain periods to meet people and have a supportive chat. There are activities available to enable them to relax and switch off a bit. There are periods when there are services available to them—an example is physiotherapy consultations. There has been very good feedback from that in relation to staff wellbeing, and we will continue to keep a focus on that.

That was initiated using a piece of specific funding, but it is an area that we want to focus on as part of our business as usual. In common with other boards, we have found that a number of ways of working and other aspects that have come out of the Covid period are now seen as positive developments, which we want to keep moving forward with. The staff wellbeing centre is certainly one of those.

That is great—thank you.

The committee has focused on recruitment as well as retention. In your submission to the committee, you highlight that

“A key element has been on education around the unique offer TSH can give for the opportunity of a career in forensic mental health care, including continuing training and development.”

You said that that

“is proving to be a successful campaign for newly qualified practitioners, and for students expected to qualify in September 2023 with a growth in applications from social media campaigns.”

Will you say a bit more about the success of that campaign and how you think it could be replicated in other areas of the NHS?

That is an interesting question. It is an aspect that is quite new to us. We have had issues with recruitment, which has been a challenge for us over recent years. The social media side of things is new for us—we have not had a big presence on social media, perhaps for obvious reasons, given the nature of the site and our patients. However, we have used social media increasingly for recruitment. That was based on feedback from new recruits, who told us about the importance of social media. That has been recognised and social media now plays a significant part in our recruitment work.

Another supportive element relates to induction and peer support and how that develops once staff have been recruited, on which we were perhaps not as strong as we could have been in the past. There has been a focus on the development of a peer support network, on the clinical and the non-clinical side of things throughout the organisation. We have delivered training sessions on that in 2023, and we now have a number of staff who are trained as peer support workers, who can provide such dedicated support. That has been seen as being very supportive of the initial recruitment development. I do not know how strong that is in other boards; perhaps that could be looked at.

That is great—thank you.

I want to touch on the fact that the sickness absence rate at the hospital exceeds the 5 per cent target—it is 7.68 per cent. To what do you attribute that? What additional support has been provided to improve the mental health of staff?

Yes, the sickness absence rate has risen. It was at that level a little while ago, then it came down. It has gone back up to the level that you mentioned.

We are now looking at some of the cases to get more clarity with regard to the reasons behind them and to try to address and pre-empt what might be causing absences. This is still in its early stages, but someone on our human resources team is focusing purely on that issue to see what has changed in this respect. In some cases, is it just the impact of the return to physical working? Some staff have been working from home for two years, and they have come back to physical working, only to find that things are a bit different and that they have needed a bit of extra time. That has certainly been the case in one or two areas, and it is seen as a potential cause for some of the increase. However, our human resources team is focusing specifically on the issue.

I should point out that the upturn to the current percentage is quite recent, and we need to see how things progress over the next two or three months—say, through the next quarter—and work on that basis. It is slightly frustrating, though, because we had got things down to a good level from the higher level that they were at a few years ago. When the numbers start to creep back up like this, it becomes a strong focus for us and something that we need to address.

Will you be able to share your findings from your work in this area once the causal factors become more obvious?

Yes, I am sure that that can be done.

That would be great.

I call Emma Harper for a brief supplementary.

I will be brief. I want to go back to what you said about induction, orientation and ways of welcoming, developing and retaining new staff. Previously, I was a clinical educator and I was responsible for developing and delivering an induction programme for all new staff. Do you get to work with other boards and see how they are delivering certain programmes? I am talking about training and induction not necessarily for mental health staff but for other practice, too, because it feels, sometimes, that the state hospital is quite separate. What do you think about connecting with other health boards?

It is an interesting area, with two aspects that I would highlight. First, I point out that quite a number of staff who have joined our human resources team in recent years have come from other boards and have been able to bring some of their learning and knowledge from those boards with them. At the same time, it is also something that we strongly encourage, and more so in recent years, not just on the staff recruitment and HR side of things but across other areas such as e-health, procurement and so on.

As you have said, ours is a stand-alone site, and we are quite different from other boards. In the past, there might have been a risk of our being faced with something and thinking that we were alone and that we had to work out how to deal with it ourselves, but in the current culture we are really driving towards ensuring that we work as much as possible with other boards and that we are not reinventing something to find a solution that already exists—or, indeed, vice versa. Perhaps we can help other boards, because we feel that we have developed things that could be of use.

The level of collaborative working across the site is significantly higher, too, not just because of service-level agreements and other areas of mutual working but because of the engagement that is happening at senior management and director level and the work that we senior executives are doing with colleagues on other boards or as representatives on national boards, peer groups and so on. We have really pushed that; indeed, we have made it almost a specific target for directors and management to do as much as they can on a collaborative basis, where that is possible.

David Torrance has questions on Covid recovery.

What impact did the Covid-19 pandemic have on patients at the state hospital and their treatment?

Just to go back to the previous question, we were perhaps almost unique in the sense that most other boards’ service delivery could or had to change during Covid but ours could not. We could not say to the patients, “Right, we need to let you go and we’ll see you in two years when this is over.” The patients remained on site and their care had to continue, so we had to ensure that we had the staff to provide that care.

In the early stages, there were times when the patients’ movements on site were more restricted and they had more time in their rooms, which is not something that we want—we want them to be out of their rooms and as active as possible. However, in the early stages of Covid, their movements were very restricted and they were not able to get around so much, but their treatment continued in the way that it should have continued. The clinical teams faced the issues of masking and so on—from the early days, extensive work was done to ensure that, as quickly as possible, as many staff as possible were fully operational in the patient areas with the appropriate personal protective equipment. That was put into place quickly and, from a clinical perspective, the staff were able to continue to work effectively, as they had been doing beforehand. However, obviously, beyond the direct clinical treatment, the supportive aspects such as activities and so on were much more curtailed until the restrictions eased.

Just before Covid, we were going to implement a new version of our clinical model. The timing was unfortunate, because that had been evaluated and was all set to go ahead just before Covid hit. The new clinical model involves locating the patients in a slightly different manner around the site—for example, patients who are ready for transfer to other sites will be located in one area rather than spread around different hubs and wards, so that they share more common experiences. The new clinical model had to be put on hold during Covid and it is only now being implemented—that got under way a few weeks ago and is currently in progress. Had the new clinical model come in before Covid, that would have had a significant benefit for the patients, but that benefit was delayed by a couple of years because of the pandemic.

The patients were never at risk of not having the appropriate clinical supervision or medication or anything like that, although physical activity was strongly curtailed during the period. Thankfully, we have been able to get that fully up and running again.

What progress have you made on the 11 recommendations in the report “Forensic Mental Health Services’ Response to the COVID-19 Pandemic”?

Progress on those recommendations is on track—that is monitored through our quarterly reporting to our liaison team. The clinical teams are pleased with where they stand on that. The issue is closely monitored through our performance directorate and the board, and we do not have any issues or concerns about those at this stage.

Thank you.

I want to go back to the first question that David Torrance asked. Has there been an impact on patient wellbeing as a result of the Covid pandemic? Has the pandemic exacerbated some patients’ problems and made it more difficult for them to have a safe transfer to lower levels of security?

11:30  

Unfortunately, that is very difficult to assess, because every patient is different. Just like everyone else, patients have been affected in various ways. The important thing is that every patient has an individual care plan and that our clinical teams do not look to treat everybody in a set way, no matter how they present and so on. During the Covid period and after it, where there were any concerns about an individual patient, whether those arose as a result of Covid or before it, as a result of other issues, those were addressed and given the appropriate levels of treatment.

That is our key focus—the clinical teams spend their days making sure that the approach is correct on a patient-by-patient basis. There is a strong focus on our patient partnership group, which has board and senior management involvement. The directors are also engaged in keeping track of what the clinical teams are doing and getting regular feedback.

To be honest, as a non-clinician, it is impossible for me to answer that question, but I am sure that even the clinicians would be hard pushed to say whether certain specific patient issues arose because of Covid or were exacerbated as a result of it. The important thing is that, however the issues have arisen, the patients get the treatment to ensure that they are addressed, and that is very much the focus of our clinical teams.

Thank you very much, Robin. The committee looks forward to receiving the follow-up information that you have committed to provide us.