Scotland’s Integration Joint Boards (IJBs) face considerable financial challenges and immense pressures on their workforce, says public spending watchdog Audit Scotland.
IJBs have reached the point where significant transformation will be needed to ensure the long-term capacity, financial sustainability and quality of services individuals receive.
IJBs plan and commission many community-based health and care services. Demand for these services is increasing, in part due to demographic change and support for people with increasingly complex care needs.
The number of care hours for those aged over 65 reached nearly 25 million in 2021/22. The proportion of care services reporting vacancies increased by 11 per cent to 47 per cent, with a 30 per cent turnover of staff each year.
Most IJBs underspent on providing services in 2021/22. This was largely because of difficulties in recruiting staff, which led to unplanned vacancies, and pandemic-related reductions in service provision. The reductions in service provision were likely to have contributed to an increase in unmet health and social care needs.
In 2021/22 IJBs returned significant surpluses, with reserves doubling to over £1.3 billion. This was mainly due to additional funding received late in the year for specific policy commitments, including Covid-19. The Scottish Government are currently exploring options to recover around two-thirds of the unspent Covid-19 money held in reserves.
Across Scotland, IJBs have a combined projected funding gap of £124 million for 2022/23.
To be financially sustainable in the longer-term, IJBs must reduce their reliance on reserves. All IJBs must put in place detailed plans that clearly show how they will achieve the needed ongoing savings on a recurring basis and support urgently needed service transformation.
William Moyes, Chair of the Accounts Commission said: “Change is needed now – it cannot wait for a National Care Service. Action is needed to tackle funding pressures, which are under increasing stress from rising demand and cost pressures.
“The workforce challenges are considerable, with mounting unmet need.
“We need to see services focus on prevention, with appropriate funding in place to transform the way services are delivered and to improve lives. “
Local government organisation COSLA agrees.
COSLA Health & Social Care Spokesperson, Councillor Paul Kelly, said: “Today’s report from Audit Scotland is concerning and highlights the enormous pressure our health and social care infrastructure is under.
“People across Scotland rely on vital health & social care services every day, and it is critical that there is meaningful investment in the system which ensures their long-term capacity.
“We must ensure focus remains on front-line service improvement and sustainability, rather than the bureaucratic structural change presented through the National Care Service Bill.”
Common Weal and STUC call for pause to National Care Service legislation
Scottish think tank Common Weal, along with the Scottish Trade Union Congress, has launched a joint letter to the First Minister calling for the National Care Service Bill to be paused (writes NICK KEMPE).
Since Common Weal supported calls from the Trade Unions to pause the bill at the beginning of December many other organisations have done the same. Until now, however, smaller organisations have had a limited opportunity to make their views known and there has been very little joint action. The idea behind the letter, which you can read here, is to change that and to show the Scottish Government the degree of concern across Scotland.
The NCS Bill has now been considered by various Committees of the Scottish Parliament and MSPs should now be aware that there is very little enthusiasm or support for it in its current form. The hearings of the Finance and Public Administration Committee received a large amount of media coverage, not least because SNP MSP Michelle Thomson broke ranks and made some scathing comments.
The Committee’s report on the Financial Memorandum accompanying the bill, published at the beginning of December, was highly critical about the absence of costings. It highlighted the absence of costs for the creation of the new service, including VAT liability, transfer of assets and staff and the creation of a health and social care record, as well as the proposal to introduce major policies “via secondary legislation or business cases which cannot be subject to the same in-depth and formal financial scrutiny as Financial Memorandums to bills”.
It called on the Scottish Government to provide the necessary financial details at least two weeks prior to the Stage 1 consideration of the bill in March – giving very little time for any outside organisation to comment/brief MSPs
The majority report published last Friday here from the Delegated Powers and Law Reform Committee – don’t be put off by the name – added to the concerns about the lack of information and that the Scottish Government is “setting a dangerous precedent, undermining the role of the parliament.” Its reason for concluding this (the two SNP MSPs on the Committee dissented) was:
“The Committee is concerned there is insufficient detail on the face of the Bill and within the Bill documents to allow for meaningful parliamentary scrutiny. Given the far-reaching nature of the proposed reforms the Committee is mindful there is a real risk of letting down those the Bill is intended to help by allowing Scottish Government ministers to use delegated powers instead of primary legislation to introduce core and as yet unknown provisions. The Committee believes the current approach significantly reduces the threshold for parliamentary approval and prevents MSPs from bringing forward detailed amendments”.
Far from increasing democratic control over care services, as we advocated in Caring for All, the NCS Bill is now threatening to undermine democracy, whether at the local level by removing control from local authorities, or at the national level by handing unprecedented powers to Scottish Ministers.
The Scottish Government needs to have a fundamental re-think about what it is proposing and how its engaging with civic society while at the same time secretly working with KPMG to design the Target Operating Model for the NCS. If you are part of an organisation which has a stake in the future of social work and social care in Scotland, please ask them to support the letter. As an individual, please also consider contacting your MSPs asking them to support the call for a pause.
Nick Kempe – Common Weal Care Reform Group
COSLA’s Health and Social Care Spokesperson, @cllrpaulkelly, commented following the release of the letter from @ScottishTUC and signed by a number of organisations which has called for Scottish Government to pause the National Care Service Bill:
The Scottish Government’s resilience committee (SGoRR) met again yesterday to discuss the challenges facing health and social care this winter.
Chaired by First Minister Nicola Sturgeon, the meeting focussed on hospital occupancy, and the measures being taken to reduce levels of delayed discharge and find care placements and packages for those clinically fit to leave hospital.
The most recent A&E statistics have shown a continued improvement in performance, with 70.1% of people being admitted, transferred or discharged within four hours – the best performance since May.
Additional funding has also been made available Health and Social Care Partnerships who have the responsibility of providing care packages for those in their locality, to provide 300 interim care home beds for people who no longer need to be in hospital. So far, 162 people have entered interim care facilities paid for using this additional funding.
The SGoRR meeting was also attended by the Health Secretary, other cabinet ministers, the Chief Medical Officer and senior representatives from NHS boards, COSLA, Integration Joint Boards and the Scottish Ambulance Service.
The First Minister said: “The continued improvement in A&E performance is something to be welcomed, but there is still much work being done on safely freeing up hospital capacity and easing pressures elsewhere in the system. That is why we are continuing to pursue a range of measures to enable people to leave hospital as soon as possible when it is clinically safe for them to do so.
“We remain indebted to the health and social care staff in all parts of Scotland who have continued to do an outstanding job, despite the extra challenges that winter has presented.”
Campaign aims to help fill vacant posts across Edinburgh
A marketing campaign to support the recruitment of more adult social care workers in Edinburgh has launched this week, to help address the high level of vacancies in the sector.
The campaign – titled ‘there is more to care than caring’ – will raise awareness of the career opportunities available in adult social care and encourage people to apply. Activity includes radio, outdoor and digital advertising, highlighting the important work done by adult social care workers.
It is part of the Scottish Government’s commitment to attract more people to work in adult social care, retain existing staff and raise its status as a profession. This builds on a pay uplift for all adult social care staff which guarantees them a minimum of at least £10.90 an hour from this April.
Social Care Minister Kevin Stewart visited Leuchie House in North Berwick yesterday to see the work it does to support people affected by stroke, multiple sclerosis and neurological conditions.
Mr Stewart said: “Working in adult social care can be challenging but offers the opportunity to have a hugely positive impact on people’s lives on a daily basis.
“We are increasing pay, improving terms and conditions in the sector, and developing clear career pathways for the workforce, ahead of the introduction of the National Care Service. This will lead to more rewarding roles for the existing adult social care workforce, and for new entrants to the profession.
“This campaign highlights that while relevant experience can help, it is core interpersonal skills such as communication, compassion, empathy and respect that are most highly valued.
“If these are skills you possess then adult social care could be the career for you.”
Councillor Paul Kelly, COSLA Health and Social Care spokesperson, said: “COSLA Leaders are clear that addressing the pressures in our health and social care system needs a whole system approach which is not just about delayed discharge.
“All partners need to acknowledge that longstanding recruitment and retention issues place significant constraints on Health and Social Care Partnerships ability to deal with challenges and we must urgently invest in fair work to ensure that progress can be made in building and developing the social care workforce.”
RCEM launches campaign to resuscitate Emergency Care as polling reveals the public’s lack of confidence in UK government’s policies to tackle the crisis
The Royal College of Emergency Medicine has outlined five priorities for UK governments to tackle the crisis in Emergency Care, after polling carried out by Ipsos on behalf of the College found 59% of respondents expressed a lack of confidence that the UK Government have the right policies to tackle long patient waiting times in A&E departments in hospitals.
The campaign launches amid the worst Emergency Care crisis on record, as reflected in A&E performance figures across all four-nations.
Five Priorities for UK Governments to #ResuscitateEmergencyCare lays out what UK governments must focus on to tackle the crisis, improve patient care, retain staff, and prevent harm.
The five priorities are:
Eradicate overcrowding and corridor care for patients
Provide the UK with the Emergency Medicine workforce it needs to deliver safe care
Ensure our NHS can provide equitable care to emergency patients
Focus on evidence-based interventions to tackle overcrowding
Introduce meaningful and transparent metrics to facilitate performance and better outcomes for patients.
More patients than ever before across the UK are facing long and dangerous waits. It has been widely reported that crowding, corridor care and long waiting times for patients in Emergency Departments are associated with patient harm and patient deaths.
The public are acutely aware of the issues and pressures in A&E departments, with an Ipsos poll, commissioned by the College, showing that:
Nearly half of those polled by Ipsos expressed that they did not feel confident they would be treated in an appropriate area if they personally had a medical emergency in the next week that required them to attend their local A&E.
Meanwhile, two-thirds did not feel confident that a hospital bed would be available if they personally had a medical emergency in the next week and needed to be admitted to hospital.
Dr Adrian Boyle, President of the Royal College of Emergency Medicine, said: “There can be no denying it; the Emergency Care system is failing and not functioning as it should.
“We can argue about numbers and calculations of excess deaths or we can work together and take the urgent and necessary action to prevent any further harm or deaths occurring. Patients and staff are rightly concerned, they deserve to see honesty and meaningful action from our political and health leaders. This is our plan to tackle the crisis.
“The roots of the problem lie in the lack of adequate capacity in hospitals, lack of staff, and lack of social care in the community. Since 2010, more than 29,000 beds have been removed from the system despite the increasing complexity of population healthcare needs.
“While for many years, social care has faced devastating cuts, meaning patients medically ready to leave hospital do not have the support they need to leave – so they reside in hospital for longer than they should preventing others from being admitted.
“The inability to discharge patients and the inability to admit patients is causing severe exit block – our hospitals are completely gridlocked, meaning Emergency Departments are becoming dangerously crowded and patients are facing extremely long waits.
“These delays and crowding impact heavily on the existing workforce, which has been stretched to its limit for too long. There are significant shortfalls of staff in Emergency Medicine; Emergency Departments across the UK are not safely staffed and the public recognise that.”
Polling shows that just 18% of respondents surveyed agreed their local A&E had enough staff to care for them in a timely way while just 23% expressed agreement that their local A&E had enough staff to care for patients in a safe way.
Dr Boyle said: “Clinicians are doing all they can and what they can to bridge the gap between an under-resourced system and the quality of care patients require, but it’s plain as day to anyone that we have too few staff.
“We are in a dire place right now, but it is fixable. We know what needs to be done to tackle the crisis and improve patient care, but this requires sustained and continued cross-party political willingness and investment to engage with the issue and tackle it root and branch.
“Our campaign to resuscitate Emergency Care shows the way forward for governments, with five key priorities to address. The first priority must be on improving flow through our hospitals to end corridor care and overcrowding.
“UK governments must open more staffed beds, where safely possible, and run hospitals at no more than 85% bed occupancy. In tandem with this, UK governments have been right to invest in community and social care but this can no longer be short-term; we need sustained expansion, resource and funding for social care to ensure patients are discharged safely and promptly when their medical care is complete.
“There must also be recognition of the impact of the crisis on the workforce, they do excellent work, but they cannot continue to flirt with burnout or this will lead to burn away. UK governments must urgently work to retain our highly-skilled frontline clinicians – but they must feel supported, listened to and valued.
“Lastly, performance is at an all-time low and metrics are currently documenting a failing service. Together with the expansion of capacity and resourcing of social care, we must see a renewed effort to improve performance and meet the four-hour waiting time target in Emergency Departments.
“We cannot afford to be in a performance vacuum any longer, metrics must have meaning and drive improvement and better patient care. In England, this must start with monthly publication of 12-hour waits from the time a patient arrives – as it is in the rest of the UK – rather than the misleading and dishonest current metric which measures 12-hours from the time a decision to admit a patient is made.”
Scottish Government campaign aims to help fill vacant posts
A marketing campaign to support the recruitment of more adult social care workers has launched To help address the high level of vacancies in the sector.
The campaign – titled ‘there is more to care than caring’ – will raise awareness of the career opportunities available in adult social care and encourage people to apply. Activity includes radio, outdoor and digital advertising, highlighting the important work done by adult social care workers.
It is part of the Scottish Government’s commitment to attract more people to work in adult social care, retain existing staff and raise its status as a profession. This builds on a pay uplift for all adult social care staff which guarantees them a minimum of at least £10.90 an hour from this April.
Social Care Minister Kevin Stewart visited Leuchie House in North Berwick yesterday to see the work it does to support people affected by stroke, multiple sclerosis and neurological conditions.
Mr Stewart said: “Working in adult social care can be challenging but offers the opportunity to have a hugely positive impact on people’s lives on a daily basis.
“We are increasing pay, improving terms and conditions in the sector, and developing clear career pathways for the workforce, ahead of the introduction of the National Care Service. This will lead to more rewarding roles for the existing adult social care workforce, and for new entrants to the profession.
“This campaign highlights that while relevant experience can help, it is core interpersonal skills such as communication, compassion, empathy and respect that are most highly valued. If these are skills you possess then adult social care could be the career for you.”
Nursing trade union Royal College of Nursing (RCN) Scotland has paused a formal announcement of strike action in response to further talks with the Scottish government.
The decision follows a meeting with the First Minister and RCN General Secretary and Chief Executive Pat Cullen today and talks this week between Scottish government, the RCN and the other trade unions currently in dispute regarding NHS pay (the GMB and Royal College of Midwives) to consider a roadmap to resolving the dispute. The Scottish government was fully aware that an announcement on RCN strike dates was imminent.
The overwhelming mandate for strike action from RCN members in Scotland has been instrumental in securing these further negotiations.
The proposal from Scottish government includes:
Negotiations for the 2023/24 NHS Agenda for Change pay offer to commence on an accelerated timetable starting next week with an aim of concluding by the end of February
A commitment to an additional payment equivalent to three calendar months value of the difference between the 2022/23 and the agreed 2023/24 pay rates
A firm commitment from Scottish government to a full review of the Agenda for Change framework in Scotland to ensure nursing is recognised and rewarded with a clear route for career progression
A commitment to match any NHS pay increase in England for 2023/24 if it is higher than that agreed in Scotland
A commitment to invest any additional consequentials for NHS pay in England for 2022/23 in NHS pay in Scotland for 2022/23.
Scottish government would also support NHS employers to agree an extension of the RCN’s ballot mandate for strike action beyond early May if required.
Pat Cullen, RCN General Secretary and Chief Executive said: “The Scottish government has shown a willingness to return to the negotiating table and to act to address the nursing workforce crisis. The pressure from you, our members, has been key to these negotiations moving forward. We need to see this process through in good faith.
“Our members in Scotland are being listened to and the First Minister is in no doubt that we will take strike action if the proposals being outlined do not deliver a significant improvement by the end of February.”
Colin Poolman, RCN Scotland Director told union members: “You have said enough is enough and that was before the current pressures trying to care for patients and keep services running.
“We know it is frustrating that things are not moving more quickly but things are moving. While the Scottish government repeated their assertion that there is no more money for NHS pay in 2022/23, it was my strong mandate from you that led to the positive discussions this week and the commitment to keep negotiating.
“The Scottish government needs to do more and to take this opportunity to do the right thing, for nursing and for patients. These new pay negotiations must acknowledge the safety critical role of nursing.”
Funding of at least £8 million for additional care home beds and efforts to boost NHS 24 capacity are among the measures outlined by Health Secretary Humza Yousaf to help the NHS and social care deal with ongoing extreme winter pressure.
Health and Social Care Partnerships will share £8 million to procure around 300 additional care home beds to help alleviate pressures caused by delayed discharge. The funding will allow boards to pay 25% over and above the National Care Home rate for beds. This is in addition to around 600 interim care beds already in operation across the country.
NHS 24 is taking forward plans to recruit around 200 new starts before the end of March. In the run up to Christmas NHS 24 had already recruited over 40 whole time equivalent call operators, call handlers and clinical supervisors.
Guidance has been issued to all Boards making it clear they can take necessary steps to protect critical and life-saving care.
Mr Yousaf said: “This is the most challenging winter the NHS in Scotland has ever faced and the immediate pressure will continue for the coming weeks. My thanks to all health and social care staff for their incredible efforts during these exceptionally challenging times.
“We are ensuring all possible actions are being taken to support services, and the additional measures I have outlined today will help relieve some of the extreme pressure Health Boards are facing. We know one of the most significant issues our NHS is facing is delayed discharge, that is why I have announced further support to buy additional capacity in the care sector.
“NHS 24 has a vital role in referring people to appropriate urgent care services outside of hospitals and plans to increase staff numbers over the course of winter, will help the service deal with increases in demand.
“Emergency care will always be there for those who need it, but for many people, the best advice and support might be available on the NHS Inform website or the NHS 24 App, or by calling NHS 24, so I would encourage people to make use of these services as many are already doing.”
Responding to the Scottish Government NHS briefing on Monday, Dr Iain Kennedy, Chair of BMA Scotland said: “”Scotland’s NHS is not just being pushed to the limit, in many places it is well past that.
“Bed occupancy of 95% across our hospitals is just not sustainable in terms of providing the safe and effective care that patients need on a daily basis either in A&E or across all wards. And we know demand is far exceeding capacity at GP surgeries too and has been for some time.
“In that context, the very fact that the First Minister and Health Secretary provided today’s briefing should emphasise the seriousness and urgency of the situation. Our members provided us with first hand testimony from all across the health service just before Christmas, and the picture that painted was really harrowing. Services and staff are on their knees.
“In terms of the short term actions that the Government indicated today, we have long emphasised the need to focus on ensuring people who are able to leave hospital, can do so – freeing up desperately needed capacity and therefore ensuring those who need to can be admitted from A&E more quickly and safely. So the focus on this is welcome, but we will need to see the details and extent of the proposals to make any judgement on the immediate impact it may have. Extra interim care beds – while something which could help as part of the overall plan – will also deliver nothing unless there are people there to staff them, which we know is a huge issue in social care.
“More fundamentally, many doctors remain to be convinced that the Scottish Government’s practical response matches up to the huge scale of the problems the NHS is facing. In particular, staffing shortages will only get worse as more staff burn out and dread going to work, unless there is a more comprehensive and urgent package of investment in staffing to support and retain them in our NHS for good.
“Longer term, these pressures are the culmination of the warnings the BMA and many others have delivered for some time, that Scotland’s NHS isn’t sustainable within the resources – both staffing and financial – we are willing to provide it with.
“We have to get serious about this and have a proper long term discussion about the future of our health service rather than just struggle to survive from crisis to crisis as the NHS and its staff endure the kind of perpetual pressures which in the past were reserved for the worst of winter.
“We absolutely agree with the assessment of the First Minister that there are no easy solutions, so the sooner we truly get to grips with the big picture issues, the sooner we can get away from having to implement short term measures in the desperate hope of bolstering collapsing services and begin actually start talking about an NHS fit for the future. That’s why a national conversation on the NHS in Scotland is required without delay.”
Clinical leaders, health experts and ministers will convene in Downing Street for an NHS Recovery Forum today.Scotland’s First Minister hosted a meeting of the Scottish Government’s Resilience Committee yesterday to discuss ongoing pressures on Scotand’s struggling health service.
In addition to his regular meetings on the health service, the Prime Minister will host the Forum to bring together experts from across the health and care sector to identify opportunities to go further and faster on improving performance and outcomes.
The Forum will major on four crucial issues: social care and delayed discharge; urgent and emergency care; elective care; and primary care.
Some of the best health and care minds in the country will use the session to share best practice and to understand whether any innovations developed at a local level could be applied to other regional areas or on a national basis.
As the Prime Minister set out in his speech earlier this week, innovation is at the heart of the UK government’s approach and will be a vital aspect of the solution, and so Forum attendees will include representatives from both the public and independent sector to ensure we’re harnessing a wide spread of expertise and talent.
The Forum is the next step in the significant action that the government has taken to improve outcomes and relieve the immediate pressures on the NHS and in social care caused by the pandemic, with further pressures due to the recent rise in covid and flu cases.
On improving capacity in the NHS, the government has provided an extra £500 million to speed up hospital discharge this winter and we’re also increasing bed capacity by the equivalent of 7,000 more beds.
The NHS is rolling out virtual wards across England, with an ambition to establish 40-50 virtual ward beds per 100k population, by December 2023. Virtual wards are where people, for example, who have acute respiratory infections can actually be treated at home with telemedicine or pulse oximeters and there is also a new fall service which can save about 55,000 ambulance call outs a year by treating people with falls at home.
In total, the government will invest up to £14.1 billion additional funding over the next two years to improve urgent and emergency care and tackle the backlog – the highest spend on health and care in any government’s history. £7.5 billion of this support is for adult social care and discharge over the next two years, which will also help deal with immediate pressures.
91 Community Diagnostic Centres have been opened so far and they have delivered over 2.7 million tests, checks and scans to help diagnose patients earlier.
The government is also continuing to grow the NHS workforce, with around 42,000 more staff than a year ago, including over 10,500 more nurses and almost 4,700 more doctors.
The government is investing at least £1.5 billion to create an extra 50 million general practice appointments by 2024, while the NHS is accelerating the rollout of new state-of-the-art telephone systems to make it easier for patients get through to their GP surgeries.
Earlier this week, the Prime Minister set out one of his key promises that NHS waiting lists will fall and people will get the care they need more quickly. He also pledged to make sure the NHS is built around patients.
The Forum will run for the majority of Saturday and attendees will include chief executives and clinical leaders from NHS organisations, local areas and councils from across the country, clinical experts from Royal Colleges and independent sector organisations working with health and social care services to deliver services for patients.
The Health and Social Care Secretary, the Chief Secretary to the Treasury, the Chancellor of the Duchy of Lancaster and Chief Executive Officer (CEO) of NHS England will attend the Forum.
A Downing Street Spokesperson said: “As the Prime Minister made clear this week, easing the immediate pressures whilst also focussing on the long-term improvement of the NHS is one of his key promises.
“That’s why we’re bringing together the best minds from the health and care sectors to help share knowledge and practical solutions so that we can tackle the most crucial challenges such as delayed discharge and emergency care.
“We want to correct the unwarranted variation in NHS performance between local areas, because no matter where you live you should be able to access quality healthcare.”
First Minister Nicola Sturgeon has chaired a meeting of the Scottish Government resilience committee (SGoRR) to discuss the response to ongoing winter pressures on the health and social care system.
In addition to the FM, yesterday’s meeting was attended by Deputy First Minister John Swinney, Health Secretary Humza Yousaf, other Cabinet ministers, and key partners from across the system including senior representatives from NHS Boards, COSLA, Integration Joint Boards and the Scottish Ambulance Service.
The latest situation with flu and COVID-19 infections was covered, along with the increased demands on acute sites and social care which have been experienced over the Christmas and New Year period.
A number of measures are being taken to alleviate pressures on the system, improve patient flow and ensure people receive the right care in the right setting. These include the use of Flow Navigation Centres as part of the redesign of urgent care, Hospital at Home and ambulance service staff providing treatment, where appropriate, to help avoid hospital admission.
The Health Secretary will update parliament at the earliest opportunity on ongoing work to support the system, and further resilience meetings will be held to monitor the situation in the coming days and weeks as required.
The First Minister said: “It is clear that health and social care is currently experiencing a period of intense and indeed unprecedented pressure. Staff are working exceptionally hard and have been doing so throughout the Christmas and New Year period.
“This comes after nearly three years of pandemic-related demands on the system, and we are all incredibly grateful to them for their efforts.
“I am clear that the Scottish Government must and will do everything it can to support our health and care service throughout the next few weeks. We remain in daily contact with Health Boards and there is already a huge amount of work being done, but we will leave no stone unturned to explore and implement any additional measures that could be taken to help alleviate pressures.
“With that in mind we will continue to work with all partners to implement actions that can help ensure the workforce is supported to deliver the high standards of care that we want everyone to receive.
“This will include actions to reduce unnecessary attendances at A&E – ensuring people get care in more appropriate settings, and those who need hospital care get it quickly, and also on effective discharge arrangements to reduce pressure on hospital occupancy. My thanks go to all those working incredibly hard across the whole health and care system during this period of exceptional pressure.”
