Health and Sport Committee

Meeting date: Tuesday, January 9, 2018

Official Report 556KB pdf

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Health and Social Care Targets and Indicators Review

Agenda item 2 is an evidence-taking session on the review of targets and indicators in health and social care in Scotland, and it follows our evidence session on 5 December 2017 with Sir Harry Burns.

I welcome to the committee Shona Robison, Cabinet Secretary for Health and Sport; and from the Scottish Government, Geoff Huggins, director, health and social care integration, and Dr Catherine Calderwood, chief medical officer. I invite the cabinet secretary to make an opening statement.

I will be as quick as I can, convener. First, I welcome the committee’s interest in the review of targets and indicators and I acknowledge the considerable work that Sir Harry Burns has done in undertaking the review and the contributions that have been made by members of the expert group.

The committee will recognise the importance of our commitment to having targets and indicators that are fit for purpose, that reflect our current priorities and which lead to the best outcomes for people. We recognise that much has changed over the past decade in our approach to health and social care. Our vision is of a Scotland where people live longer, healthier lives at home or in a homely setting and where services are integrated around the needs of the individual and are focused on prevention, early intervention and self-management. Our health and social care delivery plan, which was published over a year ago, sets out some of the actions for achieving that. It is essential that our targets and indicators are fully aligned with our work to realise that vision.

I welcome Sir Harry’s report and the principles that it outlines. Like the committee, we particularly welcome his emphasis on equality of opportunity for everyone in society to enable people to be resilient and in control of their lives. I am pleased that Sir Harry recognises Scotland’s highly challenging targets for public services, which have driven significant improvements in many aspects of health and social care.

Within the NHS, Sir Harry recognises that our targets have transformed waiting times for patients and have improved safety. Timely and appropriate access to treatment is important—I have already announced that our current cancer treatment and accident and emergency targets and the treatment time guarantee will remain—but Sir Harry was right to say that we should seek to understand performance across the whole journey of care instead of focusing on individual targets or indicators. I am pleased that he has acknowledged the progress of integration authorities in adopting such an approach, as it has led to better understanding of why patients are presenting at A and E in the first place, for example, and the provision of alternative community-based services to better meet people’s needs.

I am mindful of the demand on emergency care services, which has been unprecedented over the festive period. We know that that is down to a number of factors, including a surge in falls and fractures, as well as people presenting with flu-like symptoms. Such exceptional circumstances mean that some patients stay longer than four hours in our emergency departments, not simply because of the pressure on the service, but because that can often be the right clinical setting for assessing their needs and deciding on the most appropriate treatment. NHS boards have responded to the demand to ensure the continued delivery of safe and effective patient care, and we are working closely with the boards to support them through the winter.

In summary, we agree with Sir Harry that further work on our targets and indicators is required, and we will take that forward to create a more balanced approach, with a broader-based assessment of the quality of care. People’s wider experiences of care need to be taken into account; I am committed to doing that work with COSLA and other partners, and I welcome the committee’s contribution to it.

I want to follow on from where we left off in the previous session. When I look at the debate in the health service and reflect on my experience of running performance systems in a previous life, I often find it a bit dispiriting that there seem to be two camps—the outcomes camp and the targets camp—lobbing hand grenades at each other. However, Harry Burns’s report goes some way towards an understanding and a recognition that they are parts of the same thing. We need to know where we want to go, what we are trying to deliver and what our outcomes will be. After that, we need indicators to measure whether we are getting there, and then targets to assess how we are progressing. Those elements absolutely need to be co-ordinated—and, to be frank, people who suggest otherwise do not understand what we are trying to do here.

I am glad that we are moving in the right direction. The issue—the hard bit—is figuring out what we should measure, because it is very easy to come back and say that there have been unintended consequences, because of X, Y and Z. That is because the target system was not designed correctly in the first place and the wrong stuff was measured.

A lot of thought and hard work needs to go into this, and it is clear from the report that there is a long way to go to make sure that the system is robust. Do you recognise that the current environment of multiple and overlapping indicators is cluttered and confusing and needs clarity? Where do we go next with Harry Burns’s work?

In the next phase of the work, I want to look at and bring more coherence to the landscape. For example, the A and E target is important not just because it measures the length of time that people wait in A and E to be seen, treated and discharged, but because it is a barometer of how the whole hospital is performing. If I were a member of the Royal College of Emergency Medicine, I would be talking about its importance in enabling all our hospital colleagues to take responsibility for what was happening at the front door of the hospital.

However, with the integration authorities—and now I am getting into the territory that you have asked about—we have taken the step before that. They are looking at indicators on reducing demand on unscheduled care in the first place and avoiding people ending up in A and E who do not need to be there through the development of local services. It is all about joining the dots, and Geoff Huggins can say a little bit more about that.

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What has been quite groundbreaking is that, for the first time, chief officers and chief executives of councils are as concerned about how to reduce demand on unscheduled care as the chief executives of health boards. They see reducing demand on unscheduled care as being as much their responsibility as that of the NHS. That gets us into the right space, and the issue now is about making the whole process transparent and keeping the importance of what happens at the front door of the hospital, while considering the whole journey from what happens in the community through to a person’s admission to hospital or discharge from A and E. That is the bit that we want to do more work on. We want to measure the outcomes and how successful we will be at keeping people away from the front door of the hospital when they do not need to be there.

The work that we have been doing in that area with integration authorities, which we are about a year into, has been really interesting. About this time last year, we wrote to integration authorities to set out in the context of the previous spending review the six areas in which we were looking for them to set their own objectives and make progress. I think that Sir Harry Burns’s review learned quite a lot from that process. The indicators relate to unscheduled care bed days, attendances, four-hour A and E performance, delayed discharges, and the availability of palliative and end-of-life care, and within that, we are looking at a number of different dimensions that are all about the whole journey rather than particular points on that journey.

It has been an interesting process. When we look at what happened in local systems and in the setting of objectives, we see that there are perhaps four different dimensions to what went on. As the committee will know from evidence that we have previously offered, most integration authorities start from very different positions. In general, targets impose a level at which everybody must be, but our experience is that some areas will achieve many of the targets relatively easily while other areas will really struggle.

Our overall interest is in improvement. What has been quite interesting is that integration authorities have been looking at different starting points and have different levels of ambition. Some expect to make more progress over 12 months, while others expect to make less. They have different degrees of capability and support to take forward change, and some of them have a different understanding of how the world works and the impact of demography over time. All of those things will come together in how they present their objectives for the next 12 months.

We have been working with the chief officers so that they can see what other chief officers are doing and to offer through that process a degree of moderation in the context of their using that information to think about their plans for taking forward change that will give them the improved services that they are looking to achieve at a system level. That work is a very good trailblazer for the approach that Sir Harry Burns is looking for in the future, which involves looking at systems of care and the degree to which they function effectively to produce better quality as well as understanding the interactions between different services.

Early in Harry Burns’s report, he identifies a challenge in how targets put a sharp focus on one component of the system, perhaps at the risk of other parts. His exhortation to us is to think more broadly, and the integration work has been very helpful in that space.

That is good to hear.

You are absolutely right that we need to start at the system level, and the system-level indicators need to be aligned with the outcome for the whole health system. It is clear that there is a hierarchy below that, and a bit is missing. A lot of stuff is thrown in there, but it is not clear how things relate to one another. There will be a measure for the whole system, but individual parts of it will have their own sub-indicators that feed in through the hierarchy. There is absolutely no reason why different integration authorities would not have different targets; the important thing is that the framework is the same and that they measure the same stuff. It is clear that integration authorities will have different targets, depending on where they are in the journey.

Again, what you said was good to hear. Thanks very much.

Good morning, panel, and a happy new year to you.

What struck me most when Sir Harry came to talk to the committee was what was not being measured, rather than what was, because, as the old adage says, what gets measured gets done. Sir Harry used a lot of his time to talk about the need to collect more information about adverse childhood experiences, because trauma in childhood leads to some of the most negative social outcomes that exist and there is a lot of research on that. What is the Government’s response to that? Does it intend to start collecting such data and will it approach service delivery from a more trauma-informed position?

There is a lot of importance to what Sir Harry has said on that area. If you track those who have had an adverse childhood experience or who have suffered trauma in childhood and marry them up with the prison population, those who have offended, those who are drug or alcohol dependent and so on, the link is clear for all to see. If that cycle can be interrupted through the collective efforts of Government and services, that will be very important.

We have had a number of cross-Government discussions to look at how we can, for example, work more closely with early years services and with education to find opportunities to interrupt the cycle. In that territory, the work of health visitors and the increase in the health visitor workforce is important, as is the family nurse partnership, the attainment fund for schools and the work between the health and justice departments that is looking at how we can get better intelligence on what has happened in people’s lives and what would have helped at particular times to interrupt that cycle.

The whole of Government is keen to do something about it, and what we want to work out through the next phase is what that might look like, because it is not an easy thing to measure. How do you measure what worked in someone’s life, and when, to make the difference between a good and a not-so-good outcome? We need to put some thought into that, but please be assured that that has been recognised as something that we can do more about and in a more systematic way than we are doing at the moment.

I agree that the intent is there. However, I am not really talking about measuring what worked, although that is an important part of it. We need to get the basics right—I think that that was what Sir Harry was talking about—particularly around capturing the traumatic life events that some children experience. That includes not just the usual life events that we would expect to be traumatic, such as bereavement and loss, but things such as attachment disorder and experience of disruptive and abusive homes.

The National Society for the Prevention of Cruelty to Children produced a report called “The Right to Recover”, which suggested that a very small proportion of Scottish local authorities have dedicated trauma recovery services. What Sir Harry was alluding to was that we are not getting the business end of it right. Although there is a role in mitigating the impact of childhood trauma for health visitors, the pupil attainment fund and so on, we are not addressing trauma recovery at the sharpest end of the problem, and we will not address that until we start capturing the basic statistics. Is there a commitment from the Scottish Government to answer Sir Harry’s challenge and to start recording the reasons for the trauma and not just what we hope to do about it in the future?

I appeal to all to be brief and sharp with their questions and answers.

Yes, there is a commitment from the Government. Perhaps Catherine Calderwood would like to say more.

We need to learn from what has been done in Wales where, in 2016, there was a study on adverse childhood experiences that found that 47 per cent of the Welsh adult population have had one adverse childhood experience and 14 per cent have had four or more such experiences. When it got that data, the country was surprised at the prevalence.

We will add some questions on adverse childhood experiences, for adults initially, into the Scottish household survey, which you will be familiar with. As I have discussed with Mark Bellis, who wrote that report in Wales, we need to be aware that revealing past experience is sometimes traumatic for people, so we need to be careful about how we phrase the questions. We need to be prepared to provide help for people who come forward because they have recognised that they have ended up with certain outcomes because of their childhood and that link has not been made for them before.

We want to work with the adverse childhood experiences—ACEs—hub that has been set up and which is chaired by Linda de Caestecker, who is the director of public health in Glasgow. We are talking with her about having some form of routine inquiry for every interaction with health and social care. That would need to be done very sensitively. From my point of view, it would involve taking a medical history, but there would also be some inquiry as to the child’s background and the potential for adverse childhood experiences. It is much more difficult to ask children who are in that situation at the time, although it is obviously extremely important to do that, because we can then act and prevent.

We need the baseline data. You are absolutely right that we do not have that for Scotland, although it is unlikely to be very different from the Welsh experience. We intend to collect that data, and we have the ACEs hub, which already has a lot of ideas about how to take forward work in Scotland.

I want to follow up Alex Cole-Hamilton’s line of questioning. With regard to ACEs, Harry Burns was quite critical of the getting it right for every child approach. He said:

“Well-meaning policies such as GIRFEC have arrived, but it is time that someone came up with a system to create success at school and pulled all of that together.”—[Official Report, Health and Sport Committee, 5 December 2017; c 42-3.]

Do you agree that there is a disconnect between health and education when it comes to that agenda? Could we do more?

We could always do more. A number of discussions have been taking place about what that can be and how we can work in a more joined-up way, from the support of women before they give birth through to the early years and school. We are discussing how we ensure that there is more coherence in the opportunities to support families. We have done a lot of work in the early years zone, such as the expansion of the health visitor workforce and the family nurse partnership work. That is about trying to support families who are struggling in their child’s early formative years to deal with issues such as attachment issues. That is about trying to have a positive impact before the child enters the school environment. Within the school environment, we are trying to pick up any issues at an early stage. However, we could always do more. Catherine Calderwood and other colleagues are looking at how we can more closely join the dots across Government, particularly between education, health and justice.

On that point, one of the recommendations in the report is that

“Analysis of school attainment rates should routinely consider the effect of adverse circumstances arising from socioeconomic deprivation on attainment.”

Have you had any meetings or discussions with the Cabinet Secretary for Education and Skills on that recommendation or do you plan to in the future?

Yes, we have had a number of discussions about that. We have also discussed the whole area that we have just talked about of how we can more closely align our collective resources to provide better and more systematic support for the children who need it. We have had a number of discussions on that specific issue and the wider issue. We need to consider how we measure the impact of what we are doing at the moment and how we measure the impact of new services and supports that could be developed. Sir Harry’s challenge to us provides a format for us in doing that.

We should also recognise that this work is going on in parallel with the work on the national performance framework, which looks across all of Government. Some of the elements that appear in Harry Burns’s report are likely to end up as part of that process of taking that more overarching approach, whereas some elements are more about the health and care system.

I want to look at the role of targets and indicators. In several committee meetings, we have asked what I thought was a fairly straightforward question about who monitors one of the indicators, which is that of significant adverse events. From NHS Ayrshire and Arran, we got nothing but waffle, and Jason Leitch’s written evidence seemed to contradict his oral evidence.

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However, it is quite simple. We just asked what constitutes a significant adverse event and whether that definition was universal across health boards. It is also about who at Government level monitors that and, more important, monitors whether there are any significant changes in the numbers of adverse events in a health board area. That is obviously important because, if there is a significant change, either the board has instigated practices that should be rolled out across our NHS or it has changed the way in which it records significant adverse events. If nobody at Government level is watching that, how can we learn from the targets?

As Catherine Calderwood said earlier, there is improvement work to be done in that area. First, we need to know what the figures are and try to get a proper analysis; and in that regard we can look at what has been done in Wales in terms of the population impact. Secondly, we have to create a baseline and see how we can intervene in an effective way.

I take Mr Whittle’s point about the need to have more coherence. The work emanating from the review and the work that we are doing jointly across Government can help set a far clearer framework for our ambition. It is very ambitious to say that we seek to tackle adverse childhood events in a systematic way, because it is very difficult to do that. Once the work is more fully under way, I will be happy to come back to the committee to set out how we are doing it and how we will ensure that the monitoring and oversight of it is as robust as it needs to be.

Would it be your intention to present any measurement of changes in a public forum?

Yes. We have work to do in terms of what we will measure and how we will do that, and on baselines. That work is at an early stage, but once it has all been pulled together in a plan, I would be happy to share that with the committee.

Thank you.

I will go back to the crux of the review, which is the big challenges that we face such as the fact that Scotland has the lowest life expectancy of the 16 western European countries mentioned and that the inequality gap is increasing, with the life expectancy of affluent Scots rising and that of those in deprived areas falling. Obviously, those inequalities are complex, but the current thinking on transformational change for wellbeing suggests adopting the life-course approach across the whole of Government and focusing on social justice, growth and wealth. That would mean that, in effect, there would be one system of indicators on health and wellbeing that would cut across every Government department. Do you support the life-course approach? From a practical point of view, how can you deliver that when departments still work very much in silos?

There is huge merit in adopting a life-course approach for our priorities and measuring outcomes in a more systematic way. Some progress has been made across the Government in trying to break down the silos that you indicated. For example, the integration agenda shows that, where silos are genuinely broken down, people take on responsibilities that were previously not regarded as theirs, to be blunt. We need to see improving the life chances of the next generation—our children—as everybody’s responsibility and we need to do that in a coherent way. A lot of work has been done around that, but we need to pull it together better. The direction or challenge that Sir Harry Burns has given us will provide further impetus for us to do that. However, as Colin Smyth has identified, that is not easy to do and it can be interrupted by things that are outwith our control.

Without putting too fine a point on it, let us say that the welfare reform agenda reduces a family’s income, which affects the level of poverty—and everything that flows from poverty—that that family faces. That is a difficult piece of the jigsaw for us to have as part of our plan, because all we can do is mitigate the impact as much as possible, and we have done a lot of work to enable us to do that. We need to look at how, with all the levers at our disposal, we can do more and better in that respect, but we also have to recognise that some factors outwith our control have a pretty severe impact on household income and employment and so on.

The other thing that is quite important in the review is how Sir Harry widens the scope of the issues that we consider when we look at outcomes and indicators. We are doing work in Dumfries and Galloway on dementia outcomes and indicators, based on work that we have done with the International Consortium for Health Outcomes Measurement. The ICHOM is looking at how we can measure, across systems, people’s sense of control, their social connectedness and other things that are fundamental to broader health and wellbeing outcomes. We are finding that quite challenging, though, because those are not the things that we traditionally measure. We tend to measure things in particular, time-bound situations that can easily be put into a spreadsheet. However, in order to measure people’s quality of experience, which affects the likelihood that they will present at accident and emergency or go to their GP for support, and understand how well we are supporting them to live the lives that they want to live, we need to look a lot more at granularity in local systems. Such questions are largely an undeveloped area in our system, and indeed in systems across the world. We have had the conversation on more than one occasion about issues to do with loneliness, and the degree to which people have good social ties and support systems around them. Those factors are not part of our measurement system, although they can be as important as, or more important than, individual clinical interventions. That is quite challenging.

That approach enables us to step into the space of realistic medicine in a different way and understand how not doing something might, on some occasions, produce a better outcome than doing something. At the moment, our system measures situations where something has happened, but we do not have a methodology to understand the impact of something not happening. Once we bring qualitative factors into the story, we can understand people’s experience and perhaps help them to understand what they might want. Sir Harry has opened up how we look at indicators and outcomes, beyond the traditional understanding of how fast or how well a system is operating. There is really quite a big challenge in that.

The big challenge will be to identify what we measure, ultimately. When Sir Harry Burns talks about the life-course approach, he says that individuals need support at various key stages, for example pre-birth and in early childhood. Specifically, he argues that early years support is key. I go back to Jenny Gilruth’s point: is there scope to reinvigorate the work of the early years collaborative in the light of what Sir Harry says in the report?

We need to look at all the mechanisms that we can use, and all the expertise that is available, not just in Government and its partners but among the public—people who have been through many of the experiences that we are talking about. There is something in that. The early years collaborative has done a lot of very good work, but we first need to take a step back and reassess what outcomes we want to achieve. How will we achieve those outcomes across the Government? Are the mechanisms, collaboratives and methods for delivery of those outcomes fit for purpose, or do we need to do something different? We are looking openly at where we are, and there is a commitment across Government to refocus and re-energise work in that area. We will be very happy to keep the committee informed about that work.

Sandra White and Emma Harper want to come in on that briefly.

My question is about the life-course approach. Sir Harry Burns’s paper is spot on: this is about holistic collaborative working. I will pick up on Mr Huggins’s point about loneliness. Are we taking any data from the deep-end practices for the life-course approach? Those practices target people in the most disadvantaged areas and have shown that among older people in particular who turn up at them the issue is just loneliness—they do not necessarily need a prescription or to see a doctor.

Yes we are taking such data, and the new GP contract will enable us to get a far richer seam of data coming through primary care for measurement. We will know about the populations that are served by practices as we never have before. The data will help not just practices and their partners, but all of us collectively, to consider what services need to be delivered to their area and its population. For our deep-end practices and services for the more deprived communities, the data will tell us far more than we know at the moment, and in a more detailed and local way. It is an opportunity to drill down and not just to look at data but to formulate service delivery and support based on what the data tells us.

I will make two or three points to build on what the cabinet secretary has said. In his report, Sir Harry Burns suggests that, as part of the work to take forward the review, we should test and learn rather than simply arriving at an answer and trying to implement it. A lot of what is going in the system is that testing and learning—it is a clear objective.

Our focus is often on national indicators or targets, but there is a balance to be struck between national and local in terms of the improvement mindset. There are elements that we might expect would cascade, but there are others that we expect would be part of local system improvements and their use of data using list and source.

The third thing comes back to the cabinet secretary’s point about being clear about framing and the overall aim of the system, before setting outcomes and working through indicators. That progression is how we took forward the work on dementia outcomes, and we ended up with outcomes for which initially we did not have indicators. We built the indicators to support what we were trying to achieve; the opposite is often the case.

Harry Burns uses the word “flourishing” in his report, because we want to create a healthy and flourishing population. It is quite nice to have heard Dumfries and Galloway being mentioned a lot this morning. I am aware of some of the programmes that are being implemented to provide the best way forward for health and social care integration and to keep folk out of hospital. What resources or incentives are available to help local authorities to engage in plan-do-study-act cycles and to change cycles in whatever method they use, so that we can encourage the flourishing population that we seek?

I ask Geoff Huggins what he knows about the improvement work and support.

Our dementia activity work in Dumfries and Galloway is supported by the Healthcare Improvement Scotland team that supports general dementia work and has embedded that work in its broader change work. Healthcare Improvement Scotland’s improvement hub—ihub—provides support to integration authorities for work on issues including falls, admissions, delays and sleepovers. The context is that local systems are looking to make and to own change locally, but at times they require support—technical, data or analytical. There is a balance between national and local. Our primary objective is that local systems own and want positive changes and find local solutions to take them forward. NHS Dumfries and Galloway is a good example of that.

I will be really quick. Obviously, some boards are a bit further ahead with change programmes than others are, so they will learn from one another what works in one area and how it can be adapted for another.

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Yes. Through all the improvement programmes we identify best practice and share it. Obviously, what might work in the centre of Glasgow might be a bit different from what works in a rural area, given the different resources that can be called upon in those circumstances. However, if something works well, we want to share that and help other services to develop it in their areas.

I want to discuss NHS staff empowerment. One area that I am quite keen on, and which I have raised with Harry Burns, is professional responsibility. We often set targets for NHS and social care staff. I am sure that I am not the only MSP at the table who is told by nurses that they are often asked to record information that they think is not useful. My concern is about empowering them to do their jobs. What is the panel’s view on how that needs to change?

I will bring in Catherine Calderwood in a second, but my instinct is that we need to listen more to what front-line staff think about what we get them to record, which takes time. We need to make sure that when we ask people to record things, we are pretty clear about its importance and the reason for it, and that staff fully buy into it and feel that what they are doing has a reason and a purpose. Ensuring the engagement of our front-line staff in all this is very important.

I also hear doctors asking why we are measuring certain indicators at all, because they mean nothing to them clinically and will not improve patient outcomes. That recording is not something that clinical staff who have the expertise would traditionally have wanted to do—they want to see patients and they want to be at work. We need to make such work much more attractive so that staff will potentially have a greater impact by clinically advising patients based on worthwhile indicators and targets than they might by doing an extra clinic. People do not necessarily value that work, which looks at the national level.

We must also be careful about proportion and the burden of data collection on actual results. I was part of a big maternity audit in which I calculated how much time each keystroke took. I worked out that we could have employed 50 more midwives a year based on the time that was being taken to record data for the whole country. I am not sure that we consider such issues very well, either. We keep asking people to collect more data, but data collection must be proportionate to the improvement that collection will create.

There is another component to that issue. In our work on dementia diagnosis rates, which began in 2008, the challenge that we faced included opposition from general practitioners and others to the idea that we should be doing it at all. The process that we built in response to that was clear about the benefits. We ensured that patients’ and carers’ voices were being heard as part of the story about what mattered to them. We made it clear how diagnosis was part of a process to enable them to move forward with their lives, and we ensured that it was not seen in the way that it had been presented by some doctors. Often, the solution is to put what we are trying to do in context.

Two other components are interesting. When people get feedback and feel the benefit of the information that they provide, they are more likely to provide information. Our system ensures that people see the value and the contextual use of the data. The link to that is the work on the digital strategy, in which the objective is to automate collection of data more so that it does not require manual entry or additional work that could be done by machines.

Of the three elements, the most important is to ensure that the value of data collection can be ascribed back to the value for patients and carers.

The more current the data, the better. That is better than looking back at what happened a year ago.

The only one of the existing targets that the review suggested could be removed is the 18-week referral-to-treatment target. The suggestion behind that proposal is that the target has the possible unintended consequence of interfering with clinical and possibly even patient decision making. Is there still merit in keeping that target, or are there better indicators that we could use to get the information that we need without unintended consequences?

I want to interrogate that proposal and consider it in more detail. Harry Burns has made a good point, but we do not want to throw the baby out with the bath water, so in the next phase of work we want to consider whether there is a better way of measuring without overmeasuring. Harry’s point is that we already measure that part of the patient journey, so the question is whether it is a remeasurement of the patient journey in a different way. Therefore, we want to see what transpires from a closer look at that recommendation in the next phase of work.

I have a general question about the review. It took a long time, it was delayed and it seemed to be a wee bit underwhelming when it came out. Did you expect more from it, or is it what you expected?

We tasked Harry Burns with a big job. His review was in two parts. One part focused on targets and indicators and the other was about health inequality and how we make huge changes. He undertook an enormous task. Perhaps the remit was too enormous, but members know what he is like: once he gets going, he wants the freedom to consider all the areas.

What transpired from the review is a signal in a particular direction, the detail of which it is for us to take and build on. I thank Harry Burns for his work: he is a great asset to us. He is able to put his enormous experience to work in a way that might not dot every i and cross every t, but gives us the direction of travel. It is our job to take that and to apply the detail.

The current system allows the committee and the Government to look at comparators across the UK. For example, if we look at the figures up to, I think, November, we see that the figure for the four-hour A and E target in Scotland was 94.4 per cent and, for England, it was 84.9 per cent. In cancer referrals, the figure for Scotland was 86 per cent and, for England, it was 82 per cent. However, among some of the other indicators we see that, on the referral-to-treatment time target—one of the key targets that Harry Burns wants to get rid of—we were 7.7 per cent lower than England; on diagnostic tests being performed within six weeks, our figure was 17 per cent lower than England’s; and for procedures including colonoscopies being performed within six weeks, Scotland was sitting at 58 per cent and England was at 93 per cent.

We can see significant differences between us, England, Wales and Northern Ireland under the current system. If we change the measures but they do not, how can we have comparators with which to hold you to account and for you to use to make political points about what is happening elsewhere?

The convener makes an important point. Those are the health systems that are most comparable to ours, although the caveat is that when we look behind data, we often find variations in how it is collected. We do not always compare apples with apples: we sometimes compare apples with pears, although it might not seem that we are. The convener’s point shows why we need to proceed carefully. It is helpful for us to benchmark not only across these islands but elsewhere. However, we have to measure things in more or less the same way in order to be able to do that meaningfully, but that is often not the case. As we take the matter forward, I will be cognisant of that, because we do not want to lose our comparators, even when they challenge us on where we need to make more progress. Be assured that we will not throw the proverbial baby out with the bath water. We want to maintain an ability to compare and measure in the right way, but we also need a more sophisticated system that focuses more on the patient outcome. Often, what we measure does not give us that important bit of the picture, so that is what we want to focus on.

I have a couple of questions that I hope Geoff Huggins can help with, in relation to the timescale for things moving on and what happens next.

What will happen next is the process to take the work forward. Geoff Huggins can give you the detail on that and on the time frame.

I would like first to pick up on the previous point. Regardless of whether the 18-week RTT was a target, the data would still be there. Even if you think that Harry Burns draws a distinction in the report between information that is available for accountability of the system and information that is there for improvement, you would still be able to make the comparison, whether or not it was a target. In a number of areas where we are making cross-UK comparisons, the information in the other systems—particularly in Wales—is not a target, it is just information, so you would not lose that ability.

There will be three or four elements in the process, going forward. First, we are doing some local testing work on the use of outcomes, such as the work that is being done in Dumfries and Galloway, in order to understand how that would work within the system, using indicators and outcomes for improvement, rather than simply applying targets to NHS boards. Our take on that is that the process of implementation is likely to be more challenging than the process of reaching agreement on what the indicators should be. We need to have those two things aligned in order to take forward the change.

We are working to develop a next-stage process. As the convener said in respect of Harry Burns’s review, people have very strong views on whether things are good or bad and what the answers should be. We need a more sophisticated process to enable us to make decisions as we crunch through from the high-level aim to the outcome and to the indicator, learning from organisations and bodies that have done that previously. We will build a process, but we will do it in parallel with testing.

We also want to build in what we have learned from the integration authorities’ experience of the first 12 months of working in that different way.

The other key component is the degree to which the information systems that we will be building under the digital strategy make collection of appropriate data for improvement and accountability routine, rather than its being an add-on that is applied to the system. That will be the process.

It has been a long meeting, so I thank you very much for coming along. This is likely to be my last time convening the committee, so I want to record my thanks to all the staff who have helped me over the past two years, and to all the committee members for their work.

12:42 Meeting continued in private until 12:48.