Health and Sport Committee

Meeting date: Tuesday, November 15, 2016

Official Report 497KB pdf

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Targets

The second item on the agenda is an evidence session on targets and, specifically, on the Scottish Government’s review of targets. We have received apologies from Colin Smyth.

I welcome to the committee Harry Burns, chair of the targets and indicators review; Geoff Huggins, director of health and social care integration at the Scottish Government; and Paula McLeay, chief policy officer for health and social care at the Convention of Scottish Local Authorities. I invite witnesses to make an opening statement.

When I was asked to lead the review, my discussions with ministers were along the lines of, “Let’s have a fresh look, let’s decide what we want out of the complex health and social care system and let’s have indicators of progress that are based on the principle of information for improvement, not for judgment.” My experience over the years during which we carried out the Scottish patient safety programme, the early years collaborative and so on was that, if you give front-line staff the freedom to solve the problems that they encounter and the opportunity to test solutions, they will learn and the system will improve. As a result, in Scottish hospitals we have had huge reductions in mortality, in infection rates and in infant mortality and stillbirth rates—reductions of a level that no other system has achieved.

It seemed to me that we needed to approach the review with this in mind: targets and indicators should lead us in the direction of a change that we want. The change that we want is improved health and wellbeing across the Scottish population, which is based on people being in control of their own health and wellbeing and their own lives, and on the ways in which we support people who are in difficulty to find ways out of that and to become more engaged in the pursuit of wellbeing themselves.

I am standing back and looking at the whole system. Having said that, I expect that the public will expect some reassurance on waiting times and so on. We have made huge progress on waiting times in Scotland over the past few years and certainly since I was a surgeon at the Glasgow royal infirmary, when it was routine for people to wait two or three years for elective surgery.

We want to keep some of the things that are working, but we want to find new ways to move the system towards a more holistic approach to wellbeing. That is how we are describing what we are setting out to do.

11:15  

I am glad to see that Harry Burns is leading this initiative. I do not have a background in health, but I have a background in performance measurement from 30 years in business. When I started looking at performance management from a health point of view, I was confused by the terminology. On planet NHS, words such as “outcomes” and “targets” seem to have different meanings from those that they have in the rest of the world. There is a very well-established process for doing performance management, but the health service seems to have gone off at a tangent and is looking at it in a completely upside-down, back-to-front way.

At the end of the day, you figure out what your strategy is—that seems to be called “outcomes” in the health world. You then figure out what you want to measure, which are your indicators. An indicator has an outcome—a result—and a target. Those things are parts of a coherent measurement system, but in the health world it seems that outcomes are completely different from targets. In my mind, they are all part of the same coherent structure that you need to have in place to understand where you are going and how you are getting there. Having that structure is the first step to drive performance improvement, as you say, because you need to be able to break performance down to different levels to understand it.

What are panellists’ thoughts on that process? Have I got a correct understanding of the mix-up that we have managed to get into?

You are absolutely right. We have inherited a certain process. From memory, the target culture came from the horror stories that came predominately from London, where people were lying on trolleys for 48 hours before being seen in accident and emergency departments and so on—absolutely unacceptable situations. Targets such as waiting time targets were imposed on the system without any real understanding of how they would influence the broader suite of activities. I remember the discussion around treatment time guarantees for people who were suspected of having cancer when I was lead clinician for cancer in the 90s. Sixty-two days seemed a reasonable time for people to be seen and get that reassurance. A lot of targets were imposed without due consideration for the broader system. We need to step back and see what the broader system is telling us.

We had an interesting comment from the emergency medicine community at our first meeting. They said that the accident and emergency department is a barometer for what is happening outside in the community. If there are stresses and strains in the community, you see different patterns of problems presented. That was an insightful comment. We cannot judge performance in accident and emergency departments without consideration of the broader context in which they are working.

For example, a lot of stuff is said about breaching four-hour waiting time targets. When I worked in A and E departments, which was some years ago, we did not have computed tomography scanners or magnetic resonance imaging scanners. A and E departments were triage places. If someone came in with a broken bone, they went to the plaster room; if they had a cut, they went off and got it stitched; if they had a sore tummy, they went to a surgical ward; if they had a chest pain, they went to a medical ward; and so on. Now all that investigation takes place in most A and E departments. Treatment starts in the A and E department—if someone is having a heart attack, very often the treatment will start in the ambulance. However, we are still acting as if people are hanging around on trolleys. They are on trolleys being investigated and treated, so we need to rethink that four-hour target. It is important that people do not lie about on trolleys not being treated, but as soon as they start treatment, they are no longer just lying around on a trolley.

We are not thinking about the broad system and there is no appreciation of the complexity of modern healthcare. Over the next few months, I want to come up with some suggestions, get them out in the system for testing, get the opinion of front-line staff on how those suggestions helped them achieve better outcomes for patients, then move on from there. Industrial process control is probably not the right way to describe it, but we want to start a different way of thinking about performance in health and social care.

I am delighted to hear that. Targets are essential: the trick is to figure out how to measure the right things. That is the hard bit.

I have a couple of other quick comments. First, do you envisage that this would be aligned to the national performance framework? Secondly, I had a look at the 25 or so people on your expert group. The all seemed to be health professionals. If you were building a hospital, you would call in an architect and a civil engineer and not just have clinicians involved. We are building a performance measurement system: would it not be a good idea to bring in people who have done that in other walks of life?

We have patient representatives and health and social care representatives and a back up of people involved in the redesign of services. In another piece of work I have been doing recently, we brought together all the modern theorists and I am writing that up so that we can feed that thinking in.

I have to pick Harry Burns up on one thing. You said that we did this on the back of the things that happened in London. Many of those things also happened in Scotland. I would not like us to rewrite history at the very start of this. We all have constituents who have experienced similar things, up to the present day.

The four-hour target was initiated in England by NHS England on the back of a number of scandals. I am not saying that we were perfect. Interestingly, we have looked at performance in other countries. Very few outside the United Kingdom impose targets on A and E departments, but in comparison to those other countries we do pretty well.

I will ask two questions, one specific and one general. The specific one is about the sense of enshrining targets in law. The treatment time guarantee is enshrined in the Patient Rights (Scotland) Act 2011. I looked at the legislation this morning. If there is a breach of the guarantee, the health board must make arrangements to ensure that someone is treated early or at the next available opportunity, give an explanation to the patient and give support and feedback. My provisional view is that that does not provide any substantial pressure to the health board. I would like you to consider in your review the logic of enshrining the targets in statute. There does not seem to be much point in doing that.

I would like information to be used for improvement. If you set a target, that is as good as you are ever going to get. It might be that we are looking at exceeding and doing better than those targets. It might be that we would find ways of improving way beyond the existing guarantees, but while there is a target, particularly one that is enshrined by law, that is as good as you are going to get. Folk are not going to have any reason to go any further.

I have an open mind just now. I think that, by the time that we sit down and engage with front-line staff and patients, we might well come up with a set of ideas that leads to better performance than that currently enshrined in statute. Enshrining things in law is for you guys to decide, but it does ossify the process once you do that.

Some of the early feedback that we have had, and one of the reasons why we are having the review, is the perspective that those targets that were enshrined in law have so much more force within the system than other issues such as the provision of services in the community or broader population health gain.

The challenge that Mr Cameron is presenting is that targets do not have enough force, but quite a lot of the feedback that we are getting is that they have too much force and distort the system. That is one of the issues that we need to tease out through the review.

My second, general question picks up on what Ivan McKee was asking, and is the fundamental question of what we should be measuring. We need some kind of benchmark for performance. Patient outcome is talked about a lot. It would be sensible to have a measure of efficiency of some sort.

The four-hour A and E target is a good example, because it matters to a member of the public how long it takes them to get through A and E. They will walk out of a hospital either having been seen quite quickly, or the experience having taken ages. They will make a judgment about whether that was a good experience.

You are right and I accept that. However, what we see and, in part, what is being presented to me is the idea that, in the four and a half hours that a person spends in the A and E department, two hours of that time might be spent being treated or investigated. In days gone by, that would have required an admission to the ward and an overnight stay. We need to collect data to see what is actually happening within the four-hour target and we need a rational way of meeting patient expectations for a timely encounter with the health service. At the same time, we need a way to allow the patient to get rational investigation and treatment and, if that should happen in the A and E department, so be it.

I think that you realise that it is a much more nuanced picture than simply measuring a timeframe. We have all heard from hospital staff who say that the A and E target is useful, because it shows how quickly people move through the hospital and how the hospital is working. On the other hand, I spoke to a doctor who said that, if the primary care system is working well, a lot of people are seen in primary care by their GP and most do not get to A and E. Only the hardest cases get to A and E and, because they take longer, they breach the target.

We have encountered an interesting Australian study in which the four-hour waiting time target was reviewed in 59 hospitals. It found that patient mortality increases the closer that they are to the four-hour target. In the paper, they have not come up with a rational explanation for that, but it seems to me that those are the sickest patients. They are the patients who come in, who are being worked on, who are having things done and who are being resuscitated, therefore mortality is higher. We have to understand the processes that are at work in A and E departments and come up with a rational way of supporting them to support patients.

I welcome and thank the panel for coming to see us. Thank you, in particular, to Sir Harry Burns for his elucidating opening remarks and subsequent answers on the multidimensionality and nuances of the targets that we measure at the moment, particularly with regard to A and E waiting times, which was a point well made.

Waiting targets are fresh in the mind of committee members, not least because we cross-examined the cabinet secretary last week about the Audit Scotland report, “NHS in Scotland 2016”, which was very uncomfortable reading for the Government. Of the eight targets that had been set, only one was met, two were nearly met and the performance on the rest was pretty poor. In that session, it was suggested to the committee that the targets that Audit Scotland was assessing are some of the hardest and most challenging in the world. Is that accurate? Is it a good thing? If the targets do not capture the multidimensionality that Sir Harry Burns describes—which might offer some mitigation of the binary, black-and-white, pass-fail report that was given to us—how might they be improved?

The four UK healthcare systems have broadly similar targets. The healthcare systems of the Republic of Ireland, Australia and New Zealand are the others that we looked at that have attempted the target approach. We think that some European countries have targets for some bits of their healthcare system, but we cannot find consistent publication of data. The Republic of Ireland, Australia and New Zealand targets are far laxer than ours. For example, off the top of my head, the Republic of Ireland’s admission waiting time target is something like 25 per cent of patients admitted within two months and 100 per cent within a year, whereas our target is much shorter than that.

11:30  

We have set ourselves pretty robust targets, and, where we fail, my bet would be that a number of the failures will be underpinned by robust and sensible explanations. The problem with the data up until now is that those explanations have not been sought. All the management evidence that I read shows that where we have targets, management effort is put into ticking the box. I would like to understand what is going on out there. If 90 per cent of people meet the target and 10 per cent do not, you need to learn from the 90 per cent in order to help the 10 per cent. If all you are concerned about is ticking a box, you do not learn. We can improve way beyond what we are doing, but we have to make that effort and destigmatise the process in the interim.

I have been looking at data from one of Scotland’s largest health boards that says that the number of patients attending A and E departments has declined significantly over the past few years, which kind of suggests that primary care may well be doing the right thing. That did not come out in the Audit Scotland report, so there is stuff happening out there that we need to know a lot more about. The next three or four months is our effort to understand what is happening and reshape it.

The primary target should be about improving the health of the public in Scotland and what we need to do to achieve that through the healthcare system, the social care system, the criminal justice system and the education system. I am not sure whether the Scottish Government knew what it was getting when it asked me to do this, but I am looking at the whole system.

I agree with everything that you say. My response is possibly the knee-jerk, visceral reaction of any Opposition member reacting with some scepticism when the Government, having failed to meet a set of targets, commissions a review as to whether they should be setting the targets in the first place. It might be incumbent on us to react like that. I want to go where you are taking us, but I also want to be confident that we are not just giving the Government a pass.

Absolutely. I do not hold the knee-jerk reaction against you.

I was heartened to hear Sir Harry speak about a much more holistic approach to Scotland’s health and wellbeing. It is obvious that targets affect budgets: we spend money to meet them. Is that having an impact? Is there what some of us might perceive to be a lack of intervention and a lack of a more preventative approach because we are obsessed with targets?

I am sure that Paula McLeay will have some comment to make on that. You are absolutely right—at the moment, budgets are in silos. Despite all the efforts to get integration, people are accountable for different bits of the budget, so although money can be saved in acute care, for example, investing it in primary care and social care is different. There has to be an effort to bring the money together, to ensure that it flows to the correct place. There are tools for doing that but, at the moment, different accountability streams make it difficult for that money to come together.

I have been looking at stuff on the way in which front-line staff engage with people. Some studies from England show substantial reductions in costs in criminal justice and healthcare when we get things such as housing right. We need to think broadly.

I ask you to address another point. GPs at the deep end have produced research that argues that the way in which we allocate NHS resources, particularly under the Scottish resource allocation formula, does not do enough to tackle health inequalities.

I have some sympathy with that. I return to the point that health inequalities will not be fixed simply by healthcare and that, when people looked at one major set of interventions in the north of England, they found that the most important public sector worker in fixing a lot of things was the housing officer. Helping people to get out of difficulties with their housing seemed to have a big impact on their health and wellbeing, on reducing domestic violence and on stresses and strains. That is difficult to quantify.

Could we have NHS targets on reducing poverty?

NHS targets on reducing poverty?

We know of income maximisation schemes such as healthier, wealthier children in Glasgow, where health visitors and midwives help families who are on low incomes to access benefits.

Such work is already happening. Our early years collaborative found that health visitors in Lanarkshire who were doing 30-month assessments were referring people to money matters centres. That is what happens when the front line is empowered. When we tell those who are on the front line to solve the problem, they come up with innovative solutions and get on and do it. That is part of the culture that we want to engender.

The value of bringing the review of NHS targets and the review of health and wellbeing indicators together is that we are asking whether the whole system is pulling in the same direction. That question is really important.

We know that targets fundamentally drive behaviours. We need to focus our attention on whether the answer to an A and E target is to invest in A and E or to invest in the preventative services that keep people out of A and E. How do we ensure that we have the right targets and indicators to shift the behaviours to deliver the outcomes that collectively we agree need to be achieved for people? Fundamentally, that is the task that has been set.

We are beginning to see the integration authorities, which have the resource for A and E and the resource for unscheduled care bed days, looking at what they can do upstream. Some people say that targets drive money too much. Sometimes, however, people say that they do not drive it enough, in that the better solution to what is going on in the hospital sector is better preventative and anticipatory care.

The challenge is that we now have the organisations—although in some places we have had them only for seven or eight months—that have the pooled budgets and can look across the system and offer different solutions from those that we have had historically. We are beginning to see that happen.

Of the health and wellbeing outcomes to support integration, the fifth is a requirement on partnerships to address health inequalities. Within that, we are seeing exactly the sort of projects and work that Alison Johnstone identified. The integration authorities will be required to report annually on what they have done to address health inequalities within their responsibilities, which go beyond healthcare systems.

One process that we introduced in the patient safety programme and the early years collaborative involved encouraging people to collect data daily—for example, how many people you saw today, how many people you gave debt advice to, how many people took up the debt advice and how many people have come back and said that they were better off as a result.

Having annual reports is one thing, but what keeps the front-line staff trying new things is seeing the run charts on the wall. The classic example that I use in my lectures is of bedtime stories for children under the early years collaborative. We know that bedtime stories enhance cognitive ability. The nurseries just asked the kids whether they got a bedtime story. Nurseries did things, and gradually the number went from 60 per cent to 90 per cent of children, because the nurseries followed that up daily.

When we implemented specific infection-control programmes in the patient safety programme, the more there was compliance with the programme, the lower the infection rate was. That is tremendously motivating to front-line staff. They see change happening and they want to make it happen.

A key is the methods that we use to implement those high-level objectives. I suggest that annual reports are not sensitive enough and that we need the day-to-day flow of information.

At the beginning, you listed successes on infection control, mortality rates and so on. How many of those successes were driven by targets? If we were meeting the targets, would we be reviewing them?

The patient safety programme and the early years collaborative set their own objectives. When that is done, people get the system together and say, “What do you want to achieve?” In the early years collaborative, the aim was to make Scotland the best place in the world for children to grow up in. How would we know that we had got there? The aims were to reduce infant mortality levels by 15 per cent by the end of 2015, to reduce the stillbirth rate by 15 per cent by 2015, to improve developmental progress to 85 per cent by the age of three and so on. Front-line staff set those aims then set about trying things to achieve them. We made the 15 per cent reduction in infant mortality, we overperformed on the stillbirth rate—it was an 18 per cent reduction—and we will know at the end of this year about the other aims.

If someone from outside comes in and imposes something on the front-line staff, with the staff having no say in whether the objective is credible, the staff are perhaps not as engaged. If the staff set the objective, it will be more challenging. Not for a second did I think that we would reduce infant mortality levels by 15 per cent—I cannot find any other country in the world that has done that over the past three years—but we did it.

That approach is different from the external setting of targets. The system sets the target and tests ways of achieving that target, so we know from the start that staff are engaged with it. We might come up with that in the review, but we might not. We might have a mix that includes externally imposed targets.

If we were meeting the targets, would we be reviewing them?

There is a wider context to the work that is going on in Scotland. At its ministerial meeting early next year, the Organisation for Economic Co-operation and Development will look at how advanced healthcare systems around the world consider issues that are to do with quality and performance. The expectation is that systems will increasingly move towards patient-reported outcomes, so the question will be not, “How did the system, as a machine, operate?” but, “What was your experience of health and care? Did you feel safe and listened to? Did you feel that you had control over what happened?” There is a wider context to our understanding of what healthcare systems are for.

Michael Porter’s work on value-based healthcare is about moving beyond the approach of simply asking how fast something happened or how much it cost to looking at the degree to which it produces greater health or greater satisfaction. That is about how people understand their relationship to the healthcare system.

The challenge with such things is that, because they become increasingly related to people’s expectations and experiences in a complex distributed system, they are probably even more difficult to achieve than mechanical targets. It is probably even more difficult to offer satisfaction to a population of 5 million people on their experience each time they cross the threshold of the GP surgery than it is on how quickly they were seen. The challenge is about opening up a space in which we are likely to require not only different forms of data collection but different ways of understanding the benefit that people receive. Such things are not necessarily easier to do.

Members have to understand that there will still be things on efficiency and sustainability and that people will expect a predictable healthcare system that is well managed. However, what has been set out regarding people’s experience of their own health and wellbeing and the degree to which a health gain is produced is quite a big ask. Please do not underestimate the ambition of the work.

It is only a few years since the push came for the 12-week target. I do not know how long Mr Huggins, his predecessor or other people in the directorate have been in post, but did people encourage or discourage the Government from going down the route of targets? Are the same people who advised on that still in post but now saying, “Actually, we need to move away from something that we were involved in implementing”? I am trying to get to the bottom of how the decision was made in the first place and whether some of the people who pushed for it are in the same place and now saying, “Actually, we were wrong on that.”

There is nothing wrong with people saying that they were wrong and that they had the wrong approach. I have spoken to stakeholders who have been involved. I recently went to a Royal College of Nursing Scotland seminar at which people said, “At the time, we were all involved in it—there was a bit of an atmosphere and everybody just went along with it. Maybe we shouldn’t have.”

I am playing the devil’s advocate, which is part of the committee’s role. Are some people saying, “This is the kind of mood and atmosphere now. Maybe we should just go along with it”? In the same way as before, they might regret that in a number of years.

11:45  

I cannot entirely understand the different motivations that a range of people might have had for saying different things and for saying what they said when they said it. Our challenge is that people often say that they want us to review targets because the targets are wrong or too specific. They often ask for targets that relate to their specialism or professional interest. People say different things for different reasons.

The broader context in which we understand targets, performance, outcomes and indicators moves on. If we go back even three or four years, the work on the indicators is a good illustration of that. The first nine indicators that support the nine health and care outcomes were largely derived from information from the Scottish health survey, in which we asked qualitative questions of the population. At that time, that was the best methodology for understanding people’s experience of healthcare, such as their sense of safety and control.

However, for the reason that Sir Harry Burns outlined, we need real-time day-to-day information that gives feedback loops and engages people in the service that they deliver. One reason why we are reviewing the indicators is that we need faster access to knowledge about people’s experience of healthcare. The methodology that is used to get that information has moved on, as has our understanding of the change process. We are looking to develop systems that enable partnerships to know about people’s experience this week—not 18 months ago when the survey was done, after it has been collated and published, as such information does not give partnerships any ability to act.

The broad themes will continue, but the methodology by which we get to them may differ. The example of the four-hour target was given and was discussed at the first meeting of the expert group; different people have different views on that and have had different views over time. It is a good indicator of overall sustainability and the system’s ability to run effectively. How we understand that as part of a broader objective of producing health gain and the wider benefits of the health and care system will probably change over time, but we will still need something to carry out that function in the system.

Richard Lyle has a question.

My question has been partly answered. I have the greatest respect for Sir Harry Burns and I am sure that he will do a good job. My question is for Geoff Huggins. Boards are diverting resources to meet targets. Disproportionate amounts of money have been spent to manipulate targets by, for example, bringing in surgeons and other people to work overtime. The charge that will be made against you and the Scottish Government is that you have not met the targets so you are changing the system.

You have partly answered my question but, in all honesty, do you agree that over the years we have built up many targets and ways of doing things and had many political parties attacking the health service and attacking people such as you? You have brought in the targets and are responsible. What are we going to do about that? How are we going to ensure that people like me—and others—do not say to you that you are going to manipulate things again? How are we going to have clear, concise targets that are meaningful to people and which everyone respects?

I would like you to answer rather than Sir Harry Burns—he has spoken for most of the session and I have listened to him intently. How will we get the right targets in place that are respected by all political parties and the public?

As Sir Harry Burns outlined, we have a process to seek a wide range of views. We are able to draw on expert advice. We are able to test the ideas that come from the review process, and we will do that. The challenge is that we are doing something that is complex and will need to operate on a number of levels. The process needs to take us to the situation where we can produce better health—that is the intention of the health and care system—and where we can demonstrate that the system is running effectively and give confidence to those who hold us accountable that the stewardship of the system is being discharged effectively.

That is a range of slightly different ideas. I guess that the challenge in the review of targets is that people will tend to load all their expectations on to it as the mechanism whereby we will fix a range of ills, when it will be only one part of the solution that we need to bring forward.

I know that Sir Harry Burns will respond to this question. Are you under any pressure at all to deliver certain targets, or will the Government fully accept what your group comes up with?

You know me well enough to know that I am pretty good at withstanding pressure and that I would never put my name to something that I did not fundamentally believe in.

I know that only too well.

In discussions with ministers, I have said that I want to stand back and take an overall view of the system. However, I recognise that the public have expectations of guarantees about how they will be treated. I will do my best to ensure that we bring all the competing priorities together and come up with something that is credible and insightful and does something for the wellbeing of the people of Scotland. That is the fundamental thing that is in my head: the question is not how fast someone goes through a bit of the system but how well people are and whether we can move them to a better place.

On Geoff Huggins’s answer to you, we are where we are because, when targets were brought in, that was what people did—that was the notion in people’s heads about how to move a system, and we have learned from that. We will come up with an insightful way forward but, five years from now, other insights might well have emerged that will lead us to tweak the system even further. We can never say that there is a gold-standard set of targets.

Now that I am a free agent, as an academic, I am going all round the world telling people about the changes that Scotland has made. People are asking me to help them to set up an early years collaborative, as we did here, and they want to know what our thinking is about health inequalities and so on. Scotland is getting a lot of attention because of what we have achieved.

Now we are in the next phase, but I am not fooling myself into thinking that in the process we will not learn even more and find even better ways of doing things. That is how systems change.

The convener asked whether we would still be doing the review if all the targets had been met. I certainly hope so, because how well we are doing on the current targets is no indication of whether our system is fit for the future that we want to achieve and can drive the changes that we want in models of care, which are about shifting the balance of care, providing more care in communities, investing in social care and supporting people’s outcomes.

At the moment, what we have is siloed and operational. It is not that such things do not have a place, but they are unlikely to get us to where we want to be in the future. Regardless of what the performance indicators are telling us about the system right now, we certainly need the current review so that we can ascertain whether the whole system can drive and support the change that we want.

To what extent do you think that there is manipulation and massaging of figures around targets? The Audit Scotland report maybe did not point towards that, but I have met professionals—I do not say this to criticise them—who are not putting people on the system because they know that if they do they will not meet their targets. I have seen that happening and I know that it is happening in CAMHS and in alcohol and drug partnerships. What is your view, given the work that you have done? My concern is that whatever we put in place, such manipulation will happen all over again.

Secondly, where does the realistic medicine agenda fit into all this?

That was certainly an issue that I raised with the emergency medicine people at the first meeting of the expert group. They said that if that is happening, it is happening in a very small number of cases. The people whom I spoke to said that they are just working hard to achieve the four-hour target.

As far as the CAHMS people are concerned, I do not know. I have not specifically asked them and it is not something of which I have any direct experience. Perhaps Geoff Huggins can comment.

We did a review about three years ago—following the challenges that we had in NHS Lothian—to assure ourselves that what we had seen there was not happening elsewhere. At the time, we were satisfied with the outcome of the review.

If Miles Briggs has information that suggests that there are things that we should look at, we would be very happy to look at them. Our experience, however, is that the value that clinicians take from targets is in seeing them as something that gives them influence in relation to securing resource. To artificially present a better position than the one that they are in is not always seen as the best way forward. If you have such information I would be very happy to see it.

Part of the improvement process is to allow front-line staff to try to do things differently and to see whether that produces a better result. I say to them that if it works they should tell everyone about it, and that if it does not work they should tell everyone about that, too. The only shame in failure is in not telling people about it, because they therefore do not learn that that intervention does not work.

If there is a sense out there that the situation is punitive, that is not good. Information should be used for improvement: if there has been a failure, we should ask why it happened and what we can do next time to ensure that failure does not happen. If we create that kind of climate, the whole system will gradually improve.

The issue in Lothian was that manipulation of the system was happening and no one was being told about it.

What about realistic medicine?

I think that what is happening is entirely compatible with the chief medical officer’s approach to realistic medicine. The medical system is part of the broader health system, which is part of the broader social system, and the broader social system needs to change in order to achieve the wellbeing agenda for Scotland. Realistic medicine fits in very nicely and offers a way of conceptualising the healthcare contribution to that. I will be having conversations with the chief medical officer to make sure that we are all on the same page.

Finally, what is the timescale and what happens next? What is going to happen with the system that you have implemented?

We are developing workstreams around understanding the data, we are gathering evidence from what has happened elsewhere on what might make the improvements and we are developing understanding of how they might be applied in Scotland and of the method that might be used to drive the changes.

I hope to have an initial report ready for ministers by the end of March or in April, and I hope that it will include proposals for testing things out to ensure that they do not create perverse incentives or unanticipated effects within the system. If they do not, we will adopt a continual-improvement approach to delivery of services. In the course of that process we will want to engage with the public in a number of ways. Members of the committee are obviously a key link to constituents and so on, so we will want to hear your views.

When is the report likely to be in the public domain?

It will be in the public domain at the end of March.

Okay. I thank the panel very much for their attendance this morning.

11:59 Meeting suspended.  

12:00 On resuming—