Health and Sport Committee

Meeting date: Tuesday, May 9, 2017

Official Report 547KB pdf

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NHS National Waiting Times Centre

Agenda item 2 is an evidence session with the NHS National Waiting Times Centre. Some committee members had the benefit of visiting the Golden Jubilee national hospital back in September, and we thank the centre for hosting us.

I welcome from the centre Jill Young, chief executive; Julie Carter, director of finance; Mike Higgins, medical director; and June Rogers, director of operations. Jill Young will make an opening statement.

My statement will be brief. I am sorry that I was not there for your visit, but I am delighted that it was useful to see what we do.

I am sure that you enjoyed your holiday.

I did—thank you.

I will tell you about the unique nature of our health board, which is different from any other health board in Scotland and, indeed, the UK. We are delighted that, next month, we will celebrate our 15-year anniversary in the NHS. We believe that they have been 15 very successful years.

11:15  

We started as a national waiting times centre that was set up purely to address elective waiting time targets—for example, because someone could have been waiting many years to have a cataract operation. However, we have changed radically and significantly over the years; hence, we are now more commonly known as the Golden Jubilee foundation.

Although we provide a range of services for the people of Scotland, we have three core specialties. Our heart and lung centre is one of Europe’s largest cardiothoracic centres, and it provides a range of services from west of Scotland all-adult cardiac surgery—we treat not just elective patients but all the emergency heart attacks that come by blue-light ambulance or helicopter to be treated at the Golden Jubilee hospital—to our national heart and lung services, the best known of which is the heart transplant service for the whole of Scotland, which is based at the Golden Jubilee hospital.

Our second core specialty is our orthopaedic department, which is one of the best-known such departments in Europe and one of the largest. It undertakes pioneering work that is being replicated not only across Scotland and the UK but further afield in Europe. Twenty-five per cent of all hip and knee replacements in Scotland are carried out at the Golden Jubilee hospital, with tremendously successful outcomes. That is not just about the activity in numbers; it is about the clinical outcomes, the performance and the satisfaction of patients. The department is now moving more into telehealth and telemedicine in orthopaedics, and it is providing outreach clinics up in the Highlands and Islands as well as in Fife, for example.

Our third core business is the cataract procedure, which is quite short. It takes about half an hour in theatre to have a cataract removed and replaced with a lens, and the work is done almost totally as day-case work. We carry out 18 to 20 per cent of all cataract procedures. People travel to the Golden Jubilee hospital from all over Scotland—even from the Highlands and Islands—to have their cataract procedures. That is partly because of the excellence and expertise of the team that we have and partly because of the clinical outcomes and the speed at which we can deliver the service for people.

I will finish by briefly mentioning two other dimensions that we are unique in having as a national board, which are critical in underpinning our success. We have our own four-star conference hotel, which is unique not just in Scotland and the UK but in Europe, and our own research and innovation institute. Our research department is running about 80 research projects with international interest and input to benefit the patients of Scotland. We have also completely refocused the hotel’s business so that it is a conference centre of excellence that provides residential training conferences with highly specialised equipment for healthcare and the public sector—we have gone beyond the NHS.

What has made us so successful in our performance over the past 15 years is our staff. Their dedication, enthusiasm and commitment to constantly go the extra mile and to look to improve at every turn and make things better have been tremendous. We underpin that by providing training in human factors, values and culture as well as training on the professional side for doctors, nurses and allied health professionals. It is down to them that we provide such high-quality services and continue to improve and innovate.

Thank you.

Thanks for coming along. I enjoyed the visit to the Golden Jubilee hospital last year.

We have some data in front of us—I assume that you will agree with it—that compares the cost per in-patient case at the waiting times centre with the costs at a range of other hospitals. Your cost is significantly higher, so I would like to unpick that a wee bit to understand whether we are comparing apples with oranges, given what you do. I would also like to understand how you get linked up with demand from other health boards, whether your underutilisation impacts on costs and whether we should be leveraging that more.

Why are the numbers that we have in front of us significantly higher?

I will start and then hand over to Julie Carter, who will be able to give you the detail. What we do is complex. For example, the national services are completely different, so we are not comparing apples with apples. That is the first point.

We try to change pathways of care so that we do not bring patients down to the Golden Jubilee on unnecessary journeys. We provide alternative ways of treating them with outreach. For example, we send our ophthalmology team up to Orkney and Shetland and up into the Highlands to treat patients, which is an additional cost to us but a saving to the local health board and the local community and population. For those reasons, you are not comparing apples with apples.

I hand over to Julie Carter for the detail.

I reiterate that. The committee is absolutely looking at comparing apples and oranges. In orthopaedics, for example, all our work is on joints, and the average cost of the implants that go into the joints is £1,500 to £2,000. In comparison, a lot of the work of other health boards is on fractures and does not involve joints. That is one of the big differences.

We are unique in that our work is 100 per cent elective. We do not have any accident and emergency work coming through.

That is fine. To take that to the next stage, is there data on what you do that compares apples with apples?

Yes.

How do your costs compare on that basis?

Very well. We compare our costs for work on joints and so on. Because our average length of stay is only three days, whereas the average length of stay across Scotland is about five days, our costs come out really well. We are extremely focused on that because we have to be. We are an elective factory, so we have to be extremely efficient and look all the time to make things better.

That is what I expected. The model should work in that way, and the big advantage should be that it is a lot cheaper. You say that that is the case and that you have data that shows that you are cheaper than other health boards when doing similar processes.

You do 25 per cent of hip and knee operations and 20 per cent of cataract operations for people from across Scotland, but you have underutilisation of capacity—it is at 60-odd per cent. Given that all your work is planned, your use of capacity could and should be a lot higher than that. Why are you not more fully loaded? Are health boards resistant to giving you more operations to carry out? Does something in the costing system make it look cheaper than it really is for them to do operations in house? What are the issues behind that?

Maybe I can tease out what you mean by “underutilisation”, because at the moment we are full. On our capacity, in terms of the hospital and the board’s resources, we are absolutely full. Indeed, we are working six days a week in some specialties, and part of the reason for the expansion plans for the new elective centre is to accommodate more orthopaedics and take the numbers 25 per cent higher.

It is just that we have data that says that you are at 68 per cent occupancy versus a target of 73 to 85 per cent.

That is occupancy in some wards.

So that figure is not for operations and we can leave it to one side.

To go on to the next stage, what would need to happen for you to do more work, given that it is cheaper for you to do it than for other health boards to do it?

It is also of higher quality.

Of course.

It is the quality that drives the efficiency, rather than—

I am taking that as a given.

The point is important, because I have never seen a finance target deliver high quality, but I have seen targets for high quality deliver efficiency.

We need expansion. We are running six days a week and we are exploring running some services seven days a week. We do seven-day working in the physiotherapy and occupational therapy departments but, to get the theatres running seven days a week, we need more staff, more resources and more supply. We are exploring that in order to squeeze out every part of our current resources, but the Golden Jubilee would need to be expanded, and that is in planning.

We also have data on cancellations. The figure came in at just under 3 per cent. Do you recognise that? It is higher than the figures for pretty much every other health board but, again, you might tell me that we are not comparing like with like.

It is a bit of both. A number of our patients do not come to us for their first out-patient attendance, whereas the other boards count such appointments in the cancellations, so we are not comparing apples with apples.

The 3 per cent figure is not acceptable and we are working hard to bring it down. Perhaps June Rogers can tell you more, as she drives some of the work to do that. The figure relates partly to the distance that patients have to travel and whether they deem the time to be appropriate given their circumstances. We tend to get cancellations from people who live further away.

Can I squeeze in one last question, convener?

Yes.

There is clearly a strategic intent to replicate elsewhere what you do. You might not want to answer this question directly. Given that what you do involves planned and elective procedures and given that you are pretty good at it on your site, if you had to consider where it made most sense to invest the money, would it be in starting from scratch and building up expertise to do the work at other locations round the country or would it be in investing more in what you are doing and doubling or even trebling your capacity?

We are looking at both aspects. The elective-capacity expansion plan is looking at how much we can expand and do on the Golden Jubilee site and what is best to be delivered locally. Certain procedures should be done locally so that there is no need for patients to travel to us. We have to consider the resources—not just the physical resources and money but technology, equipment and the recruitment of staff. Sometimes that can be quite challenging on smaller sites.

To go back to the point about what we are doing, the model of care in planning the new elective centres is the Golden Jubilee model of care. We have been asked to take a lead role in that to make sure that, even if there is expansion in other areas around Scotland, those centres will be run and operated on the same model of care as we use.

Very finally, if everybody did what you are doing, how much would we save across the health boards? You might not know the answer to that and might want to get back to me.

We would save lots.

If you got back to me with some analysis, I would appreciate it.

The only thing to add is that we work closely with other health boards—it is not a matter of them and us. We share models with them and, if we can do things better, we share that with them. We work very much on a cohesive basis.

It is good to see some of the panel again after the visit last September. I will concentrate on cancelled operations, which Ivan McKee raised and which are a problem. With the exception of a couple of months last year, you were above the Scottish average for the whole year on the number of operations cancelled for capacity and non-clinical reasons and, as has been said, your figure was the second highest in Scotland. What is the reason for that high rate of cancelled operations?

There are a couple of things. The cardiac programme is included in that, and cases are often cancelled because more urgent cases come in, such as transplants.

We also have a general surgical service that is run by visiting consultants, which mostly involves things such as endoscopy and minor general surgical procedures. On occasion, or maybe more than occasionally, we have to cancel lists at fairly short notice because those consultants have been held back at their host boards to carry out more complex procedures.

Additionally, over the past year we have had equipment issues with ophthalmology. That affects large numbers of patients in one day, which inflates the percentage.

What you are looking at probably relates to orthopaedics and to endoscopy, where there are up to 14 procedures in a day, so it does not take long to rack up 3 per cent of cancellations. We have been more concerned about cardiac cases, which are being postponed to make way for more urgent procedures, rather than being cancelled.

A lot of what you do is elective surgery, for which I presume by its nature that it is easier to plan, and you rightly have a reputation for quality, as the gold standard and a national centre of excellence. Given that, do you accept that you will have to sort out the issue of cancellations to maintain your reputation?

We are acutely aware of the areas that need to be fixed. The areas that we have typically concentrated on are orthopaedics and cataracts, as Jill Young said, and we perform in the upper quartile on both those services. That has been evidenced in peer reviews. We work really hard not to cancel patients’ procedures and, if we have to cancel, to give patients a new date on the same day as we cancel them, so that they are not waiting for longer than their waiting time guarantees. We are still able to treat them. The 3 per cent is not a great number, but we are working really hard and we are focused on what we have to do.

Can I touch on the point that you made about the challenges of consultants? We have a national shortage of consultants in almost every area, and yet you are looking to expand. Given the numbers of cancelled operations, which Donald Cameron touched on, how challenging will it be to make that expansion when you have issues such as a shortage of consultants, as you mentioned?

I will start and then hand over to Mike Higgins to give you the detail. We are doing a number of things. The expansion is three to five years away; it will be two years for phase 1 and then three to five years for phase 2, if we assume that the plan will be approved.

We have set up our own training academies for theatre operating staff and radiology, which have been successful. We are taking people in and training our own staff so that they will be ready when the new expansion happens.

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Services in a number of areas are delivered only at the Golden Jubilee, so when we recruit, we are not taking staff away from other areas of Scotland; we are advertising and marketing in the UK, Europe and further afield internationally to recruit into those areas.

We have spent the past 10 to 15 years building our reputation and credibility as the place to come and work in order to get experience and high-quality professional career progression. We have skills shortages in a couple of areas, but we tend to have a number of candidates coming forward when we have a vacancy. To date, I think that there has been only one specialty in which we have not been able to appoint someone to fill a vacancy—I am talking primarily about doctors.

The challenges that we face are the same ones that are faced by the rest of the NHS and, broadly speaking, the solutions that are put in place to address those challenges are the same solutions that are being put in place across the rest of the NHS.

We have looked at what consultants do and we try to use them in a way that means that they only do tasks that consultants need to do. For instance, we have undertaken major redesign in the ophthalmology service so that the parts of the cataract procedures and outpatient appointments that can be done only by consultants are done by consultants, and we have used optometrists to take over many of the tasks that do not need to be done by a qualified eye surgeon. That redesign is on-going. We have reached a point at which we have made major efficiencies and improvements, but we would like to take the work much further, and that process is in place.

Our orthopaedic service has also grown. When I came to the Golden Jubilee in 2008, we had six or seven full-time orthopaedic consultants, and we now have 15 or 16, depending on how you count them. Before we grew the service, there was some scepticism about whether a centre that concentrated on a relatively small number of elective procedures could attract people who were interested in a professional career. Because we made the job intrinsically attractive by concentrating on high standards and ensured that our recruitment process was highly focused on non-technical skills, team working and non-technical competencies rather than simply involving a one-hour consultant interview, which made it harder in some ways for people to be appointed, we have found that the centre has become an extremely attractive place to work, and that there are people out there who want to come and work in the Golden Jubilee.

On a wider scale, if those consultants are being attracted from elsewhere in the health service, it is important that, when they are working in the Golden Jubilee, they are working to maximum efficiency so that their input to the health service is maximised. I think that that works very well.

As Jill Young pointed out, in some specialties, there are super-specialised areas in which there is a tight international market, as is the case in heart transplantation. Our Scottish pulmonary vascular unit and adult congenital cardiac care, both cardiological and surgical, is in an area in which there is not only a UK shortage of skills but an international shortage of skills, so we are playing in an international market. We have a number of international and European appointments to our jobs in the Golden Jubilee.

You make the point that you sometimes compete with other parts of the health service for staff, particularly with regard to more routine types of operations. Like other members, I represent some rural areas that are quite some distance from the Golden Jubilee. Patients want to go to where they can get the best treatment, but they would also like that to be in the local area, if at all possible. Given that you are competing with other parts of the health service for consultants, how do you think the expansion of the Golden Jubilee will impact on local health services in other parts of Scotland?

It should be a win-win situation, and we will work very hard to ensure that that is the case. There is a sense in which any appointment anywhere in the health service is in competition with appointments elsewhere in the health service. What we should do is to provide the maximum benefit from those appointments, wherever they are. That relates partly to efficiency—as Colin Smyth mentioned earlier in relation to the use of consultants—and partly to being creative. For instance, we have been looking at having split appointments under which consultants might spend half their time in one of the surrounding geographical board areas and half in the Golden Jubilee. That is one useful and practical solution.

One of the issues with our anaesthetic team is that, because we do a fairly limited range of operations and much of the work is focused on regional anaesthesia—in which patients are not put to sleep but part of the body is numbed in order to carry out the operation—there is a worry that people’s skills in putting patients to sleep are being diluted. One solution that we are looking at is joint appointments under which people will have a general anaesthetic workload in one board area and, say, an orthopaedic workload with us.

There are some simple practical things that we can do. As Julie Carter mentioned, it is important that we work collaboratively with other boards and do not set ourselves up in competition. We want to create win-win solutions to such problems.

So you do not think that the expansion will impact on local services.

We work hard to ensure that all the services that we set up are what we might call win-wins. It is not possible to give a global answer to the question. Broadly speaking, we hope that we will not impact on local services or work to their detriment. We take a global view on how to provide the best treatments at the best place so that both patient experiences and patient outcomes are optimised, and we work with other boards in order to do that.

I can give a brief practical example. NHS Dumfries and Galloway has experienced challenges in recruiting ophthalmologists while we have been looking to expand, so we have been working closely with it to see whether we can make a joint appointment. A surgeon would spend some of their time working down in Dumfries and Galloway, treating patients locally where they could do that, and where patients require more intensive or complex operations, the same surgeon would come up and work with the team in the theatres at the Golden Jubilee. We are genuinely trying to work closely so that we do not remove local services but, where there are challenges, collaborate.

In recognition of the issues in Highland and in the rural boards that Colin Smyth mentioned, we send consultants, who are orthopaedic surgeons, up to Raigmore hospital three times a year—in each visit, they see at least 100 out-patients—and patients who require surgery come to the Golden Jubilee for their treatment. It is all agreed and arranged in advance. Patients know that, if they see our consultants at the clinic, the expectation is that they will go to the Golden Jubilee to have their procedure carried out and they will have their follow-up arrangements carried out using a telehealth link. We have monitored that process all the way along to make sure that there is patient and clinician satisfaction with the service that we provide.

We have replicated that in Shetland, also for orthopaedics, and we have an ophthalmic surgeon who goes to Shetland three times a year. We are in close contact with every board in Scotland to make sure that we make it as accessible and simple as possible for patients to come to us. When surgeons go and do such clinics, patients have their pre-op assessments at the same time. We send up an administrator from our hospital to talk to patients about what their experience will be when they come to the Golden Jubilee, where a relative can stay in the hotel and what their transport arrangements will be. We have recognised that there is a gap and tried to fill it. It is a very collaborative arrangement that we have with every single board.

I want to pick up briefly on something that Mike Higgins said in reply to Colin Smyth about current staffing and having staff from the European Union. How does he see Brexit impacting on the recruitment and retention of staff at the Golden Jubilee?

I think that we have a small number of EU staff. Like everyone else, we are waiting to see what will happen about the EU, so the simple answer is that we do not know, although at the moment we do not expect any major difficulties that we will be unable to cope with.

When the Brexit decision was taken, we did as detailed a review of the situation as possible given the information that was available, and we took it to our board as a risk paper. We examined all the dimensions that were involved including export—which we do not really do—workforce and procurement. On that last point, it is important to note that a lot of the highly complex equipment that we have for magnetic resonance imaging is built and bought from abroad, and the value of the pound could have an impact on us in that regard.

We took that paper to our board for it to decide whether the risks should go on to our risk register and what mitigating actions we could take with regard particularly to recruitment, but also to expansion if we go ahead with the purchase of two new pieces of MRI theatre equipment. We are lucky that we have national procurement in Scotland so the procurement is done once for Scotland, resulting in the best deal that we can get. However, the outcome of Brexit will determine much of what we are talking about.

Was Brexit put on to your risk register?

It was not, because it was determined to be a low risk at that point. We use a matrix to determine risk, which involves the impact of the event and its likelihood. After full discussion at the board level, it was determined to be a low risk, so it did not go on to the board register. However, we still monitor it.

Most of the MSPs round the table will have been approached by constituents when their experience of the NHS has perhaps not been as good as they would have expected it to be or when they have not had the level of service that they wanted. I am therefore keen to discuss the data from your latest in-patient survey, which found that 98.7 per cent of patients had positive engagement, with 94 per cent rating your service as excellent, and that the board delivered more than its planned activity for in-patient day cases and diagnostic examinations, with activity being 12.5 per cent higher than in the previous year. You are to be congratulated on achieving that.

What learning is there for other hospitals from the experience of the Golden Jubilee and your positive engagement with your patient group?

There is a lot in that question. Those of you who managed to visit the hospital will have seen the presentation of our quality framework. For the past six years, we have been working hard to establish that quality is about being an exemplary employer for our staff because they are the ones who deliver the front-line care to patients and their families and carers; that it is about looking at the pathway of care for the patient and ensuring that it is of the highest quality; and that it is about what matters to the patient and not what is the matter with the patient.

That last point is important, because the two things are quite different. If you ask someone who is having a hip replacement what matters to them, they might say that they want to run the next 10km race, or they might say that they just want to go out and dig the garden or take their kids for a walk without being in pain.

We have done a huge piece of work around training our staff and looking after them in order to raise their satisfaction, and that contributes to the satisfaction of patients because it results in high-quality care and good communication. That communication starts before they come anywhere near the Golden Jubilee, as it involves a phone call, once they receive their appointment letter, to explain to them what will happen all the way through their treatment.

We look constantly at the indicators, the targets and the hard facts around them—the number of infections, the number of complaints, the average length of stay and the rates of cancellation and DNAs. DNA stands for “did not attend”. We triangulate the staff experience, the patient experience and the targets, and we use apps, which are in every ward and department and on all the board members’ iPads and laptops, to feed into a live digital platform that people can look at—on any day, at any hour, from wherever they are in the world—in order to monitor quality.

We also encourage patients to give feedback in a range of ways before, during and after the treatment. For example, people in the orthopaedic department found that patients were grateful for the treatment but would simply say that their treatment had been wonderful as they were leaving, because they just wanted to get out the door and go home. The department found that it was not until seven to 10 days after the operation, once the patient was home and had talked things over with their family or carers, that they were able to truly reflect on what their treatment had been like. Therefore, those patients now get a phone call seven to 10 days after they have gone home to ask them about their wound, their mobility, how their operation went and, more important, whether we could have done anything better to improve their satisfaction.

The committee has also considered staff governance. You mentioned that you are an “exemplary employer” of staff. How have you rated that? What engagement have staff had, particularly through things such as the national staff survey for the NHS?

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We get a tremendous response from staff in the staff survey. I am looking at my notes, but I think that there was 84 per cent satisfaction with our employee engagement. Our staff satisfaction rating was one of the highest in Scotland, if not the highest, which is tremendous.

The other indicators that we gather for our quality framework include things such as turnover. We have one of the lowest turnovers of staff. Sometimes it is good to get fresh eyes and to have new staff coming through but, over the past 10 years, we have been expanding every single year, which gives us the freshness of new staff coming in with new ideas.

We constantly offer staff the opportunity to tell us when things are going well and we include them right at the start. Our partnership forum has its own values, which we table every time the partnership and the staff side and the unions meet with management, and we do a 360° review at the end of those meetings to ask how our behaviours are, how the workplace is and what more we could do to improve things. There are a whole range of ways in which we ask staff for their views.

There are also confidential contacts—there is a board member whom staff can approach directly if they have any concerns, and we have a whole team in the human resources department.

We have provided human factors training to 60 per cent of our staff—that is, over 1,000 staff—in the past year. That is a basic exercise to allow them to find a voice so that, if they feel that they are in any way being bullied, intimidated, harassed or put under pressure with workload, they have the words and the training to raise that and do something about it. We made a commitment just over a year ago—about 18 months ago—that we would train every member of staff. Indeed, we are all trainers. That allows them to question it when things are not going well but, equally, to tell us how to improve things.

Can I just check something? When you mention your staff, are you referring to staff right across the estate—to your hospitality, nursing, medical and facilities staff?

It is everyone. All members of staff are employed by the Golden Jubilee Foundation. However, we take it a bit wider than that, as we include our volunteers and some of our young people. With the investors in young people gold award, we have a lot of interaction with schools, and when young people come in for work experience or volunteer work, they are included in the staff governance.

Related to that, what about the level of use of agency and bank staff, and the private sector?

There are no private sector staff. We are trying to repatriate all the private sector work for the NHS. We do have bank staff. Julie Carter can give you the detail on agency staff. We did quite an intensive piece of work, as all the boards in Scotland did, to reduce the use of agency staff. First, there is the high cost, but secondly, we could not give the assurance of the clinical governance and the expertise and skill levels of staff coming in to work at short notice. Agency staff tend to be used in highly intensive areas such as operating theatres and MRI scanners rather than as lower-grade staff in the wards. I do not think that we have used any agency staff.

Use of agency staff is really low—

Can I pick up on that? Are you saying that that is because you could not verify the skills?

No. It is because we are not aware of their level of experience. If we had an agency nurse who was at band 6 with intensive care training, we could not plan on the assumption that they would have the necessary experience for, say, a heart transplant patient who had just come out of theatre. That is quite a dedicated role within what we do.

If you have to employ bank or agency staff for those niche posts, is it massively expensive?

Agency staff are expensive, but we do not use agency staff for that. We have our own bank, which comes under our training. We make sure that anyone in our bank who comes in to work in those areas has been trained by us.

As I said, our use of agency staff is very low across Scotland, and we are keen to keep it like that.

Following on from that, I know that when NHS boards cannot provide a service locally, they can opt to send patients either to you or to the private sector. We know that in 2015-16, boards spent £81.8 million on using the private sector for NHS patients. That exceeded your income from boards, which I believe was £50.4 million. Has there been any analysis of that spend in the private sector and of whether there are any gaps that you could be filling? Are people going to the private sector because there is something that you cannot pick up on? Has there been a look at that?

Yes. Both things that you have highlighted are happening. As we do not do certain specialities, they cannot be picked up by us, but they could be picked up by other hospitals and boards around the country.

We are also, within reason, trying to repatriate from the private sector all the specialty work that we do, but in order to do that, we need the expansion that I referred to earlier. We have done predictions and projections up to 2030 of the demand for orthopaedics and ophthalmology in NHS Scotland and the rising elderly population and have translated that into how many operations will be required. We have also looked at the history of the work that has gone to the private sector, particularly with regard to those two specialties. We know how much work has previously gone there and what we will need in the future, and we are using those as our planning assumptions for the expansion.

So you hope that the private sector spend might decrease over time.

Absolutely. That is the key purpose of the expansion.

I read in our committee papers that you are

“funded through a combination of Scottish Government funding and payments”

due to referrals from other health boards. Your annual income from such boards is £50.4 million, but there seem to be reports of a few boards—Grampian, Highland and Greater Glasgow and Clyde—no longer referring to you. At the time of writing, however, the Scottish Parliament information centre could not confirm the position regarding those referrals. Will you comment on that? Are some boards or specialties not referring, or is that incorrect?

No, that is not correct. You mentioned Grampian, Highland and—

Greater Glasgow and Clyde.

All of them have an allocation capacity at the Golden Jubilee, and have done forever.

So they continue to refer to you at the moment.

Yes. We have a three-year contract with all the boards. We have referrals from every single board in Scotland now, which has taken some time—over a number of years—to achieve, and under our three-year agreement with them, they can within their allocation choose to send whichever patients they want, no matter where they are on their waiting list, or make new referrals.

We have what are referred to as see-and-treat referrals, which are of patients who have never seen a consultant in their home board area. They come to us, see our consultant and stay in our system. We also have treat-only patients, who have already been diagnosed, are existing patients on a waiting list elsewhere and come to us just for surgery. People come into our system in a variety of ways, but every board has an allocation of capacity depending on its particular needs.

As someone who represents the Highlands and Islands, I have a wee supplementary to that question. Might there be particular cases that are not being referred? Earlier this year, the press reported the high-profile case of a young woman with a cataract who had waited a year to be seen by NHS Highland. When the press made inquiries, NHS Highland said that, since the previous September, it had no longer been referring people to you.

I know about that lady. NHS Highland had an allocation of ophthalmology capacity at the Golden Jubilee. We talked to it at the time about whether it was appropriate for patients, who are generally elderly, to travel down to the Jubilee for what is often a half-hour procedure, but it needed the capacity and we were happy to take the patients. However, given that 30 per cent of those patients do not proceed to surgery, we talked to it about how we might refine things through a pilot in which the initial consultation would be carried out by telehealth link in order to avoid unnecessary travel. Highland did not manage to make that happen, because an optometrist or a specialist nurse was needed at its end to conduct the consultation and tell the consultant what they could see; after all, the consultant can see only a certain amount. NHS Highland then passed its capacity to Fife, which is now carrying out that pilot in the hope that we can then take it back to Highland as a done deal—if we can call it that. It looks as though we have found a way forward, but at that point, NHS Highland was unable to use the ophthalmic capacity that we had given it.

As for orthopaedics, however, Highland has been sending us those patients for three years now. We do outreach clinics for them, with follow-ups by videoconference. I hope that we can get back to helping out NHS Highland with ophthalmology. The lady to whom Maree Todd refers was quite an unfortunate case, and I did hear about it. Had NHS Highland phoned us to ask whether we could have taken the lady, we would have taken her.

NHS Highland has severe recruitment difficulties in that area, so it is not as though it is providing a service there anyway.

Absolutely—and that is why we send one of our ophthalmic surgeons up to do the Shetland clinic, which used to be done at Raigmore. We are trying to help as much as we can, but I hope that we can get back to doing a bit more for Highland.

As we highlight to all the boards, not just at board level but to the clinical teams and GPs who refer to us, the management and redesign of pathways and the work that June Rogers has described should never impact on an individual patient’s care. A patient should not have to hear about how we are redesigning things or moving them around and how we are working with other boards. In such cases, people just have to lift the phone—they all have our number; it is the direct number to June Rogers—and we will fix them. The patient in question should not have been caught up in the middle of that situation.

Good morning. I want to press the question of how aftercare for patients is monitored, specifically when they return to their health board areas; I am thinking, for example, of access to physiotherapy. From the monitoring that you say that you have been doing, are you aware of specific boards where this is a problem and where the pathway is not being put in place for people? That seems to have been the case for constituents whom I know in Lothian. Do people returning to their own health board areas face a postcode lottery?

I am not sure that it is a postcode lottery. Before patients are admitted, we pre-arrange their discharge; we would not bring in patients who did not already have that agreed and in place.

We have never had a delayed discharge at the Golden Jubilee for more than 10 years now. That has not happened by accident—it has taken a lot of hard work and planning. If a patient was fit and well to go home, but had their discharge delayed because they needed physio or occupational therapy or some sort of stair lift or toilet aid, that would block the bed and the next patients would not be able come in. That is obvious. We have negotiated with health boards that the next patient blocked from coming in as a result of that will be theirs, which will breach their targets. We have worked extremely hard on this, and we have contact with every social work department in Scotland, whereas most boards only need to have that partnership with their local social work department. As I have said, we have not had any delayed discharges.

I have to say that we have not had a huge amount of feedback saying that what had been agreed up front was not in place when patients went home. We need only look at the care that is received now—and which Mike Higgins has outlined—especially for orthopaedics, where patients do not get general anaesthetic, control their own pain and are up and walking the same day. They get their hip replacement in the morning, they are up and walking in the afternoon and they are back home two days later. As a result, the majority do not require additional care in the community, whereas before they would have had to spend 10 days in hospital and then would come back home with perhaps a wound drain or a big dressing that needed a district nurse and aftercare. The number of people who need that has reduced dramatically. As I have said, I have not had a lot of feedback in that respect, and we look at all the feedback that comes in.

Do your constituents have an issue with one particular specialty—say, orthopaedics?

I do not have the authority to speak about the specific case, but I can say that it was a hip replacement.

That would be unusual. Lothian sends us more than 4,000 cases a year; it is one of our highest referrers—in fact, it is the highest—so I am almost pleased to hear that we are talking about only one case. One is bad enough, though.

The complaint does not seem to be about you, but about access to physiotherapy, if that is needed, once a person gets home.

That is generally organised in advance. Most patients do not have any specific post-operative physio when they go home. When they come to hospital for their pre-op assessment, they go to what we refer to as the joint school and leave with a video, book and phone number. They are encouraged to do their exercises at home; if they have specific problems, they call us and we call their GP practice for additional support, but that does not tend to happen very often.

Access to seven-day services in local areas in the community would improve that dramatically for everyone, but that is not available everywhere at the moment.

We have seen the amount of delayed discharge across the country. Does the planned nature of your work prevent that from happening to you?

Yes, indeed.

So you are in a unique position that others are not in. You know when people are coming and can arrange services way ahead to ensure that there is no bed blocking.

Absolutely, but there is another side to that. The innovation and new technology that we have put in place mean that patients do not have to go back to nursing homes, some other hospital or some other form of care in the community. As a result, we do not have to make all those arrangements; patients just go back to their homes and their families.

Can you give me an example of that technology?

12:00  

With enhanced recovery, which has been rolled out across Scotland, no general anaesthetic is used and no urinary catheters are inserted, so patients are not discharged home with a catheter that would require care from a district nurse. Because patients are up and walking in three days, they do not get chest infections; as a result of that, they do not need antibiotics and do not need to visit a GP. Complex discharge arrangements that had to be made five or 10 years ago are no longer required. We have all the evidence behind that.

In that regard, are you doing stuff that others can learn from, or are they already doing it? If they are doing it, why has delayed discharge not been eradicated?

Enhanced recovery has been rolled out and is being used by all health boards in orthopaedics. We have spread it into our cardiac and thoracic surgery. It is a principle of care—it does not apply purely to one speciality. We have shared the approach; indeed, our team has gone round the country, training people in it.

Thank you very much for your attendance this morning. I now suspend the meeting.

12:00 Meeting suspended.  

12:05 On resuming—