Welcome back, committee members. Agenda item 3 is consideration of the report, “Delayed discharges: A symptom of the challenges facing health and social care” and the briefing, “Community health and social care: Performance 2025”, which have been submitted to us by Audit Scotland.
I welcome our witnesses: Stephen Boyle, the Auditor General for Scotland; Carol Calder, audit director at Audit Scotland; and Adam—forgive me; perhaps you can help me out with the pronunciation of your surname.
It is Bullough.
Mr Bullough is an audit manager at Audit Scotland.
We also have with us Malcolm Bell—that is much easier to pronounce—who is a member of the Accounts Commission for Scotland.
You are all very welcome. I apologise that the committee is small in number today, but we will nonetheless do our best to have a good conversation about your report, Auditor General. I believe that, before you take questions, you would like to make an opening statement.
Many thanks, convener, and good morning.
As you mentioned, I bring two reports to the committee this morning: the first is on delayed discharges, and the second is a briefing on community health and social care performance. Those reports were prepared by Audit Scotland on behalf of myself and the Accounts Commission and both were published on 8 January. The “Community health and social care: Performance 2025” briefing report is published together with an accompanying data output. The documents build on our integration joint board data tools, which set out financial data and then add national performance data. They are intended to allow integration authorities and health and social care partnerships to compare their performance with other areas and explore the reasons behind differences.
The committee will note that, in both reports, the theme of difference is common. There is notable regional variation in the performance of integration joint boards and, more specifically, around delayed discharges across Scotland. In our work on the performance of IJBs, we found that there continues to be a lack of comprehensive and consistent national performance information about community health and social care demand, workload, quality of care and outcomes. We note that there is a general long-term picture of declining performance and satisfaction.
The performance audit report focuses on the topic of delayed discharges, which has been a long-standing issue across Scotland, and which—it perhaps goes without saying—impacts directly on people and on the flow of patients through Scotland’s hospitals. We highlight that
“Most patients in Scotland’s hospitals are discharged promptly.”
However, we also state that
“Despite only around three per cent of all people discharged from hospital experiencing a delay, each delay has a detrimental effect on the individual’s physical and mental wellbeing.”
We go on to note that
“Delays also impact the flow of patients through hospitals, reducing staffing availability and capacity for other patients, and in 2024/25 resulted in 11.7 per cent of hospital beds being unnecessarily occupied.”
The reasons for delayed discharges are complex, as I hope that we set out in the report. They vary significantly by area, by hospital and by each individual patient, but we have concluded that they are a symptom of the wider challenges across the health and social care system; we set that out in some detail in the report.
The Scottish Government integration authorities and their partners in national health service boards and in Scotland’s councils have actively targeted delayed discharges as an issue. We see evidence of that right up to senior ministerial involvement and oversight of delayed discharges, and the results of that. We note that, although that
“has led to some improvements”,
there is, again, variation across the country. We say:
“The lack of a consistent approach to evaluating initiatives makes it very difficult to understand their impact. Better analysis and transparency are needed to understand both the costs and impacts of delayed discharges, what is providing better”
value and outcomes for individuals and, ultimately,
“value for money for public spending.”
Lastly, we note that
“Scotland’s population health framework, the health and social care service renewal framework and the NHS operational improvement plan”
all offer opportunities
“to make progress, with a common focus on prevention.”
I think that I said something similar to the committee when we gave evidence on the “NHS in Scotland 2025: Finance and performance” overview report in the past couple of weeks. However, we state that it is not yet clear
“how shared accountability and joint decision-making will be achieved, particularly given there is limited reflection of the critical role”
that social care services will play in the delivery of the new strategies and arrangements.
As ever, the four of us will do our utmost to support the committee’s evidence taking, but I am particularly glad that Malcolm Bell from the Accounts Commission is with us today.
Thank you, Auditor General. Given our smaller committee team this morning, you will all have ample opportunity to participate in the session. You can just catch my eye if you would like to come in on any particular answer, although not everyone should feel the need to answer every question that is posed.
We will start with questions from Mr Beattie.
Paragraph 63 of the report on delayed discharges states:
“The Scottish Government has set a target for every emergency department in Scotland to have direct access to specialised frailty teams by summer 2025, to support early identification, assessment and management of frailty at the hospital front door.”
Do you know whether that target was met?
That target has not been met. The Scottish Government advised that, under the operational improvement plan, it has proven difficult to meet that target. There have been issues with resourcing for getting frailty teams in place. Healthcare Improvement Scotland produced a report back in November that provided information on where the implementation was at. From my recollection, I think that the targets were in the process of being met in 11 boards, but as of that point, the targets had not been met.
So, that is in 11 out of 31 boards.
Sorry—those were NHS boards, so it is 11 out of 14.
Do we have any further information on that? Do we understand what the plan is to get implementation back on track? Is there a plan?
Healthcare Improvement Scotland has been engaging in looking at how that plan can be seen through and those frailty units can be implemented across the board.
How robust do you think those plans are?
I have not seen copies of the plans, so I cannot comment on that.
It might be helpful if Carol Calder could come in on that, too. The progress in 11 out of 14 boards is perhaps positive with regard to the development of the plans, recognising the variety of approaches that will need to be deployed. Ultimately, it is connected to patient flow and ensuring that people receive the right care and services at the right time in the right environment. That sentence has been said for many years, but the report speaks to the fact that there has been a great deal of focus on tackling delayed discharges. The work on frailty teams is a good example, as it is about diverting people from an emergency department into an environment that is more suitable for their care, and 11 of the 14 territorial health boards have made progress.
Setting a target can signal intent, and most health boards have progressed along those lines. I guess that it will be for Healthcare Improvement Scotland and, ultimately, the health and social care department of the Scottish Government to take a view as to why progress remains to be made in the three other boards. There might be good reason for that; indeed, the boards might just say, “Actually, we already have an alternative in place. We are trying something different.”
The point that I hope comes through in the report is that many initiatives are happening to tackle delayed discharge, but there needs to be a fuller evaluation of those initiatives, which of them can be best deployed in different parts of Scotland, why they are working and whether the money is being spent appropriately, and a clear plan to tackle what feels like a really stubborn issue.
10:45
The main thing is that progress is being made, and the issue is not just being dropped.
As we mention in the report, 720,000 unnecessary days were spent in hospital in 2024-25, and we know that people who are over 75 account for about two thirds of them. As a result, the focus on frailty is really important. Fifteen of the 28 emergency admission hospitals in Scotland have signed up to the focus on frailty programme; 13 of those 15 have a frailty team in place; and getting a team in place is in progress in the other two. The 13 that are not in the programme are designing and developing their frailty teams, too.
One of the reasons for the delay in meeting the target is the issue of what constitutes a frailty team and what it looks like, and having more clarity in that respect is being looked at in the plans. Another reason for the delay relates to recruiting people to the teams. However, the commitment is very strong; the data shows that frailty is a big issue in delayed discharges; and work is on-going on that.
So we can expect some variation in what a frailty team is.
We can. There is no clear definition of a frailty team, but the ambition is to have discharge planning on admission, to ensure that frailty is assessed, and to have a multidisciplinary team approach to the person on admission to understand what their needs might be when it comes to their being clinically ready to leave hospital.
That is the ambition. As I have said, 13 out of the 15 hospitals that are in the focus on frailty programme have frailty teams in place; the other two are developing them; and the rest of the 28 hospitals are designing and developing their teams, too. More clarity on what constitutes a frailty team is being worked on, and one of the issues with getting a team ready is recruiting people on to it.
Okay. That is good.
Moving on to paragraph 68, I wonder whether you can tell us a bit more about the variances in the approach to discharge planning across the integration authorities. In particular, how are those facing challenges such as
“workforce shortages, limited resources and varying levels of co-operation”—
which we have heard in the past is a major issue—
“and joint working”
addressing those?
Back in, I think, March 2023, the Scottish Government published its health and social care delayed discharge and hospital occupancy action plan, which was about ensuring that a standardised process for discharging patients was being followed. Obviously, it had found a lot of deviation from that.
What came across in the fieldwork that we completed was that each area is completely different, and that no one process can be applied and followed all the way through. Instead, it is a matter of following the basics and getting them right, which is the approach that has been applied. The discharge without delay programme, which is a case study that we have provided in the report, has tried to standardise the process by setting a planned date for discharge, but through a multidisciplinary team process. That has helped with the target that has been set for discharging patients.
With regard to some of the major issues that have been highlighted in the report, how are integration authorities facing and tackling, say, “workforce shortages” or “limited resources”, which I presume would be money?
Different places have different resource needs and gaps. For example, there can be gaps in physiotherapy. Obviously, authorities have gone through a process of trying to recruit. They have had success in some areas but not others. On finances, I will bring in Stephen Boyle.
Actually, I was going to invite Malcolm Bell to come in.
Mr Beattie, as you will know, the Accounts Commission has reported extensively on integration joint boards—in particular, on some of the financial pressures that integration authorities are experiencing. Malcolm Bell might want to talk a bit more about that.
Yes indeed. In the “Integration Joint Boards: Finance bulletin 2023/24” we reported specifically on how IJB reserves are being continually depleted, often, to shore up day-to-day work. That is a major issue.
Money alone cannot tackle staff resource issues. Some areas—in particular, rural and island areas—really struggle to attract staff, regardless of what might be offered financially. I do not think that any one issue can be identified; a number of issues across the regions are making it a really difficult problem.
In talking about IJBs in the past, we have noted issues around the transfer of funds into the primary function. How successful has that been? Has it improved? Is more money now coming into that area, or is it still being held tightly by the NHS?
I think that there is a long way to go to deliver on the restated ambitions that came through in the strategies of the summer. Effectively, those strategies are about prevention, so that people do not have to end up in hospital after a shorter time. There are many lifelong missions and ambitions to keep people healthy; then, when they need support and care, to provide that, as you suggest, in a primary care setting rather than in hospital. However, Scotland has not yet moved into the environment of being able to deliver a preventative model. Key to that will be the consideration of where resources are best spent: in the hospital setting or—as I think is the consensus—through moving to a community-based model that keeps people healthier outside of hospital for longer.
Those are the restated ambitions of the strategies of the summer, Mr Beattie. You will recall from both the delayed discharges report and the NHS overview report that one way of helping those ambitions to be realised is to come up with an implementation plan, with the right level of dates and accountability. The hallmark of this report and some of our earlier reporting is that moving to a preventative model requires a clear, deliverable plan.
In previous sessions, we have talked about best practice and how it can be disseminated. In paragraph 74 of your report, you talk about good practice in the East Ayrshire Carers Centre. Have you seen any plans to share that good practice of collaboration between the East Ayrshire health and social care partnership and East Ayrshire Carers Centre? Obviously, that is in connection with supporting unpaid carers, but the model could be useful nationally, if it is disseminated. Is there a process for that, and is there any sign of it happening?
I will turn to colleagues in a moment, and Carol Calder might want to say a wee bit more about that particular example. However, across Scotland, there are many examples of good practice, and our report certainly does not capture them all. Excellent, committed work happens across the country. However, that still supports our conclusion in the report that there has not been enough evaluation or analysis of those wide-ranging initiatives to really get beneath the skin of why there is such variation in IJB performance on delayed discharge.
That is one of our key recommendations: there has to be a more thorough assessment so that we are not stuck when it comes to delayed discharges. Although there has been recent progress and a reduction at a high level, we are broadly still operating at the level of delayed discharges that we were before the pandemic.
That is maybe a good point at which to bring in Carol Calder, because she mentioned earlier the statistic that there are more than 700,000 lost bed days in the country. It is about the individual impact—that is, the impact on people and their families. We touch on it only at a high level in the report, but it is about the impact on the individual in terms of deconditioning and of their being more likely to be readmitted if their discharge has been delayed.
We make a high-level assessment of some of the financial loss and we get a figure, which is certainly not insignificant, of £440 million in costs to the NHS. However, the cost will be far higher than that in terms of readmission levels and the impact that it has on patients and their families.
There is some excellent stuff happening. I will bring Carol in to talk more about the East Ayrshire example and about the role of asking, “And then what happens?”
I was not going to come in on the East Ayrshire example, but Adam Bullough can perhaps do that.
However, at the risk of repeating what the Auditor General has said, I note that evaluation and transparency are key. There is a co-ordinated effort to meet regularly to support boards in order to reduce delayed discharge. There is very focused attention on the levels of discharges and the trends across Scotland. The collaborative response and assurance group meets very frequently to discuss that data, and there are three workstreams in that group that look at different things. There is a rapid response team that goes into individual boards to look at what is going on and disseminate good practice. There is a workstream that looks at good practice specifically for learning disabled adults and adults with incapacity. There is also a third one, which I cannot remember off the top of my head, but I am sure that Adam can supply that information.
There is not a lot of transparency in the wider system about what is working well. There is a lot of focused attention among people who are involved in it, but it is about a wider dissemination of good practice. Part of the conclusion of our report is that there needs to be more evaluation of initiatives, and of the value for money of certain initiatives. That needs to be transparent so that resources and effort are focused on the things that work.
Would it be correct to say that there is still an element of the different boards being in silos, and that that is a barrier to transferring good practice across the system?
Joint working, collaboration and joint decision making are important across the board. We do not have any evidence to support there being particular silos, but the variation suggests that things are done differently in different places. As has been mentioned already, the report states that there is variability in the level of co-operation and engagement across different parts of the country. It is not only about boards but about integration authorities, councils and the third and voluntary sectors, and how they are all working together in a multi-agency approach.
Joint working and joint decision making, using data that is reliable, and being able to share good practice on what is value for money and what works will support all the boards and all the integration authorities to do the best with the resources that they have. We are saying that, currently, there is a lack of evaluation and a lack of transparency about what works.
Mr Beattie, did you want to hear more about East Ayrshire?
Yes, please.
East Ayrshire is a good example of where flexible commissioning has enabled care packages to be kept open so that an individual does not face delay if, eventually, they are able to get out more quickly. From speaking with a number of other integration authorities during our fieldwork, we know that not having a care package in place is a problem and a barrier to getting an individual out of hospital. East Ayrshire is a good example of where something can be done locally.
There is, however, a flipside. It is also about a careful balance, because keeping those funds locked in one place prevents other people from getting access to them. Balance therefore needs to be applied.
However, learning from and sharing such examples could certainly be improved.
In paragraph 77, you highlight the use of reserves to address various shortfalls in the system. In your view, how long will IAs continue to be able to use their reserves to address delayed discharges, before the reserves become depleted?
That is a question for Malcolm Bell and his colleagues. I am sure that Malcolm will mention it, but the Accounts Commission has a report due that will give a further update on the financial position of IJBs and more analysis therein.
11:00
We are working on a finance bulletin for IJBs to be published towards the end of February. It is clear from previous work that the reserves position of IJBs is worsening. A number of IJBs do not now have any contingency reserves left. In our finance bulletin for 2023-24, we reported that reserves decreased by 36 per cent in real terms, adjusting for inflation, and that trend has been continuing.
If reserves are being used to change something, the initiative to use them is a good thing. However, when reserves are being used to pay for the day to day, that is when it becomes a problem. I suspect that our report that will come out later this year will report that that trend is continuing.
I will add a couple of numbers to what Malcolm Bell has just said. In our most recent report, we said that total reserves had reduced by 40 per cent in 2023-24, but contingency reserves—money that is not earmarked for other purposes—was almost halved, and at that point nine IJBs did not hold any contingency reserves. The report that is due in February will update those figures.
The use of reserves is an indicator that the financial position of IJBs is precarious, but the funding gap was projected to be £457 million in 2024-25 and, as I say, you will get updated information on that in February in the next bulletin.
I have one final question, which is based on the heading above paragraph 86, which begins:
“The third sector is a key partner in tackling delayed discharges”.
What steps are being taken to address the negative attitudes towards the third sector that are reported to have undermined effective partnership working?
Those negative attitudes have not been the focus of our work, but you are right to say that the third and independent sectors are important in the system for social care provision. One of the issues that we raise in the integration authority performance bulletin is the lack of good data. Part of the reason for that is that there are so many different partnerships, with multiple information technology systems. Their ability to collaborate is made more difficult by that and by the fact that there are different governance arrangements and accountability lines. It is quite a messy picture, but I do not have anything in particular to say about the negative attitudes that you are asking about, Mr Beattie.
It is simply that, in paragraph 88, you quote the ALLIANCE, which highlights negative attitudes towards the third sector. Have you looked into that at all?
We quote the ALLIANCE in that paragraph, but we have not done any specific work to find out what is underpinning that.
That sounds like quite an important area if the third sector is such a vital component in addressing the problem and if there are relationship issues and negative attitudes such as are highlighted in the report. I can understand that organisational differences, process differences and so on could come into it but, as we all know, attitudes can colour relationships and have a negative effect.
You are right, and the ALLIANCE’s judgment on that is clear from its reporting. It speaks to a couple of points. One is about culture. The delayed discharges issue will not be resolved by the Government or councils, which rely on working collectively with third-party providers, with the NHS and with patients and their families. Therefore, if there is a cultural barrier, it really has to be called out and addressed.
For many years, the committee—you, in particular, Mr Beattie, in your questioning—has taken an interest in some of the funding arrangements that exist with third-party providers. We have regularly spoken about the annual allocation and the funding uncertainty that third-party providers can experience when dealing with public bodies.
There are many factors to be overcome, but the point that you make is absolutely clear. Relationships have to be effective for a rooted problem to be addressed.
I give the floor to Mr Simpson.
I will start on the money. Why is it that the cost of delayed discharges is not known?
Simply, there is no single measure to capture the system-wide position on what it costs Scotland and what that money is being spent on. However, through our work, we have been looking to put a figure on that, and we got to the figure of £440 million for the cost of delayed discharges to the NHS. That is an extrapolation of the number of bed days when a bed is occupied when that is not medically required for a patient. As we touch on in the report, there are many other facets to that; we talk about, for example, the deconditioning that affects people who spend a long time in hospital. That is an important and necessary point to take forward.
We make recommendations in the report that more needs to be done by all the partners involved about the cost of delayed discharges and the value for money that goes alongside it. It would be an important starting point to bring clarity to the cost and the opportunity cost relating to delayed discharges.
I hope that I have made the point clearly enough in the report that the £440 million will not necessarily be a cash saving if we tackle delayed discharges, but it is such a precious resource, given the impact that it could have on other patients. We spoke to the committee a couple of weeks ago on the NHS report, in which we touched on some of the challenges in flow through Scotland’s hospitals—that is touched on in this report, too—with ambulances queueing at accident and emergency departments and resultant delays that come through the system.
There is a significant prize on offer, and it is well known. Throughout the report and the fieldwork that we did, it is absolutely clear that there is a focus on resolving delayed discharges and an ambition to do so. Our report looks to provide some of the means to have better data and a better understanding of the costs and, as Carol Calder rightly mentioned, a more thorough analysis of the range of initiatives that are happening.
You mentioned the impact on somebody of staying in hospital when they do not need to. In paragraph 16, you spell out that
“24 hours in bed can reduce muscle power by two to five per cent, and up to 20 per cent in seven days, increasing fall risks and care needs.”
It can lead to “dependency and demotivation”. The risk is quite obvious. That, in itself, can lead to extra costs on the system. If people are getting out of hospital—if they do get out—and then having falls, is that not an extra cost on the system?
Absolutely. We are very clear on that point, and health and social care leaders are clear on it, too. It is not that there is a lack of ambition to tackle delayed discharging. As I mentioned in my opening remarks, there are layers of interest in this issue, with the collaborative response and assurance group and the focus of ministers, including the First Minister, on resolving it.
However, to bring it right back to somebody who is delayed leaving hospital, that delay affects their future prospects of recovery in a safe and healthy environment. We cite the sources, as we always do in our reports, and there are multiple examples on page 39 of the evidence that we have gathered. Interestingly, that supports the point that I am trying to make, which is that many of the sources are from the Government’s own documents. That is why this matters so much.
Exhibit 1 on page 11 shows that the number of delayed discharges has fluctuated, but the trend is up, certainly since 2020. Why do you think that it is going up?
I agree with your assessment of the trend. It is relatively stubborn. There is a range of factors that we mentioned. For a start, Scotland’s population is increasing and the demographics of Scotland are changing, too. I will bring colleagues in on some of the detail on that. That means that there is more complexity in the cases.
We draw out, I hope, in the report that there is variation. For example, people’s experience of deprivation will be a factor. If you live in a more deprived part of Scotland, you are more likely to be living with longer-term health conditions, and that flows through to the impact that that can have on your experience of delayed discharge.
In the first section of the report, we talk about some of the wider issues. There are financial pressures across Scotland’s health boards, local authorities and IJBs, which we have touched on. We also go on to ask what some of the barriers are. We make reference, for example, to the role that some of the legal processes have in delayed discharge. Power of attorney and guardianship orders are a necessary component if there is to be further consideration about whether that part of the system is working.
As ever, the situation is complicated. There are many factors at play as to why people are delayed when leaving hospital. We have touched on some of the care package examples, too.
I will not repeat myself, or I will try not to, but I will talk about the need for evaluation of some of the processes and the underlying commitment, which is clear. Exhibit 1 shows that, for the past four years, there has been a consistent pattern of around 2,000 delayed discharges each period. There was a very significant reduction in that number during Covid, and I do not want to draw all that many conclusions about that, but it looks like we are in a fairly stable position now in relation to delayed discharge and all the financial and personal costs that come with it.
Do any colleagues want to add anything?
Appendix 1 shows the variation in boards. There are some significant improvements and some significant deteriorations in different boards. There is not a clear pattern, and the variation is very difficult to understand. That is why the CRAG is so focused on trying to understand what is happening in individual boards and what the reasons are for that.
As the Auditor General said, there is the population element, and there is the burden of health, disease, ageing population, complexity of health needs, finance, workforce and demands on the system. All of that is in the mix, but the appendix is still interesting when questioning why there can sometimes be significant improvements and then significant deteriorations.
The number of delayed discharges averages out to around 2,000 during each period, so it seems to be plateauing. There was a slight reduction just before our report was published, but the November data shows that we are back up to more than 2,000 again. There are some very complicated dynamics at play behind the results for individual boards.
The figures in the appendix that you reference are a bit all over the place, and there is no set pattern to them. People can look at it for themselves. I am keen to explore the reasons for delayed discharges. In exhibit 2, you have helpfully set out some of them. There is no one leading reason. It could be due to waiting for a care home place, for availability at a high-level specialist facility, for a care package at home or for adaptations to be made in the patient’s home. There are all kinds of reasons.
11:15
However, I was struck by these words in paragraph 67:
“If a person is admitted to a hospital, the discharge planning process should start immediately”.
That is my thinking, because, as you have highlighted, most people who are affected by delayed discharges are aged over 75, so if somebody of that age is going into hospital, it should not be too difficult to figure out that they might need a package of care in order to leave. I would have thought—and you say—that the planning should start as soon as they get into hospital.
Adam Bullough might want to say more about that.
From speaking with integration authorities about that in our fieldwork, we know that, although it seems straightforward for that to be the case, they can have differing resources and might not be able to provide the services within that care package. There are examples where carers are not available. Although it might be possible to complete the adaptations at the house to get the patient out of hospital, in reality, there is no one in the community to undertake those care visits and to check on that person. The situation varies across all regions, which is one of the things that struck us, and there is no way that you can just focus on one thing and say, “We can do X, Y, and Z, and we’ll get this fixed.” There are so many different parts to the issue and there is variation in how authorities are able to deal with it.
I remind the committee of the part of the report that says that the average delay for people with non-complex needs is only 10 days. I say “only” even though that is a significant delay for an individual, because, in comparison, delays for adults with incapacity can be well over three to six months.
In such instances, there is the issue that the Auditor General mentioned in relation to power of attorney, which is not in place for a lot of people, meaning that a guardianship order is required, which involves a very lengthy and expensive court process. Those issues are causing the very long delays for some people. As we said in the report, more needs to be done to promote and provide guidance on power of attorney, with proactive targeting of, say, local partnerships that are dealing with dementia care, so that such things are talked about in advance, when people are being diagnosed, rather than their becoming an issue when the person is in hospital and cannot be returned to their home. There is a significant jump in the length of delays for adults with incapacity.
What is the worst delay that you have come across?
I am not sure that we have information on that. We have been looking at averages. However, anecdotally, we hear on the news that people can be delayed for over a year or more.
That is pretty astonishing.
I would hope that that is rare.
Think of the impact on the patients.
At any one time, between 35 and 65 adults with incapacity can be experiencing delays of more than six months.
An interesting statistic in paragraph 82 of the report, drawn from the Scottish Legal Aid Board’s reporting on legal aid grants, is that,
“in 2024–25, adults with incapacity cases accounted for 47 per cent of all grants, up from just two per cent”
just under 20 years ago.
We rightly talk about how the issue concerns older people and frailty, but it is not solely about that. People at earlier stages of adulthood who might have severe and complex needs can also be impacted by delayed discharges.
People do not live in hospitals; they should be there for a period of time for treatment. Finding the right package of support, care and suitable accommodation after hospital must start at the outset of a person’s entry into hospital. It is important to plan to get people out of hospital into a suitable, homely setting.
I emphasise the point that Adam Bullough made about the financial pressures that exist, especially in IJBs. When somebody enters hospital, there is a risk that their care package will stop because of the financial pressures. However, continuing the care would instead give an opportunity for early discharge rather than being a sunk cost, which is how it is at risk of being perceived.
You mentioned some things in your report that may help with the problem, and you provided some case studies. One case study is the discharge without delay programme, which I guess is what we have been talking about. That is when somebody comes into hospital and we try to get them out of hospital into an appropriate setting. Discharge without delay is described in your report as a collaborative that meets fortnightly, that has over 50 members and that covers 11 health boards across Scotland. How successful has it been?
We said in the report that discharge without delay was trialled and developed in Tayside; NHS Tayside spearheaded the process. It was seen as a positive way to deal with and specifically target elderly and more frail patients. The programme has had some success and traction in Dundee city, which is one of the fieldwork areas that we spoke about.
The fact that 11 boards have now signed up to the discharge without delay programme shows that they have seen that it is having an impact, but they are all at varying stages of signing up to the process. That is because they all have varying resources; the programme cannot just be lifted and shifted in to work straight away for whichever board or integration authority takes it up. However, from the discussions that we have had with the group, the programme seems to have been a positive step forward.
The Scottish Government has also been engaged with the collaborative, and it said to us that it considers the programme to have been a positive step. That is why the programme forms part of the Government’s plan for taking the policy forward.
Your report also mentioned the hospital at home model. There is a commitment to increase the number of hospital at home beds to at least 2,000 by December. Are we on track to achieve that?
In the report, we advised that funding has been provided to health boards. They had to put in a bid for the funding, and a partial element of the funding was provided to each of the boards. I think that the policy is due to be implemented by the end of 2026—is it 2026?
Yes.
We have not had any information from the Scottish Government to advise us on where it is at with hospital at home. However, Healthcare Improvement Scotland produced a report that provided an update on the policy.
As we touched on in the report, hospital at home has been promoted as one of the initiatives to help prevent delayed discharges. That is alongside some of the funding that you referred to, Mr Simpson, which has been provided to implement the model across the country. We note in the header above paragraph 51 of the report that there has not yet been an analysis of the cost effectiveness of the hospital at home model—in and of itself, but also relative to the success of some of the other initiatives that are happening across the country. It features as one of our recommendations for Public Health Scotland and Healthcare Improvement Scotland. We note that they should consider some of the metrics on the use of the hospital at home programme to allow for an assessment of whether it is working effectively and whether it is a successful model relative to some of the other approaches that are also in play.
Healthcare Improvement Scotland provided confirmation that, between April 2024 and March 2025, the programme had prevented more than 15,000 hospital admissions, so it has its place. In preventing those 15,000 admissions, it would have prevented delays from happening. Nonetheless, while it has its place, we say that further evaluation and analysis is required in order to understand the impact that it is having against the investment that is made.
We have a small bit of time left, although not too much. We have covered quite a lot of ground, but I will ask just a few additional questions, Auditor General, if that is okay.
The most obvious point to make is that the issue of delayed discharges has been flagged by Audit Scotland for over 20 years. My briefing says that it was originally brought to the attention of a previous iteration of this committee, and Parliament, in 2001. Two decades have passed, yet here we are, looking at your latest report. It is clear that, while we are seeing some improvement in some health boards, it is still a massive issue. It is still costing the NHS £1 million a day, and tens—if not hundreds—of thousands of people are still affected by it.
I cannot get my head around how on earth, after two decades of flagging the issue to Government, we are still in this mess. It is not necessarily for you to answer, or to be accountable, for decisions that Government has or has not made over the years. However, in your view, what is the reason why it is still such a big issue?
You are right. At paragraph 96, we refer to the report entitled “Moving on? An overview of delayed discharges in Scotland”, which was produced in 2005. There is overlap between the report that we have produced with the Accounts Commission and the conclusions that our predecessors reached at that time.
There is a complicated local and national picture with regard to the funding environment, the workforce and population change. There are more people, and people are living longer but often with multiple health conditions. In some ways, it is a measure of success that Scotland’s population is growing and that there have been increases in life expectancy. However, it is, in some respects, inevitable that that can lead to people needing more care, and different types of care, as they age. What we are probably capturing is that the system has not evolved in the way that it needed to in order to allow for some of those changes. Some were predictable and some perhaps less so.
We know, and we have seen, that there is no shortage of focus or ambition to change and to resolve delayed discharges. CRAG talked about the role that ministers are playing in looking to support collaboration and the right levels of accountability. Again, however, one of the recurring themes from Audit Scotland reports is that there needs to be better data in order to understand how the investment is being made and what it is achieving.
On top of that, there needs to be much clearer implementation planning for initiatives. Some of those initiatives will be successful, but some will not, and for those that are successful there needs to be a clear, evidence-based judgment of whether they can be replicated across the country. We hope that that will allow for the system to be focused and to evolve, continuing that collaborative model while tackling some of the stubborn issues that are in front of us.
I have to say that those three themes—better and more data, clearer implementation and planning, and more collaboration on what does and does not work well and how best practice is shared—appear in pretty much every report that you have ever written since I joined the committee. Why are those such common issues across all areas of policy in Government? Those themes are recurring—every report says the same thing.
11:30
There are consistent themes in some of our reports. I would never understate the challenges—if it was easy, it would just get done, would it not? There are complex issues involved, and prioritisation of investment will be needed. I can make recommendations about needing better data and more evaluation, but some of those will take more money and resources or people to focus on them.
Our recommendations are only that: recommendations. As the committee knows, they certainly do not come with powers of intervention. They are an independent assessment of what we think will help to bring about better public spending and better outcomes from the delivery of public services.
Again, this committee ultimately plays an important role, too, in supporting that level of accountability through taking, and choosing to take, evidence on a particular topic.
Perhaps the difference between this report and some of the others is that we have seen real evidence—as I have mentioned a couple of times—of a desire to tackle the issue. We have seen the involvement of officials from across different public bodies with the ambition to work collaboratively, so I think that we are further down the line than we are in respect of some of the other topics that we have reported on to the committee.
We hope that our recommendations, particularly the recommendation on the evaluation of initiatives, will allow for a level of clarity to enable decision makers and those who are implementing the decisions to take the next steps and tackle these issues. We talk about stubborn issues; the issue of delayed discharges is perhaps the best—or worst—example in the delivery of public services that needs to be addressed.
Do you think that delayed discharges can ever be eliminated, or is that an impossible ambition? Delayed discharges can be reduced, for sure; there is clearly evidence that that can happen when approaches work well. Carol Calder spoke about some examples of good practice. Nevertheless, while the level of delayed discharges can be reduced, they can never truly be eliminated. Are we, therefore, just setting ourselves up for failure in trying to fix the problem? Is it simply baked into the processes of the entire health and social care system?
I do not believe that it is a problem that can never be resolved. We have evidence of that in the examples of variation. There have been some tremendously successful examples in Scotland of progress in tackling delayed discharges. However, the data looks so random with regard to what is working well, although that is, in some ways, a very good place to be, because it is not as if the system is scrambling around for answers as to how we tackle the issue. There are some great examples of where things have worked really well, and many of those are set out in the report.
You asked whether the level of delayed discharges will ever be reduced entirely. I would say probably not, and we would perhaps not want it to be entirely reduced, because there is a patient safety element. Making sure that people are safe and that they are in the right conditions will always take priority over having a system that focuses solely on throughput and people leaving Scotland’s hospitals. However, we have an opportunity gap here with regard to getting delayed discharges down to a level that feels much lower and more manageable and sustainable than is currently the case.
Yes—that has been well iterated in your report.
You said in your original question that the position has not changed over 20 years. However, we have also been reporting for 20 years on the lack of a shift in the balance of care, and that is fundamental to the issue of delayed discharges.
We now have an opportunity, because we have a public health framework and the service renewal framework, but what are missing from those are the implementation plans that the Auditor General mentioned, along with a reflection and recognition of the important role that the social care sector has in this regard. There is not currently a huge amount of reflection of that. We need to see how that joint decision making, joint working and joint accountability will be achieved in practice. Nevertheless, if we can shift the balance of care, we will see a shift in the level of delayed discharges, too.
That is a good point. If someone is medically fit to leave hospital and the doctors do not want them there, and if the patient does not want to be there and their families do not want them to be there but there is clearly a blockage, what happens next for that patient?
Mr Simpson went into some detail about the variety of issues that are causing the blockages. Are you saying that, ultimately, these are all social care issues and so they are community-based problems that are the responsibility of, for example, IJBs, local councils, the third sector and care homes? There are so many other partners involved in unblocking this that it is hard to see how it will all join up so that we can finally crack this nut.
I am saying that it is a systems problem. We see too many people in secondary care, and there needs to be more investment in community care and primary care so that we can avoid unnecessary deterioration and admissions and people ending up in hospital. I am not saying that it is a problem for one part of the system—it is a problem for the whole system. We have to shift that balance. The dial on that has been very reluctant to budge, but, if we can shift investment into primary care and community care, we will see fewer of the acute problems—of which delayed discharges is just one—in the acute sector.
That is helpful. We can pose those questions to the Government in due course, based on your helpful feedback.
I also want to look briefly at social care. Adam, I was quite taken by your example. It is one of many such examples that members hear, particularly from our casework, of people being unable to access care packages. You mentioned the availability of staff. That is certainly an issue, but there are also issues around the amount of funding that is available at the local level, in councils, for packages. We have heard that, if someone is unlucky enough to be a patient between January and March, and if the money has run out, they are more likely to be stuck in hospital until the beginning of the new financial year, when the money is unlocked. Is there any evidence of that happening?
No, certainly not in the work that we were doing—we did not come across that at all, although Mr Bell might have something to say about what the Accounts Commission has seen in relation to funding. During our fieldwork, councils were obviously having to make difficult decisions about what they were doing as they considered eligibility criteria. They are having to look at what they can offer certain patients when the criteria are changed. That came through in our discussions with fieldwork sites that will have to consider those criteria, given that their finances are stretched as they move into this. However, we did not come across any evidence during our fieldwork of what you mention happening. I do not know whether Mr Bell has something to add.
There is not an awful lot that I can add to that. We all know that finances are stretched, and councils are no different in that respect. Eligibility criteria are one area that they are looking at.
In paragraph 97 of the report, we say that,
“At both a national and local level, all partners need to work together to be more honest and open about the changes that are needed”
to ensure that health and social care services can remain sustainable into the future, given the increasing demands and increasing expectation gaps that we have in the system.
Can you clarify whether all boards are signed up to—was 11 the number that you mentioned earlier?
Do you mean signed up to the discharge without delay programme?
Yes. Is it 11 boards that are signed up to that?
Eleven out of the 14 boards were signed up at the point when we reported on it, which I think was in November.
Three boards had not signed up. NHS Lothian has decided to do the Lothian partnership; it has been spearheading that as a way to proceed, but the partnership does use elements of the discharge without delay programme. Some boards found that the programme just did not fit with the rules and resources that they had. However, I think that the plan would be to try to roll it out across all boards.
Are you confident that there is still a national charge towards meeting this objective?
Certainly. We have attended some of the weekly or fortnightly meetings. Given the amount of people who have been there discussing it and the work that is going into it, I would say that it is definitely making progress.
Finally, Auditor General, you have made a number of recommendations in your report, which we can read in black and white—or blue and blue, as they are. What is your overarching message that will prevent us from sitting here, discussing this in 20 years’ time?
I—or you, Auditor General—might not be sitting here in 20 years’ time, but there is a shared desire that the issue does not go on for another 20 years, because we cannot afford the financial or human cost of its doing so. What is your overarching message for stakeholders to take heed of, so that we can avoid that being the case?
You are right. None of us would wish to have a never-ending stream of reports or evidence taking on such an important issue. We are very clear that there is a desire to tackle the matter—we saw that coming through strongly in our fieldwork with all the people we met. However, it is those deep-seated ambitions to resolve the issue that have perhaps led us to have such a range of different approaches across the country. That aspect is leading to some of the variation.
It is about dispassionate analysis and people accepting that what is working in another area might be well suited to their area but might not be the initiative that they have created. It is about getting the right data, evaluating it and continuing to work in partnership.
The themes that you referred to earlier perhaps best summarise the nature of the recommendations in our report. As ever, we do not produce reports in isolation, so we will continue to follow progress against those recommendations and bring that information back to the committee in due course.
That is very much appreciated, Auditor General.
On that note, we will conclude this item. It remains for me to thank you, Mr Boyle, Auditor General, as well as Adam Bullough, Malcolm Bell and Carol Calder for joining us and giving us evidence, which we have found extremely helpful. The committee and future committees will, no doubt, take a close interest in the issue. We also look forward to the Accounts Commission’s report on integration authorities, which is due out soon.
I now move the meeting into private session.
11:41
Meeting continued in private until 12:07.