“NHS in Scotland 2015”
Agenda item 2 is on the section 23 report “NHS in Scotland 2015”. I welcome Caroline Gardner, the Auditor General for Scotland; and from Audit Scotland Fraser McKinlay, director of performance audit and best value; Tricia Meldrum, senior manager; and Michael Oliphant, project manager. I understand that Caroline Gardner has a short opening statement to make.
Good morning. Fraser McKinlay will lead the briefing session on my behalf, so I hand over to him.
Good morning. Members have in front of them our annual overview report on the national health service in Scotland, which looks at the performance of health boards and comments on the many challenges and pressures that the NHS faces. It also looks ahead and assesses what progress the Scottish Government is making towards its 2020 vision of enabling everyone to live longer, healthier lives at home or in a homely setting.
The NHS continues to be one of our most valued public services. It delivers a wide range of high-quality healthcare services to thousands of people across Scotland every day, but it will come as no surprise to the committee that the NHS system is under significant pressure. Our report highlights tighter budgets, rising costs, increasingly demanding performance targets and greater demands on its services. In recent years, the cost of delivering health services has increased significantly, and that has coincided with a period of constrained public finances. Together, those pressures signal that fundamental changes and new ways to deliver healthcare in Scotland are required now.
Spending by health boards was £11.4 billion in 2014-15. That accounts for around a third of Scotland’s total budget. Overall, we found that boards managed their finances well, given the scale of the pressures that they face, and that they ended the year with a very small underspend of around £10 million. However, many boards relied on one-off savings, and two boards required extra financial support from the Scottish Government to break even.
Our report highlights that all territorial boards, which are those that deliver the front-line services,
“are finding it increasingly difficult to meet performance targets and standards”,
and that
“The national performance against seven out of nine key targets and standards has deteriorated in recent years.”
It says:
“Ongoing financial pressures, combined with greater activity and demand, made achieving targets and standards more difficult.”
The report also says:
“The number of people working in the NHS in Scotland is at its highest level”,
but
“The ability to attract, recruit and retain medical professionals”
on a permanent basis
“is one of the biggest challenges facing the NHS today.”
The reasons for the difficulties include the rural location of some boards, competition between boards for special staff, and greater demand from staff for more flexible working arrangements. Our report highlights that boards are
“hiring more temporary staff to help keep services running”,
but that that approach
“is increasingly expensive and only provides a short-term solution. In 2014/15, NHS boards spent £284 million on temporary staff, an increase of 15 per cent”
on the previous year.
Looking ahead, we found that the Scottish Government has not made sufficient progress towards achieving its 2020 vision. There is some evidence of new approaches to delivering healthcare, but it is unlikely that all the necessary changes will be in place by 2020. The Scottish Government plans to continue working towards the vision and has launched a national conversation on the future of healthcare in Scotland. However, there is a need for a clear change in pace if the Government’s ambitions are to be realised within the set timescale.
We make a number of recommendations in the report, which focus on improvements that the Scottish Government and boards should make as they continue to work towards longer-term ambitions for healthcare in Scotland.
Finally, members will recall that in December last year the committee published its own report on accident and emergency and invited the Auditor General for Scotland to provide an update on A and E by the end of this year. We have therefore brought a briefing paper on A and E, which shows that performance against the A and E waiting time target deteriorated over the winter of 2014-15 but then improved over the summer. However, some NHS boards are still not meeting the target, and the NHS is now moving into the more challenging winter period—although, judging by the weather, I think that we are probably there already. Since the Auditor General last reported, the Scottish Government has implemented a better and more structured approach to improving unscheduled care and sharing best practice.
As always, the team and I are very happy to answer the committee’s questions. Thank you.
Thank you.
I will open the questions for the Auditor General. I refer you to paragraph 50 of the report, where you advise us that there is an increasing reliance on the use of the private sector to meet performance targets. Can you give us specific examples of how companies in the private sector have been used?
Certainly. As the report says, we have seen the private sector being used for two main reasons. One is to ensure that waiting times targets are being met as far as possible, and the other is to provide special services that are not otherwise available in the NHS. Michael Oliphant will give you some specific examples.
The private sector is used to increase short-term capacity, particularly where boards need to get access to specialist treatment. Quite often, that is for a small number of cases that are highly complex or for individuals who require complex care, perhaps with a higher ratio of carer to patient. The cases can have complex rehabilitation requirements or severe mental health issues, and they tend to involve spend on smaller specialist hospitals, such as Huntercombe hospital in Edinburgh or the Murdostoun brain injury rehabilitation and neurological care centre in Wishaw. That is where a lot of that spend goes.
How specific is that? You are saying that, in general terms, that is the way that it has been brought forward. Is public sector capacity in the NHS available that is not being used while the private sector is being pulled in to meet the targets?
An element of the private sector spend is used for short-term capacity issues to help meet waiting times. That can involve private sector organisations using facilities over the weekend and patients using private sector facilities themselves. However, most of the spend is for the specialist treatment that is required in very complex cases. The NHS will be able to provide some element of support and care for those cases, but the private sector helps out with increasingly complex cases.
You said that the Government is failing to meet the 2020 vision targets that have been set. Will you give us some specific examples of that and the lack of direction of travel that you have set out?
I think that it is primarily a question of pace. I ask Fraser McKinlay to pick up the specifics on which we based that conclusion.
As you will know, the 2020 vision is all about ensuring that people can have care in a home setting. When we look at the evidence across the system, we see some pockets of good practice in that area, but not at the kind of scale and pace that we need. In particular, resources are not being shifted from acute services in hospitals—dealing with people when they walk through the door at A and E and other places—into the community in a big enough or fast enough way. That is the main point.
Does a political decision need to be taken, or is it a management decision on the part of various boards?
The report tries to set out the fact that the Government has a lot of things under way that are designed to help the situation, including the integration of health and social care. We are publishing a report tomorrow that will come to the committee in a couple of weeks. It will update the committee on progress on the integration of health and social care.
Politically and managerially, the Government is putting in place things to help the transition. However, given the ambition of the vision, achieving it by 2020 is looking extremely challenging. The Government is now looking beyond the 2020 vision. It has started the national conversation, which is about looking to the 10 or 15-year period beyond that. We expect to see some stuff coming out of that by next spring. However, the national conversation is not going to fix the issues or deal with the pressure that we are experiencing at the moment.
To be fair, “looking extremely challenging” is a bit of an understatement. When I read the report, I thought that the situation was looking very depressing.
Having been in the Scottish Parliament since 1999, I noted that the recommendations on page 6 were the same recommendations that I read in 1999 or 2000, when Richard Simpson and I were on the Health and Community Care Committee. We are seeing exactly the same things. Boringly, I read the report from beginning to end. I was looking for a few gems of progress, but there was nothing there.
I am sorry to strike a depressing tone, but exhibit 3 on page 19 says:
“The national performance has declined in seven of the nine key waiting time targets”.
I find that deeply worrying. The following page shows that the worst decline was in child and adult mental health services and that the health board that meets the least targets is NHS Grampian. It is no coincidence that that is the poorest funded board in terms of the NHS Scotland resource allocation committee funding formula—I think that its funding is more than 2 per cent less than it should be. Is there a direct correlation between that lack of funding and the fact that it is unable to meet so many targets?
The other point that stood out to me concerned CAMHS in Tayside, where there was a reduction in targets met from 79.9 per cent last year to 35 per cent this year. We all know that investment in mental health in children saves thousands if not millions of pounds in adulthood, so it is worrying that we are missing that window of opportunity in children. What does Audit Scotland do in these circumstances? We can understand 1 per cent or 2 per cent changes happening from year to year, but a change from 79 per cent to 35 per cent is deeply distressing and worrying. What do you do with serious outliers like that? What should we be doing? What should NHS Tayside be doing? What should the Government be doing?
I think that you have set out the people who should be doing things in reverse order. Clearly, the board has the primary responsibility for improving performance against targets. It is worth saying that the overall performance around CAMHS—you will see that a number of those services took a dip this year—is partly due to a more challenging target being set for the time that someone has to wait. Michael Oliphant might have some specifics on the Tayside number.
The national figure is 81 per cent, which is pretty poor, but 35 per cent has to be pretty worrying.
By way of comparison, in paragraph 47, we talk about the target becoming tougher during 2014-15. The comparable figure to the Scotland figure for the CAMHS target that you see in exhibit 4 is 88 per cent. That means that there is still a decrease, but it is not the same as it would be if the figure was 81 per cent.
09:45
Okay. We are talking about the NHS—
I was going to ask my colleagues whether we have the specifics of the Tayside team. Do we?
No, not in this report.
We can have a look at that, Mrs Scanlon. In answer to your question about what should be done, as I am sure that you are aware, all the HEAT—health improvement, efficiency and governance, access and treatment—targets are managed closely both within boards and within the Scottish Government. When there is such a performance dip, we would expect a plan to be put in place to turn around the situation. We will see what we can do to find out a bit more about that.
Will you ask NHS Tayside what it is doing to address that very worrying situation?
Yes.
Okay. I have two questions that I have asked when you have been here previously. I tend to keep a bit of an eye on sickness absence rates. I was surprised that the Scottish Ambulance Service has the highest rate. Its rate has been consistently high over a period—the information is in paragraph 67 on page 29. For many years, the Ambulance Service’s rates have been higher than those of other service in the NHS apart from, I think, NHS 24. Why is its rate above 7 per cent? Why is the Ambulance Service such an outlier?
I will ask about another favourite topic of mine, which the committee has asked you about quite often: backlog maintenance. I direct you to paragraph 95 on page 39. Despite all the assurances that it would be addressed, it is pretty disappointing that the backlog maintenance requirement is £797 million. We are most concerned about backlog maintenance with significant risk, which accounts for 35 per cent of the total amount, or £279 million.
I think that I am right in saying that “significant risk” refers to risk to not just staff but patients. We have a requirement of about £280 million for backlog maintenance with significant risk. Why is that figure still so high, given all those assurances? Will you define, for my memory, what “significant risk” means in terms of health and safety?
I will answer your question about sickness absence first. We cited high levels of musculoskeletal complaints as the main reason for the high rate. That is about how ambulance service staff have to work and the unique demands that are put on them. As you say, the rate seems to be stubbornly high, and we would expect the board to continue to look at ways of mitigating that. At the same time, we need to accept that working as a paramedic or in ambulances is a very physically demanding job.
You are absolutely right, and you make an interesting point about the similarity of the recommendations that we have made over the years. On the one hand, we make no apology for that—we will keep plugging away and making the same points—
It was not a criticism.
I know, and I did not take it as such. Those issues are very important to us and they are becoming even more important.
There have been areas of progress and improvement. If we look back over the period, we see that waiting times, for example, are better now. More recently, we see a squeeze and all the pressures to which we refer. A significant pressure is, undoubtedly, backlog maintenance. It is a classic case of spinning lots of plates at once. As we mentioned in the report, we are investing in new assets, buildings and hospitals to make them more fit for purpose in a 21st-century health service. At the same time, we are dealing with increasing demand, rising costs and making inroads into backlog maintenance.
I am not absolutely sure about the “significant risk” question, so I will ask Michael Oliphant whether he can help with a definition of that. If not, we will come back to you with one.
I do not have a definition to hand. The Scottish Government publishes the details as part of its assets and facilities report. I think that the next one is due out early next year, if the timeline is the same as it has been for previous years.
Mary Scanlon mentioned the figure of £279 million for backlog maintenance that is considered to be significant risk. Of that figure, £80 million relates to properties that are expected to be disposed of in the next five years and £65 million relates to replacements that are planned for the next five years.
In the report that I mentioned, the Scottish Government has a plan in place for reducing the backlog over the next five years. The nature of backlog maintenance means that there will always be an element of it. The Scottish Government’s focus is to bring it down as much as possible. It is looking to a five-year horizon in which to make some large movements on that.
I want to take the backlog issue a little further. I note that 96 per cent of the estate is described as high risk as opposed to significant risk. It would be interesting and useful if we could get figures that show the turnover. NHS boards will be dealing with the high risk that was there, but new high risk will be coming in and your report does not make that clear.
Given the fact that there was a 57 per cent reduction in capital between 2008-09 and 2014-15, I am surprised that you did not comment on the consequences of that for the maintenance backlog. If we are not investing sufficiently in new structures because of such a massive reduction in capital, which I know is partly a result of the UK Government’s reduction and also transfers to revenue, there will be consequences.
It might be useful to get a slightly fuller report on the inputs and outputs and the consequences of the capital risk. Do you want to comment just now or come back to us on that?
I am happy to comment briefly.
The question is a good one. Every year when we do the overview report on the NHS, we are always looking for things that we might want to drill into a bit further for future work on behalf of the Auditor General. We can look at maintenance and managing the estate as part of our programme development activity. I am happy to take than on board.
That would be useful. It would also be useful if we could divide out the unused buildings. Those buildings might have public safety issues but, even if there is a high risk within the building, that does not affect clinical care. I am really interested in the part of the estate that is fit for purpose; that is in your report, but the percentage is not very high—I think it is at about 65 per cent.
I will turn to my main point. We have this debate about the health budget and whether it is increasing or decreasing. Of course, both figures are in your report, which shows the 0.7 per cent real-terms reduction in overall health spend in Scotland between 2008-09 and 2014-15. That is an overall reduction in capital and revenue, with an increase in revenue and a decrease in capital. How will the 2.2 per cent increase in revenue relate not to real terms, which is what you have given us, but to the fact that the NHS deflator is always different and always higher?
I know that the deflator varies a bit. Pharmaceuticals, for example, have not been increasing by the expected amount, although recently there have been big increases. However, I am trying to get a handle on that NHS deflator, and you have not commented on that at all. I know that it is difficult, but we should have a figure from you for what the NHS deflator has been over this period of time. The statement of a real-terms reduction is obviously a big political issue as well as a concern to the public that spending on health has gone down in real terms. Can you give us a further comment on the NHS deflator?
I will ask Michael Oliphant to come in on some of the specifics. I am always struck at how the answer to a simple question such as, “Is the money going up or down?” can be very complicated. You have just explained that extremely clearly, Dr Simpson.
We say in the report that costs are increasing. We have reported in the past about the specific nature of inflation in the health service. We will take the feedback on board for future reports, but it is important for us to use numbers that are absolutely reliable, robust and understandable, and that everyone can recognise and sign up to. As you said, coming to a figure for NHS inflation is quite tricky.
That said, Michael Oliphant might be able to help with any specifics.
Healthcare inflation is perhaps a bit more volatile than the gross domestic product deflator would be, but the GDP deflator is probably better recognised when looking at the overall budget figures.
The health budget largely relates to staff costs, which would fall in line more with the GDP deflator than the healthcare indexes would show. A key component as to why specific healthcare inflation might be more variable is drugs costs. It is mentioned in paragraph 27 that, looking ahead, boards are
“planning for average cost increases in primary and secondary care drugs of five and 16 per cent respectively.”
We are looking at a drugs budget of £1.4 billion; it is still a decent chunk of the overall NHS budget but you would not be able to apply those rates to the whole budget.
No. I understand. The hepatitis C costs are one of the major factors in the pharmaceutical budget.
On the workforce, I am quite impressed by the agency versus bank staff costs. Agency staff costs at £42.97 per hour are three times the cost of using bank staff. However, if we look at the helpful exhibits that you have given us on that, we see that the number of hours done by bank staff have not risen, yet the number of hours done by the agency staff have. One of the highest rates per hour for agency staff was £57 in NHS Dumfries and Galloway.
From a financial perspective, is there potential for putting on a national cap, as has been done in England? Would that work? Also, what should the boards be doing to convert some of those agency staff into bank staff, which would produce considerable savings? The number of hours worked by agency nursing and midwifery staff increased by 53 per cent in 2014-15.
The vacancy rates have been deteriorating every year since 2011 and the increase in vacancies is accelerating not decelerating, so it is an area that really concerns me. Can you make any suggestions as to how the boards should be addressing the issue or how the Government should be addressing the issue nationally—other than the national locum provision, which I think is one of your recommendations?
The vacancy rates concern us too, Dr Simpson. We focused quite heavily on the workforce issues this year because we have recognised in the past couple of years that it is an increasing pressure. As Michael Oliphant said a minute ago, the NHS is a people business in a lot of ways.
First, it is not for us to say whether a cap is a good thing or a bad thing. That is a policy decision, rightly, for Government. I will say that, before we get into a conversation about caps, there is a lot that could be done, and you have just mentioned some of them. In particular, being able to convert some of the agency staff into bank staff would save quite a lot of money and would be a good place to start. Agencies are used to plug some short-term gaps, and that needs to be done sometimes, but shifting the balance would be important.
We make a recommendation in the report about the need for a more co-ordinated and national approach. One of the things that struck us, looking at the plans in more detail, is that given that it is a national service—delivering broadly the same services across the country—we might have expected more by way of national co-ordinated workforce planning. That is why we made that recommendation; we will be interested in seeing the Government’s response.
There is the new workforce plan. I do not want to be too critical but it seems fairly nebulous. It is all very aspirational and there is not much detail. Revitalising the bank system and having better retainers and supported training, a bit of which is done already, might work—treating it as an auxiliary workforce rather than the traditional bank system that I used to be involved in.
I would like to come back in later, but I think that I have had my say for the moment.
Exhibit 3 on page 19 of the report has a line on delayed discharges—an issue that has exercised this committee in the past. The progression from 2012 to 2015 looks like a fairly dramatic deterioration, but the target has become very challenging—it has gone from 42 days to 28 days to 14 days. Has there been a deterioration in the patient experience, as the headline figures would seem to indicate, or is it simply that the target has become more challenging and more difficult to meet?
10:00
It is difficult for us to know whether the patient experience has deteriorated. The patient survey that we mention in the A and E report suggests that, overall, patient satisfaction and experience are improving slightly. However, as you say, the target for delayed discharge, which people recognise is a major problem for individuals and the system, has been toughened up significantly. That is partly why the performance is as you see it. Michael Oliphant might help me with the exact reference, but we also say in the report that the number of people who experience very long waits has been increasing, which cannot be a good thing.
It is difficult for me to say that the situation is definitely one thing or the other, but there is no doubt that it is no coincidence that the delayed discharge target is one of the two that have been significantly toughened up in recent years.
Delayed discharge arises for a variety of reasons, but to what extent is it caused by the partners?
Again, it is difficult to be specific about that, but it is clear that delayed discharge is a systemic issue. It is not just about the hospital or social work; it is about everything working together. As I mentioned earlier, the integration of health and social care is, in part, designed to help with that.
The Scottish Government has been investing in reducing delayed discharge, and we think that there are some examples of good practice that can be shared more widely and more quickly. However, you are absolutely right: delayed discharge cannot be fixed by one bit of the system on its own. Everybody needs to work together to improve it.
You state in paragraph 40:
“Between March 2010 and March 2015, inpatient cases ... increased by 13 per cent”.
To what extent has that impacted on bed nights? Has it put any strain on available beds? Does it have a knock-on effect on delayed discharges?
We do not have any specific analysis that would back that up, but we certainly flag up as another pressure in the system the fact that, as well as demanding targets, the NHS has rising activity and there is rising demand for healthcare. In-patient cases and out-patient appointments are examples of places where we have seen increased demand for healthcare, and that just adds to the pressure in the system.
It is clear that an increase in in-patient cases will impact on overnight stays, the time spent in hospital, the availability of beds and, potentially, delayed discharge as well.
We are doing some detailed modelling for a report that is due for publication in 2016 around changing models of health and social care, which I think will shine some light on both of your questions.
The system is complex, and there are trends pulling in different directions. For adults with acute needs, lengths of stay are continuing to shorten. There are also increasing levels of day surgery. However, on older people, there is a group who, once they have been admitted, are difficult to discharge safely. The issue is not just social care to get them home properly, but health and social care services to avoid the need for admission in the first place, where possible.
It is a really complex system, but I hope that the work that we are preparing will give a bit more insight into what is happening.
Throughout the report, there is mention of the need for “greater flexibility” in managing finances. What do you mean by that?
We mention that regularly in the report. I have heard it said that meeting the financial targets at the year end is a bit like landing a jumbo jet on a penny piece—it is a very difficult thing to pull off. As we explain, there is quite a lot of movement in year, and a lot of things happen towards the year end to try to balance the books.
What we are saying about flexibility is that, if boards did not have to do that balancing every year, they could take a longer-term perspective on investment and consider where to invest in different services or redesign how healthcare is delivered. That would give them a little more room for manoeuvre and freedom to plan into the longer term.
We have a section in the report that talks about new powers coming to the Scottish Parliament and, ultimately, the Scottish Government. As well as giving the Government the potential to raise more taxes, that will give it a bit of flexibility to use existing money for the health service more flexibly. The Auditor General has recommended that for a number of years, and we are still very keen on the idea.
The Government has made some moves to that end—for example, boards can now keep surpluses that they make in the year—but we think that there is more to do. If the Government is, as it were, trying to ride both horses of keeping the service running from day to day and investing in and redesigning services for the future, it is critical that something is freed up.
In paragraph 25 on page 15, you talk about non-recurring savings. You say:
“25 per cent of boards’ savings in 2014/15 were non-recurring”.
Obviously, that is a concern from the point of view of sustainability. Are you satisfied that the boards are addressing that and that they are aware of the need for non-recurring savings to be replaced by recurring savings?
My short answer would be that I think that boards are aware of the need to address that but that they are finding it very difficult to do.
I think that that is it. Quite often, if we look at some of the projections on recurring and non-recurring savings in the local delivery plans, the balance probably looks a lot more favourable on the recurring side but, as the financial years get closer, the non-recurring element increases to more than what was anticipated. There is variability across the boards, as you would expect, but it is a key pressure. Ultimately, boards would like to redress that balance more in favour of recurring savings, as that is better for their longer-term financial sustainability.
If we look at the headline figure, it does not look as if there has been a great deal of progress over the past two or three years. Is there an underlying trend? You very much look at trend analysis. Is there an underlying trend of improvement?
Again, I will ask Michael Oliphant to come in.
As we said, the pressure continues to exist. The key thing is that the non-recurring savings can be made only once, and so there is a limit to the extent to which non-recurring savings, whereby boards look to sell assets and so on, can be used. Boards have used them quite a bit over the past few financial years, so in future it will be even more challenging for them to find such savings. That means that there will be more pressure on boards to find recurring savings to ensure that they meet their savings targets.
We say in the report that the non-recurring savings figure of 25 per cent is 4 per cent higher than it was last year and 3 per cent higher than two years ago. I know that that is not going very far back, but it might signal at least the beginning of a trend. Later on in the meeting, the committee will consider reports from the Auditor General on specific boards where that is very much part of the story.
Although we are by no means saying that one-off savings are a bad thing—if a board can sell off a surplus asset or building and get a capital receipt, that is a good thing—our concern is about the extent to which boards are relying on them to break even. There is at least one board, a report on which the committee will consider later on in the meeting, where that has been the case.
Good morning, colleagues. I will start with a plea. I go back to exhibit 3 and the data on delayed discharges. I understand that you are having to report against targets that are moving but, to me, the numbers in that table turn out to be meaningless because the target has moved. Is it possible that you could generate data that sticks to the same target over a period so that we have comparative long-term figures, even if they do not relate to the Government’s target at the time? In asking that question, I recognise that the Government might report against its current target and not against the old target, so the answer might be that it is simply not possible to do that, but that does not help members.
I turn to—
Can I respond to that? It is an important point.
Please do.
The underlying data is available, and we can certainly show you what is happening across Scotland and by health board against the targets. However, the broader point that we make in the report is that the system as a whole is under pressure for reasons that we all understand. We are concerned that it is not clear what the effect is of tightening targets such as the one on delayed discharge and the one on A and E performance. The extent to which that tightening adds to the pressure on the acute system and has knock-on effects for the wider community system is important and much less visible. That is one of the reasons why we have reported in the way that we have.
That is a very fair point.
I want to go back to the point that Michael Oliphant made about the reasons for using the private sector. Could you give me some thoughts on whether what you saw seemed reasonable and appropriate? Clearly, most boards will not have very specialist facilities. Did that seem to be a reasonable use of facilities and resources?
I hope that you do not think that I am ducking the question, but that might not really be a question for us because a lot of the decisions are clinical ones and so it is not really for us to comment on their reasonableness. Another observation is that we are talking about a very small amount of money proportionately to the overall budget, although it is still a significant chunk and it has increased.
As Michael Oliphant said, the fact that some private services are being used to manage the capacity issues and waiting time pressures is one thing, but it is also about clinical decisions on the best place for treatment, and it is not really for us to make a judgment on that.
The fact that you are not saying that it is inappropriate is probably all that I need to hear.
I will move on to long-term affordability. You commented earlier on the problem of meeting the financial targets at the year end, which you likened to landing a jumbo jet on a very small space. The end-of-year financial planning is plainly ludicrous, as it is for every large organisation that has to plan annually. You have spoken about the need to get over the year-end issues, and of course we plan on a two or three-year basis and maybe five if we are lucky.
With the benefit of your long experience, do you agree that even that is not sensible and that the changes that we need to make to the NHS need to be planned over 10 or 20 years? Boards sometimes need to be able to do that. If we give them carte blanche, everything will undoubtedly be pushed back for ever until the board members have all retired—one does not need to be cynical to see how that might go. Sometimes, however, it will surely be appropriate to have a 10-year financial plan. For a very big hospital, anyway, that is surely the case.
Yes, I think that we would agree with that. Although it would be beneficial to have more flexibility at the year-end, that lack of flexibility is not a reason for boards not trying to plan for the longer term.
The report recommends that boards need to look beyond the three to five-year horizon, which many boards do, to the five to 10-year horizon and possibly even beyond that. We now understand quite a lot about demographic pressures and how they will change. Of course, that involves making all sorts of assumptions but, as we say in the report, boards should be able to plan for the best, worst and most likely-case scenarios, and we absolutely encourage them to do that.
I want to come back to the workforce planning issue. In paragraph 56, and probably in other places, the report mentions the demographics of the workforce and the length of time that it takes to train doctors. Should we not simply be planning around those who are available?
I am sorry, but I am not sure that I understand the question.
I assume that someone is trying to plan the NHS around the services that they think they want to deliver. I just wonder whether it should be planned around the services that might actually be deliverable given the staff who will be available.
If I understand the question correctly, I think that both need to be done. That is the challenge that I described earlier as riding two horses.
We know what the vision for 2020 says and, as I said, we will see what the national conversation brings out. Because of the changing demographic, the kind of healthcare that is required in 20 or 30 years will probably not be the same as the care that is required today. Therefore, as well as managing the system now and dealing with the pressures that we currently face, boards also need to be redesigning services so that they will be more fit for the world in 15 or 20 years. That has to include considering the kind of people that the NHS employs, the balance of those people and the skills that they have. Boards need to look to the future as well as managing the day-to-day issues.
I did not see any information in the report regarding the implications of the move to the European system of accounts 2010, or ESA10. How much effect did that have on the capital situation and on new buildings and the backlog maintenance?
As far as we are aware—certainly for the projects at the Dumfries and Galloway hospital and the Royal hospital for sick children in Edinburgh, which we mention in exhibit 10b—that is part of on-going discussions that the Scottish Government is having with the Treasury. At the moment, they are planned as non-profit distributing projects, but we understand that the talks are still on-going and that there has been no decision around their status.
10:15
Okay. Nigel Don touched on the issue of delayed discharge, and I was going to ask about the comparison, but I will move on to workforce planning. I do not disagree with the comments in the report about work to decrease agency costs for the NHS. There are, however, major events that take place in the country. For example, last year’s Commonwealth games were not just about building new infrastructure to host the games, because a huge amount of workforce planning for the games took place throughout the public sector, for which there were costs. How many of those additional costs will have been factored into the report?
Michael Oliphant will keep me right on this, but I do not think that we specifically picked out that kind of event. When we reported on the Commonwealth games, we looked at the additional costs. As luck would have it, Michael Oliphant did that report as well, so he will be able to tell you more. However, from memory, that report said that we did not identify many significant additional costs to other public sector partners as a result of the games, albeit that we might have expected to. However, that was not what we found.
I guess in any year stuff will happen, although perhaps not something as significant as the Commonwealth games. We therefore look at the longer term to identify whether there is a trend in the use of agency staff that really could be managed.
I imagine that people might want to join an agency rather than become a direct employee of NHS Scotland for a variety of reasons, one of which would be the potential for flexibility in dealing with their individual circumstances. It would be very difficult for anybody running the NHS in Scotland to attempt to manage the issue effectively or well, if people want to join an agency rather than become a direct employee. How could NHS Scotland manage that effectively?
There is no doubt that people will have all sorts of reasons for choosing how and where they work. I suppose our starting point is exhibit 8, which shows that the cost of using agency staff is going up and that there is a very significant cost difference between using agency staff and NHS staff. Specifically, the average hourly cost for agency staff was £42.97, and that for NHS staff was £15.62. We are not suggesting that we will necessarily reach the position where no agency staff are used at all, but shifting that balance will save some money and that has to be a good thing—I guess that that is our challenge. We are not suggesting that it is easy for any part of the NHS—it is not an easy system to manage. However, it seems to me that the cost differences are really quite significant and that therefore more needs to be done to try to shift the balance.
I reiterate that I do not disagree with the points that are made in the report regarding work to reduce costs, but I recognise that individuals join an agency to fit their own circumstances—perhaps family circumstances—and that that is a really challenging thing to try to address.
First, on all those mentions of jumbo jets, I am really grateful that you are the national auditor, Mr McKinlay, and not the pilot who will take me home this weekend.
I have a couple of questions. The first one follows on from Mary Scanlon’s point about mental health services. I was told on Monday night at a meeting of parents in Lerwick who are dealing with mental health services for family members that NHS Shetland is discharging people to avoid not meeting its HEAT target. Did you come across any evidence of that when the work on the report was being undertaken?
Not specifically. It was a national overview, so we tended to use nationally available data in the accounts and such things. Therefore, we would tend not to get into the detail.
Where would the detail appear, if anywhere?
If people had concerns about how waiting times were being managed, they would blow the whistle, I think.
It is an audit issue, because it is to do with being accurate about what is going on. I genuinely do not know how we tackle it or find out the reality. I have heard an anecdotal story and have found eight cases that I can point to, but I would be worried if it was happening right across Scotland.
Sure—as would we. It is important that the people who have concerns raise them through the appropriate channels.
Yes. Okay.
I refer to paragraph 72 and agency staff, which is an issue that Richard Simpson rightly raised and which Stuart McMillan also mentioned. Two things strike me. First, there are specific rural issues, which you have mentioned. There are rural and island board issues to do with locum, agency and bank costs, all of which are going the wrong way; indeed, the numbers are even worse in rural parts of Scotland.
You answered Nigel Don’s question about a five to 10-year horizon. There does not seem to be any real focus on the specific problems for rural and island boards that are clearly very costly to the NHS. Have you pushed that point with the Government or the NHS at the most senior level? Have you said, “Right. In workforce planning terms, there’s a specific problem here. What is being done about it?”?
I think that the Government and boards—particularly the boards that deal with pressures in the islands and remote and rural communities—are absolutely aware of the point and are absolutely trying to do things to manage the issues. We mention in the report the innovative things that some boards are doing to try to attract and recruit people, but we also mention that boards are quite often in competition for the same sort of people.
The point that we make in the report is that boards cannot fix the problem that in isolation. That is why the recommendation about national workforce planning is directed at the Scottish Government. There are things that boards can and should do, for sure, but a national co-ordinated approach is needed. We think that more can be done around national workforce planning to make it more targeted and focused to deal with some of the immediate pressures in a way that has an eye to what healthcare will look in 10 years’ time.
Sure. Paragraph 77 of the report says that
“Local workforce plans ... do not give an overview of national workforce issues or trends and do not provide solutions across boards, or nationally, to problems such as difficulties in recruiting and retaining staff.”
That is fundamental, is it not? I would tend to agree with Mary Scanlon if those things are not happening—I do not know whether you mean that they have not happened in the timespan that is covered by this particular Audit Scotland report or whether it is a long-term issue. We have been at the matter for 15 years, and you make a pretty fundamental finding in paragraph 77 about what is not working.
In paragraphs 78 and 79, we go on to give a bit more detail about what the Government has done and why we think that that is limited and that more needs to be done at a national level. The six priority actions for 2015-16 that we mention at the top of page 33 are fine and good, but we think that the approach needs to go further because of the sense that it is still a bit too focused on individual boards and what they can do rather than on taking a nationally co-ordinated approach.
None of those six actions relates specifically to rural and island boards, which face the highest costs. Given the costs and problems that, as you rightly say, boards have been totally aware of—I know that they are aware of them—would it be legitimate and fair to say that there should be another bullet point that specifically recognises that?
The issue needs to be specifically recognised somewhere, but whether that should be through another bullet point is for someone else to decide. There are very particular issues in rural areas, and there are particular pressures on other parts of the system, too.
I have one question and a couple of comments.
When the Health and Sport Committee looked at finance and got the finance directors in front of us, we tried to drill down into the costs of having a 100 per cent guarantee as opposed to a 90 to 95 per cent guarantee. They and Paul Gray certainly admitted that the struggle to achieve a 100 per cent legal guarantee, on which we are failing 10,000 Scots a year—we are not successfully achieving it—has massive marginal costs.
Again, I am somewhat surprised that, although the overview is very good on bank and agency staff—it shows the costs in that area—it does not show the other costs, as far as I can see. Maybe I missed that bit, because we have a lot of papers to read. The finance directors were either not able or not prepared to give us that information on an area where we know there is a constant struggle. We know anecdotally of locum costs of £3,000 for one session—that was in the press recently. Those are massive costs.
Mr Oliphant referred to the private sector. Leaving aside Huntercombe and the Murdostoun brain injury unit, which are an appropriate use of the private sector, there is an overspill that is used for private operations on bunions and other such things, where there is no real clinical urgency but a target must be met. I really would like to know the cost of that, or at least I would like to have some idea of the cost. Is there any way that you can—or could in future—give us that information? Could you require the boards to provide such information, given that they must know it?
I will ask Michael Oliphant to comment on the specifics of whether we can figure out the additional cost that is involved in meeting those targets. We have said in the overview report and in previous reports that we recognise that there is a disproportionate effect from focusing on delivering on the last few percentage points of a target. That is one of the things that make it more difficult for the system to redesign the way in which it delivers healthcare. We said that in 2013-14, and in the overview report we make the point about challenging targets more generally.
Your make a very fair point about the extent to which we have gone into the specifics of that area in the overview report.
Finding out the cost, or the marginal cost, as Dr Simpson described it, would be difficult. It is actually quite difficult to look at the cost of meeting one target in isolation—for example, the cost to the NHS of meeting a delayed discharge target—because the targets are very much interlinked. It would be very difficult to separate them out to get an accurate figure for the cost. Some analysis could perhaps be done to provide an indication, but we would need to explore that with boards to get a sense of the data on costs that they might use.
As Fraser McKinlay mentioned, at paragraph 51 of the report we draw out the point that the Scottish Government and boards put extensive effort into meeting the targets. We flag up that there needs to be a balance between focusing on short-term targets and looking at the longer-term transformational change that is required for the NHS. It is important that the right balance is struck.
Perhaps I am being very simple, but if boards are spending the money on trying to reach that last 1 or 2 per cent of a target, they will not have the money for transformational change.
Can we get an update at some point on daycare? You did a very good report on daycare, which showed huge variation between boards. I do not know whether you intend to produce an update on that—perhaps I can write to Ms Gardner on that point and on other questions.
I want to follow up the point about marginal costs, which are crucial to any economic model. I appreciate that, as auditors, you go looking for the data that is already out there and try to analyse it. If the marginal costings in the NHS are not available, should someone be asking for some research so that they are? That information is surely absolutely crucial to the economic model.
I will step in to echo the frustrations that Ms Scanlon and Dr Simpson have expressed today. It feels as though, for as long as I have been involved in public audit in Scotland, we have been talking about poor cost information in the NHS.
Michael Oliphant is absolutely right: over and above the amount that is spent with private sector providers to meet waiting time targets, it is very hard to come up with the total cost of the NHS’s contribution to meeting those targets and other priorities. Having that better data is fundamental to enable boards to make the shifts that we know are needed; otherwise they will not keep up with the pace of the financial pressures and the demographic and other demands on the system.
Various colleagues have mentioned the workforce and vacancies. I am quite worried about the figures for consultant, nursing and midwife vacancies. Exhibit 6 on page 26 shows that there has been an 87 per cent increase over the past year in vacancies that are open for six months or more. Paragraph 58 drills down further into that. The report looks at referral and treatment targets for cancer of 62 days and 31 days, but most patients are worried—as I would be; I hope that it does not happen to me—not so much about the first doctor that they see but about whether their treatment will lead to a good outcome and whether they will have a good survival outlook.
I apologise for going back, but for as long as I can remember—for more than 10 years—there have been shortages in clinical radiology, and 12 per cent of the posts in that area are still vacant. I am worried that the actual targets are pretty meaningless. The first time someone sees a doctor, that is fine, but I would be worried about whether I would get my treatment on time, whether it will treat my cancer and whether I will have a good outcome.
10:30In future, can we look at the impact of vacancies on survival rates, which we do not look at just now? My information is a bit out of date, but I think that I am right in saying that the survival rates in Scotland are quite poor in comparison with those in the rest of Europe, and I wonder how much the vacancy rates affect that.
The vacancy rate is 17 per cent for general acute medicine and 12 per cent for radiology. Perhaps in future, rather than looking at the fairly meaningless targets, we can look at the outcomes. That is not what we are seeing just now. I am only here for another four months, but that is something that the Auditor General could look at in future.
We need more stark figures about survival. We have had more than 10 years to work with universities to get more radiologists, but the situation is still as bad as it ever was. If people going for cancer treatment know that there are 40 vacancies, they will worry.
That is a timely question, as our team is currently in the process of planning what we want to include in next year’s overview report. It is like painting the Forth rail bridge: we are constantly starting on the next version.
I take your point about there being scope for more information about outcomes in the report. Equally, it is important—particularly for this committee—to keep a clear focus on inputs: on the money and on the other things that deliver services. We will look at how we can deliver that in ways that are meaningful—as you can imagine, the relationships are quite complex.
Before we move to item 3, I will suspend the meeting for a few minutes to allow for a change of witnesses.
10:32 Meeting suspended.Next
Section 22 Reports