“NHS in Scotland 2013/14”
I welcome Caroline Gardner, the Auditor General for Scotland, Tricia Meldrum and Jillian Matthew. I invite the Auditor General to make opening remarks.
Thank you, convener.
The national health service in Scotland plays a significant role in the lives and work of millions of people every day, and it is essential that the service is able to meet the needs of the population and deliver good-quality healthcare. Spending on the NHS accounts for about a third of the Scottish Government’s total budget.
My report comments on the performance of the NHS in 2013-14 and on its future plans. The overall message is that the NHS in Scotland faces significant pressures at the same time as it needs to make major changes to services to meet future needs. We know that NHS boards are finding it increasingly difficult to cope with those pressures in a tightening financial situation. The report also comments on the increasing evidence of pinchpoints in the complex health and social care system, which can lead to delays in patients getting the care that they need in hospital or in the community. Some of those pinchpoints are shown in exhibit 13 on page 40 of the report.
We found that NHS boards in Scotland delivered a small surplus of £23.4 million, against an overall budget of £11.1 billion in 2013-14. All NHS boards met their financial targets, but several boards required additional funding from the Scottish Government or relied on non-recurring savings to break even.
Despite significant efforts, the NHS did not meet some key waiting time targets in 2013-14. We consider that the current level of focus on meeting waiting time targets may not be sustainable when combined with the additional pressures of increasing demand—such as from the growing older population—and tightening budgets.
We highlight in the report that increasing numbers of people being admitted to hospital from accident and emergency departments, rising numbers of delayed discharges and more demand for out-patient appointments are creating blockages in the system, which put further pressure on services. NHS boards need a more detailed understanding of current and future patient demand, of how they use their capacity and of how patients move through the system. That will help them to assess how they can deliver services differently in the future better to match needs.
The NHS has made good progress in improving outcomes for people with cancer or heart disease, and in reducing healthcare-associated infections, but progress has been slow in moving more services into the community. Further significant change is needed to meet the Scottish Government’s ambitious 2020 vision for health and social care. It is clear that the NHS will not be able to continue to provide services in the way that it currently does. We recognise that it will be challenging for the NHS to make the scale of changes that will be required over the next few years, but doing so will be critical if it is to meet the 2020 vision and the future needs of the population.
We make a number of recommendations in the report. They focus on NHS boards working with their partners to develop clear plans about how they will deliver sustainable and affordable services in the future, including how they will release and move funding to provide more services in the community. We also recommend that NHS boards and their partners use information better to understand where the blockages in the system are that lead to problems such as people having to wait in hospital for longer than they need to.
Looking at the bigger picture, the NHS needs to take a step back and look at what it is trying to achieve. It also needs to develop clear long-term plans for delivering sustainable and affordable services for the future. As part of that, we have recommended that the Government reviews its performance framework to ensure that targets and measures for the NHS are consistent with and support its 2020 vision.
As always, my colleagues and I are happy to answer questions.
Thank you.
You mention that the waiting time targets may not be sustainable, yet we know that the setting of targets has had a remarkable impact on service delivery. We need only think back some years ago to the waiting times that people used to have for treatments that are now seen as relatively routine things that can be done quickly. If you think that the targets may not be sustainable and if it is accepted that targets have made a contribution by improving the service for patients, what is the solution?
It is important for us to be clear that we are not saying that targets are not important and may not be useful. We know, for example, that waiting times matter to all of us and our family and friends in knowing how quickly we will be treated and ensuring that we are treated as quickly as possible. However, after a long period in which, as you said, waiting times across the system have been coming down, that trend is starting to be reversed.
We have particular concerns about increasing waits for out-patient appointments when people enter acute hospital care and about delayed discharges when they are waiting to go home. Our concern is that the focus that people in the health service are putting on meeting those targets is making it harder to step back and look at how the acute system as a whole is working, and at how it fits into the wider system of health and social care. With the tight budgets that we know are likely to be in place for the foreseeable future and the growing needs of older people, our concern is that balance may not be sustainable. We are not saying, “Do without the targets.” We are saying, “Make sure that the targets are achievable and moving the health service in the right direction.”
Which is the most critical factor—increased demand for services or squeezed budgets?
It is a combination of all the factors; it is not possible to pin down the contribution that each of them makes. We know that the Scottish Government has protected the NHS revenue budget with slightly above-inflation increases year on year. We know that healthcare costs tend to go up faster than general inflation, so that money is not going as far as it would do in other services. We also know that the population is getting older, and older people tend to have more complex healthcare needs. We have more challenging waiting time targets now, and we outline in the report how some of the targets have got tighter over the past few years. All that together is contributing to the picture of increased pressure that we are painting today.
When we look at exhibit 5 on page 23, we see particular issues in some health boards compared with others. For example, in NHS Grampian and in NHS Greater Glasgow and Clyde, there are a number of areas in which we see a deterioration, no improvement, or just a failure to meet the targets. NHS Forth Valley also has significant areas of concern. Are there specific reasons in those health board areas? Is it a management issue? Is it a budget issue? Why do those issues arise in some boards and not others?
There are specific issues in specific boards across Scotland—that will always be the case—but we believe that the evidence shows pressure on the health service right across Scotland. Later this morning, you will be looking at section 22 reports on NHS Highland and NHS Orkney, which suggest that the pressures that are coming out there particularly strongly are financial pressures. For the boards that you have highlighted in exhibit 5, I think that the pressures are coming out particularly in clinical performance, especially with regard to waiting time targets.
We highlight other boards that have had an increasing focus on non-recurring savings or support from the Scottish Government to balance their budgets. One of the lessons that we have learned in recent years is that it is risky to look at financial performance or service performance in isolation. You have to look at the picture in the round, and all the evidence suggests to us that there is increasing pressure in the system.
At paragraph 48, you mention that the NHS
“spent £128 million on bank and agency nursing and midwifery staff in 2013/14, an increase of 15 per cent”.
That is a staggering figure, yet at the same time, in exhibit 7 on page 28, you show that the number of nursing and midwifery vacancies is rising. There is an increase in vacancies and we are using more private staff. Why can we not simply recruit some of those private staff to fill the vacancies?
In general terms, there are often occasions when using temporary staff is a good thing because there are peaks in the workload. For example, when long-term sickness absence needs to be covered, in our view using bank staff is the preferred option. Bank staff tend to cost less than staff from private agencies and, because they are on the hospital’s own bank, they tend to know the hospital and its safety and quality procedures better. The question is why there is overall pressure on nursing staffing and how it can best be managed.
I understand that but, in paragraph 48, you also say that spending on agency staff increased by 46 per cent, and that followed a rise of 62 per cent in the previous year. We are not talking about marginal and trivial changes; we are talking about substantial changes.
Absolutely, and that is why we have drawn attention to it in the report. Spending more on agency staff in that way is a pressure on the finances of the NHS; it also brings additional risks to patient safety, because the bank staff are less familiar. I ask Tricia Meldrum to talk you through the background.
Prior to the past two years, the general direction has been that we recognise that there is a need for some flexibility around the nursing and midwifery staffing and that has come largely through the bank staffing; the staff are people who are already employed by boards, are already working there and can do some additional hours. That is seen as being the more efficient and effective, and the safer, option. Obviously, the bank has not been able fully to meet the needs and that is why we have seen an increase in the use of agency staffing. Sometimes that is in very specialist services where one would not expect bank staff to be available. That can be an issue, but it is an indicator of increasing demands and pressures. It is still a very small percentage of the overall spend, but we have highlighted it because of the change in the trend that reverses what has been happening in recent years.
09:45
I want to return to information technology. The committee has talked about IT a huge amount and it seems that lessons are never learned—we are always told that next time round all will be fine.
Case study 3 on page 15 is on “NHS 24’s Future Programme”. It states:
“NHS 24 has delayed implementation as it considers that the new application … developed does not meet … patient safety”.
The original business case was £29.6 million, but the total cost to date is £38 million. The report goes on to say there is
“brokerage of £16.9 million and £0.8 million in revenue funding”
and then a further £2.2 million. The original business case was £29.6 million. How much is this costing at the moment? When is it likely to be finished? Have lessons been learned? What is the final cost and why has it gone so badly wrong?
There is a limit to what I can say about that particular case at the moment, Mrs Scanlon.
There is a court case and some of this may be sub judice, so I think that we must bear with the Auditor General in any comments.
I was not aware of that. It is on the record, but can we flick over carefully from that one? I apologise, convener.
Okay.
We will report more in due course when we are able to do so.
It is certainly worthy of further investigation, so I will watch that carefully.
I appreciate that we are coming to NHS Highland under the next agenda item. However, NHS Highland was being told 15 years ago that it should not depend on non-recurring savings. That was in 1999-2000, but it is now 2014. NHS Highland is not the only one; I mention it because exhibit 3 on page 17 shows that many boards are dependent on non-recurring savings, obviously apart from NHS Greater Glasgow and Clyde and, to an extent, NHS Forth Valley. Why is this still happening when it was a problem 15 years ago? Nothing seems to have changed.
It is a concern for us across Scotland. I think that you are referring to exhibit 3, which shows that NHS boards across Scotland are relying on non-recurring savings to varying extents. They can be a useful way of balancing the budget in year, but they add to the pressures on health boards in the longer term, because those savings must be found again in future years. That is why we have made recommendations about improving both longer-term and in-year financial planning. Not only does it take pressure off in future years, but it makes it more likely that savings are helping to reshape the services for the medium term, rather than running the risk of making that more difficult by making easy cuts that may well make it harder to develop community-based services and new types of service for the future.
That could explain why NHS Highland is facing the pressures that it does, but I appreciate that that is for the next agenda item.
I turn to exhibit 5 on page 23. I notice that NHS Grampian has not achieved any of its targets for 2014 and that NHS Highland has achieved only two. No health board has achieved the out-patients target for within 12 weeks. Five out of 14 boards achieved the day-case treatment time guarantee target. Five out of 14 met the accident and emergency target. On urgent referral to first treatment for cancer, the figure is also five out of 14—almost a third. For delayed discharge, it is three out of 14.
The report states:
“Performance against some waiting time targets deteriorated”.
Having read these reports annually, I wonder whether the waiting time targets are too stringent, or is the money simply not there? Why are things getting worse rather than better? Is it a management problem? Is it a financial problem? Is it how we do things? Every time that we come to this, there are a myriad problems, which we are told will all be sorted by next year. Then the next year comes along and we are full of optimism, but things have deteriorated again. Why have most health boards not achieved their targets? I appreciate that there are difficulties with Grampian and Highland, because they do not receive their full national resource allocation committee allocation.
There are a combination of factors, which apply across the health service but apply to differing extents in individual boards.
First, we know that finances are tight. The Government has protected NHS revenue budgets for the front-line delivering boards, with increases that are slightly above inflation, but healthcare inflation tends to be higher than that. We know that the population is getting older, so there are more old people who tend to have more complex needs and who need more support to be discharged from hospital once admitted. We also have particular financial pressures in some boards, such as those that are below their NRAC allocation, which adds to their challenges. You can see from looking across the table that some boards are managing better than others, and we have talked before about examples of how services are being delivered and redesigns that help to manage those pressures at a local level.
The NHS as a whole is doing some work to improve its understanding of patient flows and the pinchpoints. Some of the targets have become more stringent over the past few years, which is why we suggest that it is time to take a step back and to ensure that the balance of targets, the available funding and the longer-term vision to reshape healthcare are all in the right place to be able to work effectively, rather than running the risk of inefficiency by focusing on an individual target at the expense of the bigger picture.
Looking at this report, it does not seem to be progressing, but let us have hope for the longer term.
My final point is on exhibit 13 on page 40, which I thought was quite interesting. It is about digging below the figures, quite a few of which stood out, but I am sure that colleagues will raise issues about them, too. In the bottom right, in one of the red boxes, it states that there has been a 4,200 per cent increase in the number waiting for more than 12 weeks. We would always like to think that the focus is on clinical need rather than on meeting targets, but that seems to suggest that more and more people are having to wait for longer than 12 weeks and are perhaps just being treated before the day of the target in order to come in on target. That is a huge increase. Does that mean that, regardless of their clinical need—I am putting words in your mouth, but this is how it appears to me—more and more people are having to wait for the target to kick in, rather than being treated on the basis of their need? A figure of 4,200 per cent is one of the highest that I have ever seen as far as a change within one year is concerned. Am I misunderstanding that, or could you explain it and clarify it?
We can do; I will ask Jillian Matthew to come in on that specific point in a minute. More generally, we are trying to ensure that we understand the way in which this complex system works in practice, because we know that some targets are being met by most boards, although not all of them, but we are seeing these warning signs of pressure building up for out-patients waiting for their first appointment, and delayed discharges of people waiting to leave hospital safely at the end of their treatment.
The convener asked earlier whether the targets were a good or a bad thing, and the answer, of course, is that they are both. It matters to all of us that we are seen as quickly as possible and that we have some certainty.
I think we would all agree with that.
Indeed, but equally having a target that is unachievable—so that people’s efforts simply go on meeting the target, rather than on ensuring that the whole system can work smoothly—is not helpful.
We have tried to identify where the pinchpoints are—where there appears to be real pressure in the system—and where the risks of managing to the target may be higher than they would be elsewhere, when a system is running in steady state. Jillian Matthew will pick up the specifics of what is happening with that particular aspect.
Some clarity would be helpful, thank you.
The figure that you referred to is around out-patient waiting times for 12 weeks. On page 24 of the report, we lay out some of the figures around what is happening there. The number of people is increasing at a much higher rate than the number of people who are being seen, but that is going back to the overall increase in demand from various issues around the ageing population and more people with long-term conditions.
With exhibit 13, as the Auditor General said, we were trying to show overall where some of the main pressures are for the NHS. Out-patients was one of those pressures, along with delayed discharges and increasing numbers being admitted from A and E, especially older people. Out-patients is one of the areas in which we are seeing the pressures, but the boards are trying to look at the whole system. In the past, the boards would have looked at separate areas such as A and E and what is happening in out-patients, but they are starting to look at the whole system.
Work is going on, and the Government is supporting some boards in piloting a new approach to look at the whole system, patient flows, what is happening in A and E, what impact that has on in-patients, out-patients and community care, and how that is all joined up. That work is quite early, but there is quite a lot going on around understanding that better.
That relates to my previous question, and to the fact that no board met its out-patient target.
Am I right in saying that, in March 2010, 157 patients waited for more than 12 weeks, and that in March 2014, 6,754 patients waited for more than 12 weeks? Let us say that everyone who goes for a hip operation has different levels of pain and need. Does it appear that clinical need is being surpassed to meet targets, because more people are waiting for more than 12 weeks? It is significantly more—4,200 per cent more. Is there a distortion?
We all agree on targets. No one wants to go back to a two-year wait for orthopaedic surgery, but at the same time we do not want the urgent cases to be lumped in with the 18-week target. This seems to be the first indication that I have seen that everyone, regardless of need, has to wait longer than 12 weeks. Am I interpreting that wrongly?
No, but we have not found evidence that people are being managed to the target or, for example, that people with less need are being seen sooner than people with greater need just because of the target. However, we are seeing that increase in the number of people who are waiting for more than 12 weeks—the number is still relatively small if you compare it with the 350,000 or so people who are being seen as out-patients each year, but it is going up markedly. As Jillian Matthew said, more people are being added to the out-patient waiting list than are being taken off it, so at the moment the trend is for that number to keep increasing.
That is the pinchpoint that we wanted to identify in the report as one of the signs of the system being under pressure. It may be that the 12-week waiting time target is not quite right. It may be that the targets for treatment after that could be adjusted. We think that the Government needs to take a step back and say, “How do we get the system in balance? How do we make sure that the targets we are setting are helping us to reshape the service for the 2020 vision rather than making it harder?” We think that that is the risk at the moment.
Do you agree that the increase is significant?
It certainly is.
We are getting the percentages and the amounts, but what is the total through number of out-patients in the service? That will give us an idea of how many people out of the total are failing to meet the target.
The number of new out-patients seen during 2013-14 was 367,259 so, as I have said, the number of people waiting more than 12 weeks is a relatively small number at 6,754. It is increasing, however, and the current trend is that it will continue to increase.
I am trying to get the number in perspective. Although the percentage rise may well be a trend that you have identified, in terms of the total amount going into the system, it is still a relatively small number.
Absolutely. As I said, it is about 6,750 people out of 367,000 new appointments, but the trend is upwards.
That takes me back to the question that the convener asked about bank staff and, of course, private staff. I assume that the total number that has been taken in is very low in comparison with the total staffing number for the health service, which shows that there is not—shall we say for the sake of argument?—a privatisation menu. The aim is simply to deal with the pressures that are being faced at this moment. There is no policy decision to move to using private or bank staff on a permanent basis for a service.
10:00
As Tricia Meldrum said, the £128 million spent on bank and agency nurses last year is a relatively small amount in the overall spend on the NHS, and the evidence available to us suggests that it is meeting short-term needs for staffing in different health services.
My next question is about something that has come up over the past couple of weeks in various places. Reducing Westminster budgets have meant a 10 per cent reduction in Scotland’s overall fiscal budget—the cash revenue and capital combined—between 2010-11 and 2015. That has meant a capital cut well in excess of 20 per cent. As the Scottish Government is using non-profit-distributing programmes to ensure that investments in NHS infrastructure are carried on, would you consider the equivalent capital value in future NHS budget assessments?
The report looks at the amount that came out of the information from the audits of all NHS boards last year. You might recall that we reported last year on a wider basis across the Scottish budget about the importance of improving and increasing transparency, particularly about revenue-financed investment.
We know that the capital budget is decreasing and that, for the known planning period, it will be reduced. For understandable reasons, the Government is investing in other ways through the NPD and other models and is planning to use the new borrowing powers that it has under the Scotland Act 2012. All those are entirely appropriate policy choices for any Government to make but, in my view, it is important to have transparency about that spending, what we are getting for it and what the long-term revenue commitment is, to enable the Parliament to understand the context of the Government’s financial decision making and the longer-term choices that that involves.
I am asking about keeping a broad perspective on how the Government is dealing with the problems of diminishing capital investment.
We have tried to give as much information as we can in the report about the revenue and capital budgets and about outturns. There has been a further announcement just in the past few days about new health service investment coming from the NPD model. That is not included in the report but, as it comes through the NHS accounts, it will be in the future.
So you would put that into this sort of report in the future.
As investment comes through the NHS accounts, it is always included.
I am looking at paragraph 13, at the top of page 16, which is on the allocation of funding. The Scottish Government is aiming for all NHS boards to be within 1 per cent of their allocation by 2016-17, which is not very far away. At the moment, four bodies are below their target allocation. Two of them—NHS Highland and NHS Orkney—are featuring today under agenda item 3 because of a funding issue. Is the target realistic? NHS Highland and NHS Lanarkshire seem to be going the wrong way. Is there a plan? Have you seen it?
We understand that the plan is for each board to be within 1 per cent of its allocation by 2016-17. The background is that the formula has been in place since 2009-10. It takes account of the make-up of the population, levels of deprivation and other health needs, and the costs of providing services in remote and rural areas. The intention is that each board should be funded on that basis by 2016-17. At the same time, we know that the Government has made an explicit declaration of policy that, in moving towards that aim, it does not want to destabilise individual health boards and particularly those that would lose by having money moved away from them. The formula is a way of allocating the overall NHS pot and not of providing more money to the boards whose allocations are currently below their formula level.
We understand that the policy intention is in place. I think that we have seen additional funding to NHS Grampian in recent months to help it to move forward more quickly, in recognition of the clinical challenges that it has faced. In broad terms, it is a policy decision for the Government to make about how quickly to move towards the intention and what exceptions it might make in either direction for particular boards.
Just to be clear, the funds—there is quite a bit of money there—have to move from other parts of the national health service to achieve the aim.
Yes. The formula is a way of allocating the overall NHS budget, not of adding new money into the system.
There has been some talk about bank nurses and so on. The last sentence of paragraph 48, on page 29, says:
“Agency staff are likely to be more expensive than bank nurses, and also pose a greater potential risk to patient safety and the quality of care.”
Why is that the case?
That is because bank nurses are employed by the local NHS hospital or system. They are on the bank permanently, so there is the chance for proper induction, for continuing training and development and for them to build up their awareness of things such as the crash procedure, if somebody has a heart attack on a ward, and how things are done to maintain drug safety on ward rounds.
Agency staff are employed by a private agency. They tend to be used for shorter periods and in different areas of the health service, so they do not have the opportunity to be trained and inducted in the same way or to build up their experience of how the system works. The broad professional consensus is that bank staff are cheaper and can provide a better quality of care. Agency staff may be needed on occasions, but they should be a last resort that is used when needs cannot be met from bank staff.
Agency staff are increasingly being used. You say in paragraph 48 that the spend on them has increased by 46 per cent. Surely they are trained up to the same standards as NHS staff. Surely it is in the agencies’ interest to ensure that they are trained in NHS procedures. I am concerned about the comment on patient risk.
You are absolutely right—agency staff are trained to the same standards as nursing staff across Scotland, and a good agency has every incentive to invest in professional development for its staff. The issue is familiarity with how things work in a hospital, a speciality and a ward, and the ability to build up experience of knowing where the drug cart is, what the processes are and about the other members of the team, which are also important elements in the quality of care for patients. It is that familiarity more than anything that makes the difference.
So the issue is nothing to do with the skills of the agency nurses who are employed; it is to do with the short-termism of their attachment and their potential unfamiliarity with the area that they are working in.
That is right.
Can I clarify the reference to the evidence for the report’s comment? Is that evidence from the 2010 report “Using locum doctors in hospitals”?
Yes. We did work on bank and agency nurses further back than that, so we have been building our expertise in that area over a long period.
So there is evidence about nursing staff as well as doctors.
Yes—very much so.
Paragraph 59, on page 33, deals with pensions, which have come up before. Public sector pensions are quite a big issue, because almost every area is running a deficit. You have not quantified any deficit in the NHS. Do you intend to do any work on public sector pensions in the future?
We have not quantified the deficit in this report because we have focused on changes and future pressures. We have reported a couple of times on NHS and public sector pension schemes more widely.
One challenge for the NHS scheme is that it is not a funded scheme, so there is a large liability, but there is no asset against which to match it. The challenge is ensuring that the liability is understood and that its long-term cost implications are being factored into long-term financial planning. There are moves across the United Kingdom to make changes to pension schemes—both to the way in which costs and benefits are shared and to the way in which they are funded, to make them more sustainable in the long term—but the NHS scheme is currently unfunded. The report refers to things that are changing the pressures that health boards face.
If the scheme is unfunded, does that mean that there is no pension pot?
You are right.
So pensions are paid out of revenue.
Yes.
That is quite a big liability.
It is, and that is the case for most public sector schemes, apart from the local government one. The local government superannuation scheme is the only one with a pension pot to match the liabilities, but all the others are paid from revenue, which is why we have reported in the past on how the overall liability is being managed, and why we have focused in the report on how the costs of meeting that liability are increasing because of known changes that are coming through.
I realise that this is a UK-wide issue, but did you say when you were thinking of doing the next review of public sector pension liabilities?
We keep that under review all the time, because it is significant. We are likely to include information on it in our next report on developing financial reporting, which is due in the new year. I have not made a decision on doing another in-depth look at pensions, but that might well come up in the programme in the next couple of years.
There are a number of worrying comments in your report. Am I right in thinking that there have been about 2,000 fewer beds over the past four years in our health service?
That number sounds right; I will ask colleagues to keep me right on the detail. We have reported to the committee before that a large part of that decrease is because there is very much a move from surgery being provided on an in-patient basis to day surgery. The number of beds has decreased, but the impact is not the same as might appear on first impressions.
You say that people are moving away from being in-patients, but you also point out that there is a huge increase in out-patients, that no one is meeting their out-patient targets and that the length of out-patient waiting lists has increased from 187,000 to more than 250,000.
As I said earlier, it is clear that one of the pinchpoints in the system is the time for which people are waiting for out-patient appointments. That is partly to do with the fact that, as a population, we are ageing, and older people tend to have more complex health needs and to make more calls on the health service. That is one of the pressures that underlie the challenges that health boards are facing in balancing their budgets, meeting targets and reshaping services for the future.
There are fewer beds and out-patient waiting lists are getting longer at the same time. Is the Government addressing the issues? Do you detect that there are initiatives in place to address those problems?
In part 2 of the report, we say quite a lot about what the Government and health boards are doing to manage the challenges. We mention the QuEST—quality and efficiency support team—work that is being done with NHS Forth Valley and some other boards to understand the flows of patients, where their pinchpoints are and how they can manage those pinchpoints. Work is going on.
My concern in the report was to say that, even with that work, it feels to us that the combination of the tight budgets that we face, higher healthcare inflation, an ageing population and tight waiting times targets is making it harder to reshape services in the way that they need to be developed for the future. Work is going on, but the question is whether the big picture is sustainable as it stands.
I will return to that in a minute. Is the Government aware of—or doing anything about—the fact that out-patient waiting times are rising?
Yes. We say in the report that considerable efforts are going on across the NHS to manage individual waiting times targets and the broader HEAT—health improvement, efficiency and governance, access and treatment—targets, which do not focus just on waiting times, and to meet the financial targets. A huge amount of effort is going into that at health board level and in the Government. The challenge is whether that is possible to do, and particularly whether it is possible to do while making quite significant changes to move more services into the community to help us all to live longer and healthier lives at home. Our concern is that the focus on short-term targets is making that harder.
Pardon me if I am getting this wrong, but I should have thought that out-patient activity would increase if we were going to a different model that moved away from in-patient care—you have pointed out that there are 2,000 fewer in-patient beds—to more out-patient care. The Government is supposed to be addressing the issue, yet every single board is missing its target. Why is it getting that so wrong?
10:15
The answer is that the subject is very complex. More new out-patients are being seen. The number of out-patients rose over three years from about 324,000 to 367,000. The numbers have gone up markedly over that period, but the number of people who are looking for out-patient appointments has gone up faster, which is why the number of people who are waiting for more than 12 weeks has increased. The number waiting for more than 12 weeks is quite small, but the trend is in the wrong direction.
The challenge is not just to meet the out-patient target but to develop the whole system, so that people can be seen as out-patients, receive the treatment that they need—whether that is as an in-patient or a day case—and be discharged safely home, while at the same time services are reshaped across the piece. That is a complicated thing. It would be hard to do in any circumstances but, when budgets are tight, it is that much harder.
The QuEST team that we talked about has quite significant programmes of work on supporting changes and redesigning out-patient services. The case study about fracture clinics on page 25 is one example of how a board is trying to release capacity by preventing people from having to go to out-patient clinics. We know that there is also quite a big drive towards increasing use of things such as telehealth and telecare, which help people to avoid having to come into hospital in the first place. Quite a number of programmes of work are aimed at reducing some of the pressure.
One pressure that you identified is delayed discharge—it was called bedblocking in the past. Bedblocking has been around for a long time, yet you say in the report that it has increased over the past five years, despite the political and Government attention that it is supposed to be getting.
The number of delayed discharges came down for a period and now the trend is going in the wrong direction again. Once more, we think that that is one of the signs of pressure on the system. Discharging people from hospital needs to be done quickly and safely; they need to be able to get things in hospital and those things need to be right. There also needs to be an assessment of the services that they need in the community, and those services need to be available.
The report focuses on the NHS, but we know from previous work that local government social care budgets are under pressure at the same time, because the population of older people is increasing. The system as a whole is under pressure. The out-patient waiting times for people coming in and delayed discharges for people leaving the health service both show the same picture of increasing pressure.
You are not making me feel any better.
It is important to say that there are no easy answers, which is why there needs to be a step back to ask how to best balance what matters to people on waiting times, access to services and the money that is available for spending on the NHS against the other services that we all rely on and the bigger picture of an ageing population that needs different services. That is a difficult set of choices for us to make as a society. There is no magic wand that will make it right.
Indeed. You point out that delayed discharge costs £78 million. Is that right?
I do not have the figure to hand, although colleagues will. That is the figure in the report. It is one of those classic examples of things going wrong in the system that are not only making things harder for patients but tending to cost more money. The challenge is breaking out of that system. We think that the answer is to step back a bit and look at whether the individual short-term targets are right and are helping us to make the moves that we need to make towards the 2020 vision.
You paint a vivid picture of hard-pressed staff doing their utmost to address short-term or immediate, urgent problems, but the whole health service and care generally are creaking under the strain of demand and not enough resources.
We know that the short-term targets are there for good reasons. Waiting time targets matter to all of us. We are asking whether all those aspects are in balance and whether, with the available funding, the milestones that the Government has set towards 2020 are likely to get us there. There are clear signs of pressure in the system financially and in waiting times. We need to step back and look at what will help us to ease the immediate pressure so that we can invest in change on the scale that is needed. That is the question that I am asking in the report.
There are a couple of other milestones. You pointed out that the Government was supposed to get rid of all the high-risk capital maintenance backlog, but it has failed to do so. It was supposed to reduce its significant-risk maintenance backlog by 2016, but you suggest that it will fail to do so quite dramatically.
As you say, the figures show that the backlog maintenance estimated cost has increased and that it will take longer than expected to clear the high-risk backlog. That is not surprising in the context of the financial pressures that we are talking about, but it is another pressure that has to be taken into account when setting the financial and performance targets for the health service and thinking about the investment needed for the longer term. It may be that some models of hospital care that we have in parts of Scotland are not right for the future. That all needs to be played into the estimate of the cost and the priorities for spending.
On a slightly cheerier note, the graph that gave me the greatest hope in the whole report is on page 34. As far as I can see, we are all going to live for ever, according to your report.
The changes in life expectancy are startling. The life expectancy of a baby born today is decades longer than it was when we were born—I am making assumptions about our relative ages. Life expectancy is changing year on year. The General Register Office for Scotland estimates are changing very fast. That is a huge success story. We should all be proud of it and individually pleased by it, but it brings costs with it. We know that older people tend to become frail, whatever happens. We have more complex health needs and older people need different health services from 20-year-olds, who are at risk of breaking a leg or being injured in some other sort of accident. That is why the issue is so important; it is at the heart of things.
That is greatly encouraging. Unfortunately, the previous page points out that the health budget will fall by 1 per cent over the next two years.
We know that the finances will stay tight for the foreseeable future across Scotland and the United Kingdom. That is the case whatever scenario we might look at over the next period.
The challenge is to think through how we can manage the competing pressures. We have the ageing population and we have tight public finances. Healthcare inflation will continue to be higher. All those things mean that the questions will not go away. There is no quick fix for them. As a society, we need to debate that and make choices about it.
The key thing is not to take a short-term approach but to look at the bigger picture. Is that your key message?
Yes. We have been talking about long-term financial planning for a while. That is part of the key. Another issue is to ensure that we understand the impact of the short-term financial and performance targets, which are in place for good reason and are helping with the long-term picture, rather than making it harder.
I will go back to a point that Mary Scanlon raised, because it put in a nutshell a lot of the pressures that we are talking about. She rightly pointed out that there has been an increase in people waiting to be seen but, at the same time, there has been a 13 per cent increase in those who have gone through the system, which suggests that the health service is taking this seriously and is dealing with more people every day.
The other side of it—the increase in those waiting—shows the continuing pressures that we are under, with an ageing population and, of course, the on-going financial situation. Targets are coming up time and again. Almost every questioner has asked you about them. This is probably more of a question for the whole committee, but do you think that there is a case for the Scottish Government to come and explain to us the rationale behind its targets—why it selects certain targets and its judgment in putting those targets forward?
That would be a really helpful conversation to have. I recall the evidence session that you had with Scottish Government colleagues a few weeks ago about A and E waiting times. They were very clear that the four-hour target for A and E is a good target, because seeing people more quickly keeps the system moving and leads to better outcomes for those patients.
There is always a judgment to be made, but we know that a number of targets elsewhere in the system have got tighter over recent years. I do not know whether the debate has been had about whether the 18-week referral-to-treatment target is the right period and about how it fits with out-patient targets and delayed discharges, but it is important for the committee to discuss the sense of the whole system and the way in which targets play into that.
Ken Macintosh talked about having no short-termism. Surely that is what the 2020 vision is all about—it is about looking at things in the round and ensuring that we get there. We have to deal with short-term issues, because every short-term issue is a person with a problem, but at the same time as we are dealing with those, we have a responsibility along with health professionals to ensure that, sometimes, we put away our political hats and look at the picture in the round, which is not easy for any of us. Is there anything that you as Auditor General have picked up while you have been producing the report that you would suggest is crucial or helpful to put in the mix for the discussions that we should be having?
You have already put your finger on it. There are good reasons for having annual or short-term targets for the finances and for performance. Ensuring that those fit together in the system in the year is one important issue, and ensuring that all of them are moving us towards the 2020 vision, rather than making it harder, is the second issue.
My concern is that both those aspects look to be getting more difficult for health boards and the Government to achieve because of external pressures, such as the rate at which we are all getting older and living longer. Taking a step back and saying, “Is this moving us in the right direction towards the 2020 vision that garners widespread support across the piece?” would be an important contribution for the committee to make.
The only thing that I will say is that, the older I get, the happier I am with the graph that Ken Macintosh pointed out.
That is a frightening thought.
Hello, Auditor General. You have mentioned several times that the Scottish Government has protected, in real terms, the revenue budget, and there is evidence to support that. There are plenty of good messages in your report, including improving outcomes in cancer, heart disease and healthcare-associated infections, and increasing patient satisfaction. On page 32, you say that spending from the UK to Scotland is forecast to reduce by 0.7 per cent in 2016-17 and 2017-18. Is there a quantifiable amount of money associated with those reductions? Are those reductions compounded—in other words, are we talking about 0.7 per cent on top of another 0.7 per cent in the second of those years?
The cumulative percentage reduction is shown on the right-hand side of the exhibit as 0.93 per cent. We can certainly put a figure on that; I am not sure that we have that information with us just now, but we can provide it. The point of the exhibit was just to give the sense that the financial pressures are going to increase, whatever decisions Government and the Parliament make about the funding for the health service in Scotland.
With regard to the discussion about targets, have you found any evidence that the failure of a particular health board to meet a particular target is having any consequential impact at all on health outcomes or patient satisfaction? Is there any evidence to support that at the moment?
We do not have evidence of that, but it would be a useful area to explore with Government. First, we know that, for any of us, it is a disappointment not to be seen within the time that we expect to be seen within. Given that we want to be treated as quickly as we can—and that we want to have some certainty about that because it helps us make plans for the rest of our lives—the missing of targets has an impact. We know of conditions where it will have an impact, either because the condition itself gets worse or because with things such as hip or knee replacements people have to live with discomfort for longer than they should, but there are other areas where it might not make very much difference other than inconveniencing people.
The bigger question is the way in which individual targets fit together. Having a very short waiting time target for out-patients followed by a longer period for treatment might make less sense than having a longer out-patient period and then a quick follow-up, but that is really a policy and clinical decision rather than an issue for us. Because a lot of this is about patient flow, targets need to fit together throughout the system.
I come back to Mr Dornan’s question about this being the time to have that debate. My sense is that people right across Scotland know that there are difficult choices to make because of all the pressures on the health service; they do not expect everything to happen instantly. If the committee were to have a public discussion about what mattered most and about how to balance the different priorities, it would be a very timely move.
We know from other data that patient satisfaction is higher than it has been for a number of years and that overall waiting times are lower. Having listened to your message about the significant pressures on the health service, I wonder where for us as an audit committee the chances and opportunities to make the greatest gains can be found. Can we make greater gains by looking at these targets? If there is no evidence to support the suggestion that failure to meet a particular target is having a consequential impact on health outcomes, do we need to look at the targets in a bit more detail? Is that where we might gain most?
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Looking at the individual targets and the way they fit together, looking at the clinical evidence and the evidence about what matters to people and asking people about this whole issue could really help to move the debate along. My sense is that people might well be prepared to wait a bit longer if they were sure that they would be seen within the time that was set. That might help the whole system to run more smoothly and would let people divert their attention to the longer-term changes that are needed instead of firefighting.
Some of the pressures manifest themselves in areas that are not particularly covered by targets. With regard to in-patients, for example, one of the issues that we have raised in the report is about boarding—in other words, patients not being managed in what is necessarily the correct ward or being managed in a ward for a different speciality—which we know can have a detrimental effect on the patient experience, patient outcomes and length of stay. Some of the pressures do not necessarily come through in the targets, but they come through in other indicators.
My last point is about the Auditor General’s remarks in her opening statement about the slow progress in delivering health in the community setting. I have made the same point several times at previous committee meetings. Are you getting a sense that we are making progress here, or do we need to do much more work to effect real gains in this area and influence any future report like this one that might come to the committee?
When, back in June, we reported on reshaping care for older people, our finding then was that progress was slow. Efforts were being made, but I think that there is increasing evidence in this report that those efforts have been made harder by the need to keep the system running in the short term in order to meet short-term financial and performance targets. Taking a step back and looking at the whole system will make acute hospitals run more smoothly for everyone involved—health service staff as well as patients—as well as provide the breathing space, the money and the time for people to think about how to reshape services for the longer term. It seems to us that that is a really important debate to have, and we need to think about the best way of moving us to where we need to be with the 2020 vision.
I have just a brief question. Like you, Auditor General, several colleagues have mentioned the ageing population. Given that, the need for home care and so on, I was a little surprised to see in exhibit 13 on page 40 that the number of care homes is down by 10 per cent and that they have 36,578 fewer residents.
Moreover, it has always been our understanding that much more personal care would be delivered at home, but that is down by 11 per cent. I think that I am right in saying that the figure is taken over the past five years, but the figure of 60,950 fewer people receiving home care is significant. Given everything that we know about demography, I had assumed that there would be an increase in care homes and care home places and a significant increase in home care, and I do not understand why the figures are going in the opposite direction.
I think there are broadly two things going on here. The first is the increasing recognition that for many older people care homes are not the best place. If we can stay at home for longer with good quality of life, we should be doing so, and I think that that accounts for some of the fall in the number of care homes and the people who live in them.
Secondly, the care-at-home figures seem to reflect higher thresholds from local authorities. An increasing number of people who might have received an hour or two of help a week in the past are not qualifying for social care at home and, instead, care is being focused on people with more complex needs who really need that help to keep them at home.
Again, this is another sign of the pressure on the system. We know that the 2020 vision will require a much wider range of services that can provide much more flexible and responsible support to older people and keep up with their changing needs as they get older and frailer.
What you are basically saying is that the eligibility criteria for free personal care for the elderly have increased—I should note that the convener and I were both members of the committee that passed that policy in the first session of Parliament—and that, in order to get care at home, your needs must be far greater than they would have needed to be 10 years ago.
It is about not just free personal care, but all social care—
Well, all home care.
The answer, though, is yes. There is more of a focus on people with more serious and complex needs than was the case in the past.
I have a question about the maintenance backlog, which is mentioned on page 18 of the report. I note that Fife had the largest increase—of, I think, £13.5 million—but is that because in the past year it has moved to a new hospital extension and because it now has a large number of buildings that are surplus to requirements and which have been vacant for a year, if not longer?
I do not know if we can answer that specific question for you this morning. We know that some of the increase is because of new backlog maintenance requirements that have been identified through surveys, but we can follow that up with the committee in correspondence if that would be helpful.
I thank the Auditor General and her staff very much for a very full contribution. This is clearly an issue of huge interest not just to politicians but to the public right across Scotland, and I do not think that any of us underestimates the strains and challenges involved in delivering services. This is not just about party politics. You have outlined the broad demographic and financial strains very well, and we will no doubt come back to the matter.
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Section 22 Reports