“Review of orthopaedic services”
We now come to item 3. We have been dealing with the section 23 report on orthopaedic services in Scotland. We have heard from a number of witnesses and this is a further evidence session. I welcome John Connaghan, director of health delivery; Dr Harry Burns, the chief medical officer for Scotland; Stephen Gallagher, the depute director of health delivery; and Colin Sinclair, the director of national procurement for the national health service in Scotland. Kevin Woods has sent us his apologies and has asked John Connaghan to take his place today. Is there anything that you would like to say by way of introduction?
Yes. Thank you, convener. I will make a brief opening statement.
Thank you. Can you perhaps tell us exactly the remit of the director of health delivery?
There are six main areas. The principal one is performance management of the NHS and, in that respect, providing assurance to ministers that all key Government health targets are being delivered. Another area is oversight of the health improvement, efficiency, access and treatment—HEAT—targets system, which is where we set targets for the NHS. Another one is efficiency and productivity: we co-ordinate the national efficiency and productivity programme. Through the improvement support team, which is headed up by Stephen Gallagher, we also deal with the modernisation of the NHS, spreading best practice, introducing new techniques and encouraging innovation. Last but not least, a big area of our work for the past five years has been co-ordinating efforts on the reduction in waiting times.
Can Mr Connaghan explain how his responsibilities link in with those of the chief medical officer?
We are part of the health management board. The chief medical officer provides advice to the board, and to me today, on any clinical or medical aspects. Harry Burns can perhaps say a word or two more about that.
I am here to answer the clinical questions—why one prosthesis is chosen over another and so on. I try to keep myself to clinical matters; management matters rest more properly with John Connaghan.
Are you ever conscious of the fact that the administration of the health service in Scotland may be just a little top heavy?
The issue is under constant evaluation by boards. Each board has its own savings programme. This year boards are targeting in the order of £275 million of savings.
I meant centrally—at Scotland level, rather than at board level.
That issue is also under review. There is a shaping-up review across the Scottish Government. For the past year and a half, all posts have been under scrutiny. Replacements are very carefully considered, and central Government has its own savings programme.
No doubt we will return to the matter at another time. I want to respond to the comments that Dr Burns and John Connaghan have just made, specifically in relation to orthopaedic services. Dr Burns, what input do you have to discussions? Later, my colleagues will ask about purchasing of implants and so on, and about issues relating to investment and outputs. What comments are you invited to make from a medical perspective about whether orthopaedic services are working efficiently and effectively—whether they are using the right implants and so on? Do you have a role in that process?
I meet regularly the Scottish Committee for Orthopaedics and Trauma, which has an opportunity to raise with me any clinical concerns that it has. I transmit those concerns to Kevin Woods, the chief executive of the health service, and to colleagues and to ministers, where appropriate. Similarly, it is my role to go back to clinical groups such as SCOT to explain to them Government policy in a variety of areas. I act as a conduit and interpreter of clinical advice. We are all aware of the fact that, when you get 10 senior doctors in a room, you may end up with 11 different opinions on various issues. Part of my role is to interpret the evidence that I get in the light of my clinical experience and to distil out the important issues.
Are you classified as a civil servant?
Yes.
Are you bound by the same rules in relation to involvement in political issues and so on?
Absolutely.
Although you are a medical professional, you are nevertheless a civil servant.
Yes. My colleagues will correct me if I am wrong but, by custom and practice, chief medical officers are allowed to comment publicly on issues of concern to public health. At times, they are allowed rather more latitude than conventional civil servants on such matters of public interest. For example, the previous chief medical officer in England made comments about pricing of alcohol and tobacco control that, at times, drew adverse political comment from ministers, although it would be too strong to say that there was a falling out. It is chief medical officers’ role to push the boundaries in the interests of public health.
Nevertheless, everything that you say is said within the context of the civil service rules.
If I am to be effective, I must be able to challenge Government policy in a sensible way. My main concern is to work with ministers to make change. It is only prudent for me to do so.
I do not know whether what I am leading on to is so much a medical issue or an issue for Mr Connaghan. What we come across consistently—we have seen it here, in orthopaedic services—is that there is often a problem with data collection and the comparing of information that is brought in from different health boards. Indeed, we sometimes find that the information is either not recorded or is not accurate.
In some circumstances, it is perhaps not the data collection that is the problem so much as the interpretation of the data. In that particular instance, the question that was asked of the data system was about how many children were brought in with the word “drunk” on the data collection form. Some of the children—in fact, the majority—had drunk things that did not contain alcohol. It is a question of the insight that was used to interrogate the data systems.
Forgive me, but this applies not just to orthopaedics, but to everything else. You have information coming in and intelligent, well-educated and—I know that this is George Foulkes’s hobby-horse—very well-paid people analysing it, but they do not have the ability to interrogate the information to distinguish between young children who have drunk whatever liquid and young children who have drunk alcohol; therefore, they come and tell us that all the children were suffering from the effects of alcohol. If the people who give you the information are not able to interpret it, how can we know—for example, in talking about productivity in orthopaedics—that anything that we are hearing is actually true?
If I had been trying to find the number of children under the age of 15 who had been admitted to hospital as a result of drinking alcohol, I would not have asked the question: the people from whom I would have sought that advice would have asked the question appropriately.
Mr Connaghan, how good is the collection of information in orthopaedics? Are you satisfied that you have all the relevant information and that it is accurate?
Let us examine the information that we have on efficiency and productivity. Over the past few years, we have developed a number of benchmark indicators; there are now more than 80 that we can look at. Not all of them were examined in the Audit Scotland report, but a fair few were. Some of them are really quite important to us and are in common use throughout Scotland for comparing productivity. I will mention a few. Average length of stay, day-case rates, occupancy, new-to-return ratios and theatre utilisation are all in common use within boards and among boards in comparing performance.
So, the information that is collected by every health board in Scotland is completely comparable and there are no discrepancies. The boards all include out-patient and community activity and all the information is recorded in the same way.
You have raised an issue of different definitions. Although we have good information systems, we also need to be careful about changes in clinical practice, as Dr Burns said. That is why ISD Scotland has a system whereby it constantly revises the definitions that are attached to some of the activity. You asked whether all the information that is gathered throughout Scotland is directly comparable. That is clearly not the case, because boards do different things. Teaching boards have specialist services, there are island boards, some boards have single-site orthopaedics and others have two sites for orthopaedics. I would like to give you the impression that, although we can have some broad surveillance of activity and the efficiency and productivity indicators throughout Scotland, we need to be careful about the interpretation and to look behind the statistics, as Dr Burns said. However, that is not to say that the statistics that we have are of no use.
We are not able to make that direct comparison, however. It is necessary to be an expert and to understand all the differences to get behind the figures. In a small country such as Scotland, why cannot we collect figures that make comparison easy?
We do, and we set national indicators for them. We have a range of efficiency and productivity indicators in our HEAT targets, and boards have been working to those. I have already mentioned some of them, such as average length of stay, day-case rates—
You have mentioned some of them, but you are still indicating that there is a range of things in which the statistics are not directly comparable. You told us that we have to be careful.
Indeed.
So why, in a small country such as Scotland, cannot we just sort it out and get statistics that we know are comparable so that we can show that there is consistency? Why do we need to be experts to be able to understand the figures?
I have already explained that, in addition to ISD Scotland’s continuing work on statistics and their definitions, we are engaging with it on a relatively wide exercise between now and the end of the year to take a look at the forward five-year strategy. Things change. The pattern and configuration of services change, and so does clinical practice as clinicians move into new techniques. It is important that we keep abreast of that and that our information systems are capable of gathering those changes.
I will give a personal example of a problem in information collection that I was involved with some years ago. It is part of the continuing refinement in increasing accuracy—it is a dynamic situation.
I am sure that things are improving all the time, but the problem is that, in relation to the NHS, this committee consistently hears from Audit Scotland that there are problems with data collection and problems of consistency, which makes it difficult for ministers to make the right decision and difficult for us and the committee to exercise scrutiny—indeed, it makes it difficult for Audit Scotland to say whether public money is being well used. For example, our briefing states:
I said earlier that this was the first study of its kind. Audit Scotland worked with us to take a look at the data during production of the report, which in itself is quite interesting. Since we got the report, we have had the luxury of a little time to digest the information in it and to work with the NHS boards, particularly looking at the long-term productivity trends that NHS Scotland identified. Perhaps we will come to this later, but when we get beneath the surface of that it is interesting to see what emerges in terms of productivity comparisons of how we have been doing in orthopaedics over the past 10 years. We have done quite a bit of work with boards since the report was published. I need to link that to the fact that the ISD and the Scottish Government are embarking on another five-year refresh of our information strategy.
I agree with you, convener, about the outcome data. I have been banging on about outcomes for 20 years—it started out with cancer and so on. Orthopaedics is particularly interesting because the outcome that we want is fit people who are walking around pain free, in control of their lives and independent. That is a particularly hard outcome to get a clear definition of and because those people are not in the system, it is very hard to collect those data. However, I think that we should pursue that. We should try to get some sort of system that measures wellbeing in the community. However, no one can do it, apart from some very highly defined and very expensive American health insurance systems—there are some niche markets in the United States. You are right, convener, but if we want comparisons between the effectiveness of different hip prostheses and so on, we need 10 or 15-year follow-ups.
I do not dispute what you are saying, Dr Burns, but that does not disguise the fact that, on other aspects that are easier to measure, such as cost data, there are significant concerns that have not been sorted out. There are inaccuracies in staffing data, which have nothing to do with measuring wellbeing. If we do not know the facts about staff, I do not see how we can properly manage. However, I do not want to hog the whole of the questioning. Does anyone else want to come in on this section before I move on to variation in activity?
We are on national data collection—is that right?
Yes.
I will follow up on what the convener was asking. Under national data collection, you start off by saying that
It is maybe even the best.
That is even bolder. [Laughter.]
I do not hang back.
The Auditor General’s report states on paragraph 36:
That point has been the subject of reports from the Auditor General, and we have now taken steps to capture that information. It is necessary to differentiate between activity and cost. Each board knows exactly what it spends with each supplier, particularly in the private sector. That information is captured as part of its general ledger, so we can have a very accurate picture year on year of costs and what we spend. However, I fully accept that in previous years the recording to split out the activity that had been undertaken either in whole or in part by the private sector was not, perhaps, up to the mark. For example, all the activity may have been recorded under the health board name rather than part of it being recorded under a private sector name. However, we have taken steps to address that since 2007-08, and we now think that our data for the latest year are much more robust, with actual numbers on activity.
But—
Can I say one other thing on that? We do not want to ensure just that data come into us on a once-a-year basis, because that does not allow us to get a good management picture. Therefore, we have recently set up a quarterly management report to tell us about activity and cost, and we are in the process of considering writing to boards to say that, before they pay an invoice to the private sector, they need to have the record located. That will give us extra insurance in the issue.
What are the figures?
Our estimate of activity is in the region of 2,500 discharges—that was contained in a recent note that I sent to the convener with the answer to a parliamentary question. Our estimate of spend in 2008-09 is in the region of £10 million, which is a little drop on the previous spend four or five years back when we allocated £15 million centrally and ring fenced it for use in the private sector.
I was going to ask about this later on, but as you referred to that PQ we are as well doing it now. The letter that you sent referred to an answer to a PQ that was asked by Mary Scanlon. You mentioned a reduction in expenditure in the private health sector from £15 million to £10 million. However, activity seems almost to have doubled. Is that because the system is now more efficient, or are we talking about simpler procedures? We are spending £5 million less—a third less—but we have doubled the number of discharges.
This answer goes back to my previous answer. We accepted the criticism that prior to 2007-08 our recording of the number that should be allocated against the private sector was not up to the mark. As I have explained, we have taken steps since then, particularly from 2009 onwards, to have a much more robust data collection system among boards for the ISD. The increase in the discharge figures is simply a reflection of the better data collection system, which is more accurate. As I said, that system will be supplemented by quarterly reports linking activity to the payment of invoices.
Thanks for that. We will move on to variation in activity.
I want to follow on briefly from that discussion. Over many months, the Public Audit Committee has looked at various sections of the public sector and come up with similar comments, particularly about data collection and management. It appears that validating the data is a consistent issue. Often it is dangerous to present statistics as read, as though they are correct and accurate.
I will start with the issue of day-case surgery. My colleague Stephen Gallagher will comment from his perspective.
We accept that there is variation in the rate of same-day surgery across boards. There could be multiple reasons for that. It could be related to the availability of a day-case unit or to whether pre-operative assessment is routinely in place. There could be a technical reason: someone is listed as an in-patient, but the procedure is carried out as same-day surgery. Patients may have been admitted the day before surgery—an issue that must be linked to the availability of pre-operative assessment. There is a range of reasons for variation in the level of same-day surgery.
What about the other examples that I cited? You said that the reasons for variation “could be” such and such. Do we know that those were the reasons for variation in the particular cases that have been mentioned?
Yes, but I am saying that the reasons will be different in different boards, depending on the physical infrastructure, such as whether there is a dedicated day-surgery unit or an established pattern of pre-operative assessment. The work that we are doing in detail with the boards in performance support allows us to get to that level of detail about specific issues in specific boards, and we make recommendations for improvement based on those specific issues.
What about some of the other examples, such as the average number of days spent in hospital and the number of consultant team day cases? Clearly, those lead directly to additional costs.
Earlier, you mentioned the NHS Forth Valley example. At the outset, I should say that we fully accept that variation exists in performance across Scotland. That is why we have established the procedures that we are discussing. Mr Gallagher outlined what we intend to do about that. There are efficiency savings to be made; we cannot pretend otherwise.
That tells me that the indicators are not the same across the board. If Forth valley has a training element that the others do not, that does not allow us to make correct comparisons, which might lead us to make inaccurate assessments of variations.
It is fine to consider one indicator in isolation, but you should be careful about drawing absolute conclusions from that indicator. We tend to consider a range of indicators because we need to understand how the system is set up, what the contributions are of other members of staff and so on. We need to consider that, for example, one board has a series of one-stop out-patient clinics where a patient is seen by a number of professionals, whereas another does not have that sort of productive and efficient system. That is the sort of thing that leads to variation. It is crucial for us to be aware of the variation that exists, but we need to get behind it and tailor the response from each board in order to achieve a better way of working. That is part of what we do in the efficiency and productivity programme.
What explains the difference between the average length of hospital stay in Glasgow, where it is five days, and in the Western Isles, where it is 15? How can you possibly explain that?
One aspect of life in the Western Isles is that, because there is only one hospital and people are scattered throughout the islands, people might not have the capability to simply step on the number 64 bus and get home.
I have nothing to add directly to what John Connaghan has said, beyond saying that I think that we are on the verge of future challenges in getting the length of stay down even further. Colleagues of mine recently visited an institute in Denmark where people get out of bed on the same day that they have had a total hip replacement and are walked up and down the stairs.
I would like to question you a bit further on that. Correct me if I am wrong, but my understanding is that when someone has had a hip replacement, early mobility rehabilitation is critical to improvement.
Yes—depending on their general state of fitness.
Yes but, generally speaking, the more quickly a patient can be mobilised, the better. Conversely, the longer a patient is left without mobility rehabilitation, the less favourable that is for their long-term improvement.
In general, yes.
If someone breaks their hip on Christmas eve, which coincides with public holidays, and the operation is carried out on Christmas day, will the necessary rehabilitation services be provided to ensure that that person is encouraged to be mobile, or is someone who breaks their hip and has to have an operation during a holiday period taking their chances?
No. As a point of principle, people should get the treatment that they need when they need it, regardless of external circumstances. I would be disappointed if that was not happening.
I know for a fact that it does not happen, but we can converse about that separately.
My colleague Stephen Gallagher has outlined that when we run into a difficulty in truly understanding variation in driving better board performance, we go to another level of support for boards. That involves the establishment of an expert team that takes apart that system, its statistics and working practices, and reassembles them. When we did that for cancer, we saw a remarkable improvement in cancer performance, and we are doing it now for quite a number of acute services and in orthopaedics. We get to the bottom of such issues.
Is it not a sad reflection on the bureaucracy that is the NHS that the solution in local areas is yet another co-ordinator? Rather than get a manager who is well paid to manage the service, we need yet another bureaucrat to co-ordinate at a time when the number of front-line staff is being reduced. The whole thing becomes absurd.
You assume that there is no clinical input.
Sorry, but you did not say that it was a clinician; you said that it was a co-ordinator.
I take that point, but I make the point that a co-ordinator works across agencies. It is not only the health service that is involved. The process is about ensuring that the patient has enough support when they leave and that community services, as well as acute hospital services, are co-ordinated effectively.
We know for a fact that the number of nurses in the health service will be reduced, but you are saying that there will be more co-ordinators.
In this case, we think that one co-ordinator for every health board is a wise investment.
One of the significant issues in the report was the variation between health boards in the cost of surgical implants for hips and knees. You say in your letter that you have saved £1.2 million so far through the new contract. Will you clarify the period over which that saving has been made? Is the figure based on a like-for-like comparison? We could save £1.2 million by buying fewer surgical implants, so is the figure an actual saving?
I ask my colleague Colin Sinclair to address those questions directly and to say a little about our strategy on the issue, because you will want to know where we are going on it.
There was a huge variation in orthopaedic procurement across the service. Historically, each health board built up different local clinical practice for, principally, hips, knees and trauma. Until the first contract came in—the one that has saved £1.2 million—it was predominantly individual boards and in some cases individual hospitals that procured for their own use based on local clinical practice.
I was going to ask you about the NHS Greater Glasgow and Clyde mini-competition. I thought that NHS Lothian was opting out of the national framework. Does that have a negative impact on the NHS National Procurement contract?
No, the Glasgow decision was very much allowed for. We were to some degree hoping for it, under the conditions of the first framework—the contract allowed people to go down that route if they felt that they could drive value, which is what NHS Greater Glasgow and Clyde did. It took a while for the board to pull that together, but it managed to do so about three or four months ago.
What about the issue of an ODEP rating for knees in addition to the ODEP rating for hips?
I will probably have to refer that issue to Dr Burns.
John Connaghan said in his letter, and you have also said, that the national procurement contract had to be phased in—you referred to phases 1, 2 and 3—because
I will turn to Dr Burns on clinical preference.
Clinical preference is really interesting and there is an issue to explored. Part of the problem is that different prostheses are likely to wear out at different rates. For example, metal on plastic wears out faster than metal on metal, but metal on metal might have some complications associated with it. It takes 10 to 15 years of use to work out those different factors. In the process, clinicians will be influenced by papers that are published. Sometimes, papers are published without declarations of interest—they may be funded by the manufacturers and so on, and they could well cloud clinical preference inappropriately. It is not as straightforward as comparing drug A with drug B, with hard, randomised control trials taking place within a definable timescale. There will always be debates between clinicians about a certain prosthesis being safer in certain circumstances and so on.
We will have questions from Murdo Fraser, Bill Kidd and then George Foulkes.
I wanted to come back in on an issue that was raised earlier, which is why I was trying to get in before Anne McLaughlin.
Murdo Fraser wants to raise an issue that arises from something that has been said, so I will bring him in.
Thank you. I will follow up on a point that Mr Sinclair made about the national procurement contract and the position of NHS Lothian. I was checking the evidence that we took on 9 June from Colin Howie, who is the chair of the Scottish Committee for Orthopaedics and Trauma. I will quote what he said in the Official Report when we asked him about the national procurement contract—I believe that he is associated with NHS Lothian. He said:
I was aware of that. In principle, where I believe we are would contradict what Mr Howie said. Similar to NHS Greater Glasgow and Clyde, NHS Lothian, at some point earlier this year, thought about going down the mini-competition route, but did not think that it would be able to go quickly enough through the necessary discussions that Dr Burns has outlined. There are savings validated with NHS Lothian from the contract that started in 2008; however, I do not think that there was a national contract arrangement in place through NHS National Procurement prior to 2008. There might have been other local arrangements, but there was no national arrangement before February 2008. When I consulted procurement colleagues in NHS Lothian, they did not understand either that point about NHS Lothian withdrawing and believing that it could get better local pricing.
Thank you for that. It would be helpful for us to have some clarity on the matter. When the committee is trying to understand the position, it is not helpful to have witnesses coming here and giving widely disparate views on it. It seemed to be Mr Howie’s belief that NHS Lothian’s costs went up as a result of national procurement. If you are able to provide further clarity to the committee on that, that would be extremely helpful.
I will do that.
George, do you want to follow up on something that has been said?
I did not quite understand the reply to the convener’s question about the co-ordinators who will be appointed for each board area. What will their role be?
An example is an allied health professional consultant-level appointment who works with the Scottish Commission for the Regulation of Care. Their particular role is to support staff in care homes for older people in implementing a systematic, person-centred approach to falls prevention, and in implementing management that is based on best practice and the current evidence base. Other co-ordinators will develop a resource to support the provision of prevention training for—
Is that specifically for orthopaedics?
It is specifically for musculoskeletal rehabilitation, which Dr Burns will confirm is mainly in the area of orthopaedics.
There will be one co-ordinator for each health board. Are they new appointments?
They are new appointments. There may already have been a similar function of sorts within each health board. I do not have the detail behind each of the health board appointments with me today, but I can give you some further advice on that.
What sort of salary level are the appointments going to be at?
I do not have that detail with me.
Perhaps you could write to us with the detail about how many appointments there will be, where they will be located and what their salary level will be.
I will, indeed.
I am just a bit concerned that your solution to the problem of variation is to appoint, as the convener said, bureaucrats to deal with it.
Can I—
I am going to ask you a question, Dr Burns. We are not talking about rocket science in most orthopaedic procedures. We know that they are best delivered by having good, well-resourced and well-supported front-line health teams of doctors, nurses and health support workers—that is nothing new.
I would be surprised if the work of those individuals was not carried out by physiotherapists and nurses who are already in the system. For a number of years, we have been working hard on falls prevention. Health boards hold a considerable body of knowledge about how, using a number of techniques, to stop old people falling and breaking their hips, so that will be achieved through focusing on existing staff. The co-ordinators will not be bureaucrats and probably will not be new appointments.
There is a disjunction between what you are all saying today and what is actually happening on the ground. At our meeting, NHS Lothian said that Lothian alone is going to lose 333 nurses: that is just nurses. It is going to have to cut back on all sorts of other staff as well. How is it going to be able to deliver services in orthopaedics, rehabilitation and other areas with fewer people on the front line?
The committee needs to understand that from Dr Burns’s account of why this is important. I might come back to the wider issue of other staff in a minute. Some studies have been published about older people and their risk of falls. It is the primary cause of hip fracture. If the work of the co-ordinators on falls prevention in hospitals, care homes and elsewhere reduces that risk, there will be a benefit to the NHS downstream in terms of the amount of resource it uses.
From what has been said, I am a wee touch unsure about how hands-on or hands-off NHS National Procurement is in setting parameters for the health boards to make savings and ensure best service delivery. I wonder about the fact that the most populous health board area is undertaking a mini-tender because it seems to think that it can get a better deal, and that Lothian, which is probably the second most populous health board area, might also do that. Does that put the national procurement programme at a disadvantage in making the best possible deals to purchase equipment and knee and hip replacement therapies?
I do not believe so, in that case. When we started in 2007-08, the problem was that each health board had its own local clinical practice and purchased its own hips and knees, depending on its policies, what its clinicians needed and so on. The phase 1 option of drawing all that together immediately drove a benefit in the region of £1.2 million.
Is national procurement being rolled out across all the other health sectors in Scotland?
Very much so. The figure moves around, but there are roughly 182 national contracts in place, which cover about £700 million of NHS Scotland spend. There are other national frameworks in different areas, which takes the overall spend, under a national overview, up to about £1 billion. The strategy is very much about how we roll that out further, particularly given the current financial climate, to leverage more benefit from suppliers when we are buying the same or similar products and services across the whole service. The national procurement agenda, which was underwritten by the McClelland report, is very much the direction that we need to take, given the financial climate that we are in.
We were given a very different picture at the previous evidence session. You heard from Murdo Fraser about some of the things that were said to us on the record. There is clearly a culture in some of the health boards whereby they like to keep open the opportunity of going for a mini-tender or something outside the national procurement process. Are they permitted to do so?
The expectation is that health boards will engage fully in national contracts. If they have a specific local need where the national contract cannot provide that cover, they can make local arrangements. There are occasions when they feel that they can get a better price through a local arrangement than through a national arrangement.
I am just trying to press you as to how and when Glasgow, Lothian or whoever can step away from the national arrangements. Are you saying that that is now no longer permitted, or would it be permitted only in exceptional or local circumstances?
Nothing has been absolutely laid down that says that health boards must use national contracts. There is a general push in support, through the chief executives group, to which I report on occasion, of national contracts being used. Given the nature of the health service and how it has come to the position that it is in, with a lot of local activity and authority, there are still occasions when boards will buy things outwith a national contract. However, in principle, all health boards work to national contracts. We have very good implementation and take-up rates of national contracts.
I presume that the health minister, who is ultimately responsible for all the health boards, could detail these requirements and could set a requirement that would prevent the hiving off of individual health boards and the sort of confusion that we saw just a few months ago when we took evidence previously.
Yes. That would clearly be within the minister’s power. From a procurement point of view, I would say “yes”, but I want the health boards to work with NHS National Procurement because we deliver service and value and savings, not because they are forced to do so. I very much want it to be a partnership arrangement whereby we understand the boards’ requirements, the boards see the benefit that we can deliver and jointly we drive forward value. The orthopaedic contracting process is a very good example. It is coming across a wee bit as though mini-competition is a problem: it is not actually a problem—it is a legitimate tool in the procurement armoury to try to drive value and it is being used.
I have two quick questions, but first I should say that I am sure that, when Colin Howie was here last time, he was representing an orthopaedic association and was not speaking on behalf of NHS Lothian.
My understanding is that one of the main drivers of the ODEP rating is the expected length of life of the prosthesis. There are possibly other issues with knees, which are a different kind of joint because they are ball-and-socket on one side and much more surface-to-surface on the other. There are more technical issues involved in the failure of knee joints such as different stresses and so on.
When you say that
I will certainly ask the question.
Excellent.
I will do it today.
I do not know who my other question should be directed to. I think that it was Dr Burns who said that NHS Greater Glasgow and Clyde had a proper clinical debate about the use of surgical implants. That sounds extremely sensible to me. You have to include clinicians in such discussions because there are all sorts of reasons why the cheapest is not necessarily the best. Can you or anyone else do anything to encourage or compel other health boards to do the same thing?
I believe so.
Colin Sinclair outlined the fact that there are three phases to the strategy. We have had phase 1, which realised some savings. We are just about to embark on phase 2, which is, by and large, the clinical debate that you describe. It will take into account in the round the efficacy of the use of particular implants. That is scheduled to happen for the next couple of years as part of phase 2. I ask Colin Sinclair to say a little about the long-term plan after that, or phase 3.
Phase 3 is to drive more standardisation when each health board has been through the process that was described for Glasgow. I have a list of five health boards in which procurement staff are engaging with clinicians in exactly that kind of debate. I know that they have already started the discussion on whether we should have two knee manufacturers and two for hips and are actively engaging in that. If we can standardise things more in phase 3, we can go back to the market again in two years—that is our first option, but we can extend it if we want to—with much reduced variation and try again to drive better pricing.
Anne, do you want to ask anything about the purchasing of surgical implants that has not already been asked?
I do not think so.
As there are no further questions, I thank our panel for their attendance. This has been a fairly lively session. We look forward to receiving further information from Mr Sinclair about NHS Lothian, from Mr Connaghan about the co-ordinators and from Harry Burns about Anne McLaughlin’s questions.
“Using locum doctors in hospitals”
I invite the Auditor General to brief us on the report, “Using locum doctors in hospitals”.
I will introduce the report briefly, as I am conscious of the pressures on your time this morning. As ever, I will rely heavily on the Audit Scotland team to answer any questions that you might have.
Thank you for that. You have identified that the demand for locums has increased since 2006-07, but the ability of agencies to meet the requests has fallen. Has that affected the price that agencies charge? In other words, if there is a scarce resource, can agencies push up the fees? Does it cost the health service more because the demand cannot be met?
There is some evidence of that. I invite the team to give you the details.
It is fair to say that it is very much a supply-and-demand issue. If supply of locum doctors decreases, generally, there is an issue of increased cost. However, it is hard to quantify that. We found that we cannot necessarily quantify exactly how much the costs go up by, because that depends on the individual doctor and circumstances and, obviously, the post to which they are appointed.
Do you have an idea of how much more expensive it is to employ a locum doctor than it is to have someone on the payroll?
Exhibit 6 on page 11 gives an indication of the different types of pay rates at April last year when the national contract for locum doctors was still in place. For internal locums, there are nationally set pay rates and then there are national contract rates, which were in place until May 2009 last year, until when the national contract ran. Then there are costs for locums from agencies that were outwith the national contract. As you can see from the exhibit, the pay rates for external locums, particularly non-contract locums, were much higher than those for internal locums.
You refer to NHS internal locums. Does that mean that the NHS already has its own system to plug gaps but that it is not sufficient to do everything?
By internal locums, we mean staff who are already substantively employed in the NHS, who may either fill gaps in service where there is a requirement, or work at a different hospital or for a different board. There is no specific system yet, but we make the point in the report that the Government is considering the establishment of locum banks.
For a few years, the NHS has been running nurse banks of direct employees. The intention is to see whether the model can be developed and implemented effectively for doctors, too.
That is correct.
Is there concern that the limits that are set by the working time directive will be exceeded if, as well as doing their own jobs, people are taken on as locums, through internal banks?
Yes, we identify that risk in the report. It is up to individual doctors to behave in a professionally responsible way, but there is nothing to prevent a doctor from doing locum work in a health board other than the board of their main employment. It is appropriate to ensure that people who do that do not work excessive hours.
That is an important point. So, there is no way of checking how many hours a doctor is working if they work as a locum in different areas.
That is correct. Health boards ensure that the staff whom they employ do not breach the terms of the working time directive, but if a doctor chooses to work additional hours elsewhere, there is currently no mechanism to monitor that.
It is possible that people will be in the position of working excessive hours, but we do not highlight that as a major risk in the report.
Should the board that takes on a locum require them to sign a document indicating how many hours they have worked in the current period, or a declaration that they have not worked excessive hours? Surely boards should seek guarantees from those whom they employ when they take them on.
The question is probably best addressed to the health directorates.
Boards must undertake pre-employment checks on locums whom they intend to use. Currently, they are not required to check the number of hours that a locum has worked. The development of locum banks will help to address the matter, because a centralised system will make it possible to monitor such issues much more closely.
My question relates to another issue of patient safety. From time to time, we hear—at least anecdotally—concerns about the employment of locum doctors from foreign countries, whose command of English may not be particularly strong. There are concerns that such doctors may have difficulty communicating with patients or other NHS workers. Have you identified that as a risk in your report?
We did not have that information; I am not sure how we could get it. However, as Nick Hex said, health boards are required to carry out pre-employment checks, which should provide some kind of safeguard. At UK level, arrangements for employing in the NHS overseas doctors from outwith the European Union have been tightened up.
Doctors from outwith the EU are required to undertake a proficiency in language test by the General Medical Council when they come into the country, but doctors from other countries in the EU are not required to do that. The issue has been in the media recently, and I know that earlier in the summer, the UK Government said that it would look into it, with a view to tightening up the system.
I have a general question to ask in the context of the Auditor General’s report. Is it his experience that the information that is available to the NHS in Scotland, which is both critical to and criticised in many of his reports on the NHS, is the best in the world?
The short and not very helpful answer is that I am the Auditor General only in respect of Scotland and not the rest of the globe.
That is a good answer.
Taking a wider view—
A more helpful answer might be to remind the committee that late last year, we presented a report on the management of information in the NHS, which it is fair to say presented a very mixed picture of progress in developing information systems that are fit for purpose. We recognise that a lot of effort is being put into that, as we heard this morning. Given the urgency of the issue in Scotland, the pace of that work continues to be extremely important.
On the point about excessive working hours, would not that be revealed through the pay-as-you-earn tax system? Notwithstanding the recent problems with the tax system, surely it would pinpoint the fact that a person had worked in excess of 48 hours.
That is an interesting question, but it is well outside the scope of the report, as you might imagine. We all know that HM Revenue and Customs is extremely careful about data protection issues and about releasing anything to do with the financial circumstances of people who pay tax. I do not imagine that there would be any realistic prospect of getting access to those data for such a purpose.
If there is nothing else, I thank the Auditor General and his team for their report.