“Review of orthopaedic services”
Paragraph 25 in the key messages report talks about the variation in Scotland. It states:
Item 2 is a section 23 report entitled “Review of orthopaedic services”. I invite the Auditor General to brief the committee on the report.
We have not had a response on that recently. The committee has considered the issue a couple of times and took evidence from the then Health Department. There is activity going on. The challenge comes at the interface between the consultant’s clinical judgment, which must absolutely be sacrosanct, and the ability of a board to challenge that by using data about what other consultants and boards are achieving for similar patients and similar types of care. There is not a single right answer for any individual patient. As auditors, we certainly cannot identify what that might be. However, those are proper questions for health boards to ask and for the committee to understand better, too.
You are quite right. We cannot explain the range of variation in length of stay for in-patients. That is worthy of further exploration.
This excellent report illustrates the convener’s general comment about the high quality of the reports that we get from Audit Scotland, which is extremely helpful.
The message that we found through the work that we did is that information on that is not collected consistently at a national level. Doubtless, the boards have some of the information at a local level, but there are issues about how consistently it is recorded and reported. We cannot say how many people throughout Scotland are referred in that way because the information is simply not available.
We are not aware of any work that has been undertaken nationally on standardising the cost of implants, although we say in the report that such work should be carried out. There is certainly scope for boards to make savings and secure value for money from the implants that are purchased; for example, as our work shows, there are differences in consultant preferences. We discussed the issue in great detail with NHS Scotland Procurement, which has more detailed information on the matter.
The report highlights a range of issues where we found quite a lot of variation in cost and activity; indeed, it usefully demonstrates such differences. When we examined certain variations and areas where savings could be made, we heard no particularly reasonable explanations as to why these variations existed. As I said, it is another area in the report where there appears to be scope to save money by making things more consistent. You might be right in suggesting that this information has not been drawn together in a consistent way before, and there might need to be a more co-ordinated approach in that respect.
We will return to the issue later.
I have a related question on the cost of procedures that brings us back to George Foulkes’s point about the Netcare contract at Stracathro hospital, which falls within my parliamentary region. I was a bit surprised to hear him say—if I remember it correctly—that he was pleased that it had gone back into the NHS, given that it was his colleague Mr Andy Kerr who, as Minister for Health and Community Care at the time, pioneered the project.
I will pass that on to Claire Sweeney.
It must be a hard one.
We did not consider prices of individual procedures at the treatment centre, but exhibit 7 shows the overall costs. You will see the costs that were agreed. The costs were rearranged slightly after the inception of the contract. At the time, the issue of potential overpayments for treatments that had not been done attracted quite a lot of attention. The centre took quite a bit longer to set up than anticipated. It could not receive patients or perform major procedures as quickly as it could have so it had to renegotiate the contract. NHS Tayside has provided us with figures and we are happy that the board has kept with the contract, that satisfactory payments have been made and that it has not paid for anything that has not been done.
We have been trying to get those details, but we are unable to get any information until PwC publishes the final figures. I am not sure about the level of detail that the report will get down to, but we have asked to be sent a copy once it has been finalised.
Any time now. I can chase that up.
We may have some figures on the prices that were set for procedures. We need to go back and check. I cannot remember whether that was based on the tariff costs that have been set for some of the procedures. However, we could look at that and see whether we can compare.
It would be useful if you were able to give us information that would tell us whether what was being delivered by Netcare was more expensive or less efficient than the NHS.
There is an issue with the procedures that the treatment centre was able to do because of its location and medical back-up. For example, it could not take complex procedures or procedures involving certain conditions among elderly people. It had to do fairly straightforward procedures because it did not have medical back-up if things got complicated. It would not have the same case mix as boards, for instance.
I return to the convener’s opening question on exhibit 3 and the divergence between spend and activity. I would like some clarification on that issue. It is a bit difficult to understand how there can be spend without related activity at least matching it. The report talks about some £32 million that was spent on reducing waiting times. Does that count as activity?
Yes. The activity that was done specifically to reduce waiting times will have increased both activity rates and cost. In many boards, cost will have increased more than activity increased because the work was done at weekends or out of hours and through other providers or in different ways. That activity will have increased both cost and activity rates while decreasing productivity, because cost went up faster than activity did.
So it is not a specific problem with hip fractures; it relates to any operation.
The report looks at exactly that question of rehabilitation in hospital and once people have been discharged. Claire might want to say a bit about it.
Thank you again for a good and comprehensive report. I am sure that we will follow up on it.
We have examined day surgery several times in the past 10 years. The picture for orthopaedics is similar to that for specialties as a whole. We have found a wide variation in the percentage of procedures that are carried out as day cases. Exhibit 12 in the main report shows, for six procedures, the Scotland average, the target and the performance of the boards for which data are available. For example, for cruciate ligament reconstruction, the rates range from 2 per cent in Grampian up to 62 per cent in Lothian. That is an extreme range of variation, although it is not outstandingly extreme.
Are there any issues to do with availability of resources? We know about some of the challenges that Greater Glasgow and Clyde NHS Board has faced. Although it is not hugely behind health boards in other parts of Scotland on carpal tunnel release, it is significantly behind on other procedures. Is that to do with investment of money?
When we have looked at the issue in detail in the past, it has been clear that doing same-day surgery rather than in-patient surgery has an effect on cost, depending on how things are organised. If patients are treated as day cases in an ordinary in-patient ward, not much money is saved—the ward will still have to be staffed 24 hours a day and the same levels of cover will be needed. It is much cheaper to treat patients as day cases in a day-case unit that closes overnight, where work is planned in that way. Most health boards now have such units available for most specialties.
I am not going to say anything about that. [Laughter.]
Would each individual board would have the information?
The boards would have some information around the issue, but we have questions about how easy it would be to draw comparisons and how consistently and routinely the information is recorded. We certainly cannot give a picture for the whole of Scotland.
The boards might not know. The consultants might not be too keen on the information being available because they get a lot of extra money by referring people to the Murrayfield hospital or a private insurance company hospital somewhere. They might not want it to be known.
I have a couple of questions on the cost of treatment. I read with interest paragraph 92 of the report, which illustrates the striking variations in the cost of certain procedures. It states:
Just before you go on to that, I would like to follow up that response to Murdo Fraser’s question. Essentially, you are saying that the cost differential is down to consultant preference. I presume that we are talking not about inferior products or products that are less likely to provide a satisfactory outcome but about products that are proven and reliable. Frankly, if that is the case, I find it unacceptable that consultant preference should be costing the NHS so much. It might be happening because consultants are not aware of what else is available, in which case NHS Scotland should be taking urgent steps to ensure that everyone is aware of the most cost-effective units. On the other hand, consultants could be left open to accusations that they have chosen more expensive products for some other reason. That would be unfortunate but, whatever the reason is, there appears to be no justification for continued expenditure on what appear to be overpriced products.
Audit Scotland does not have a view on the use of tariffs. In England, they underpin the payment system for NHS work; that is not the case in Scotland, but that policy decision is outwith the remit of our interest.
This is an important issue. If you are comparing the two methods of service delivery, and you are assessing the best use of public funds, you need to know whether providing services through Netcare was more expensive or less efficient than doing it through the NHS, or vice versa. Otherwise, we will not know whether the decision to set up Netcare was right or the decision to disband it was wrong. We have no way of knowing if we do not have that information.
George Foulkes is right. However, you would be able to compare the cost of similar procedures.
What explains the growing divergence between the activity and the spend that is put into the system? What explains that growing gap?
I should also emphasise that, as we mention in the report, that picture can be seen across the whole of the NHS. We looked at how the performance of orthopaedics was placed to check whether there were problems in orthopaedics that were not being seen across the rest of the NHS, but there is a standard picture. That perhaps emphasises the point that the issue is probably due to staffing being more expensive and to procedures being more complex. There is a consistent message across the picture.
That comes back to the point that I made at the beginning. If the gap is because more complex procedures are being carried out than was the case previously, we need to be prepared to accept that. If the gap is because procedures—whether routine or otherwise—were previously rushed and staff were overworked, we should also be prepared to accept that gap. However, if the gap is simply due to costs going up without any other explanation along the lines that I have suggested, that would be a worry. The gap might be due to a mixture of those issues. We might need to look at the matter further to find out exactly why that gap has emerged. Indeed, from what has been said, the issue applies not just to orthopaedics, so it might well come up again elsewhere.
A number of people have mentioned the issue of sharing best practice. Paragraph 96 states:
Although the review was a look at the national information, we did some detailed work at board level to do a sense check and get a feel for whether there are any trends. One of the big messages that came through was that people are often unable to explain some of the variation. That is why we have not presented you with concrete answers for why some of the information looks the way that it does. That suggests that there is a need for boards to look in more detail at why there is variation, and there are some issues with case mix that might have an impact. That information has come out from the local work.
Can you give me an example of what you mean when you say that people’s home circumstances might lead to an increase in readmission rates?
That is right.
However, there is an issue about quality and procedures, which I know about from personal experience, when my father fell and broke his hip. The ability to get patients into rehabilitation and doing the proper exercises immediately is an important facet of recovery from a hip fracture, but I know that in some hospitals that does not happen as it should. That will impact not only on the length of stay in hospital but on the ability of the person who receives treatment to live successfully in their own home. Frankly, some hospitals are still not meeting acceptable standards.
Thank you very much. A couple of the things that you said intrigue me. You mentioned that the number of consultants has increased by 50 per cent, but that activity has increased by only 12 per cent. Exhibit 3 on page 6 of the “Key messages” document shows that total activity is lagging behind total spend. That is worrying.
I invite the deputy Auditor General, Caroline Gardner, to introduce the report.
Orthopaedics is a national health service speciality that matters. Back pain, hip problems and other orthopaedic conditions seriously impair people’s mobility and their quality of life. Orthopaedic services treat a high and increasing number of patients every year—there are around 76,000 in-patients, 24,000 day cases and more than 500,000 out-patient appointments every year, at the last count. The service costs about £370 million a year, making it the third biggest after general medicine and general surgery.
It is a complicated picture, and the ability to draw firm conclusions is limited by gaps in the data. The number of procedures has significantly increased over those 10 years, but the number of procedures per consultant team has gone down. That is explained by the increase in the number of consultants of about 50 per cent over the period.
The picture is indeed slightly more complex, given the procedures that are technically possible now. That change, which has taken place over time, will account for some of the difference. There is also a link to cost—some more expensive procedures are now being carried out.
There is an argument that a reduction in the number of procedures per consultant team might be a good thing, either because too many operations were previously being carried out in too much of a hurry because of understaffing—which would clearly be a worry—or because more complex operations are being done that take more time, as you say. Is there a way of telling whether we have a welcome trend and a reduction for the right reasons, rather than an unwelcome trend as a result of investment not giving the proper returns?
It is probably important to mention the changes in contracts, particularly for medical staff, which we think will have an influence. We could not go into a great deal of detail on that, as the report examined published and available national information. However, from other projects in which we have carried out work in more detail on the issues around the consultant contract and the impact of the European working time directive, with changes to the way in which junior doctors are trained, we know that, potentially, the amount of what we might call medical hours is reduced at the same time as there is a greater focus on more complex cases. All that needs to be taken into consideration in the round. We could not give hard-and-fast numbers on what that means for consultant hours on the ground, but it is certainly a factor that boards should consider in more detail.
The issue of consultant preferences is interesting. On the one hand, the variation could show that consultants are showing initiative, working at the top of their game and delivering excellent results. On the other hand, the worry is that NHS Scotland is not considering best practice and asking why others are failing to deliver similarly. Has there been any response from NHS Scotland on what it is doing to improve performance and standards throughout Scotland?
We will hear from Bob Doris then George Foulkes—I am sorry; I meant Bill Kidd, not Bob Doris. I passed Bob Doris in the corridor earlier on. Sorry about that—it was a senior moment.
For suitable patients, most of the procedures in question do not require much in the way of health and social care after discharge. All the evidence is that if the treatment is got right on the day and people are discharged with proper pain relief and instructions on how to get help if they need it, the quality is just as high as it would be with in-patient care.
Paragraph 29 in the “Key messages” document says that the average length of stay in hospital following an orthopaedic procedure is 5.2 days for patients in Glasgow, whereas for patients in the Western Isles it is 15.5 days. That is a considerable difference, notwithstanding the fact that Western Isles NHS Board will have a smaller consultant team, which will have a different view about how to treat patients. It may be more difficult to deliver community health care in a more spread-out area such as the Western Isles than it is in Glasgow, but that seems to be an issue that we should look at, with a view to drawing the two treatment methods closer together.
I ask Claire Sweeney to answer that initially.
There are two separate issues and it is worth while to distinguish clearly between them. In the report, we are talking about patients who are referred to private facilities by their NHS board and whose treatment there is paid for by the board, mainly to meet waiting time targets. Separately, some individuals choose to pay for private treatment, either under insurance schemes or by paying as they go. The boards certainly have information on the first category although, as Claire Sweeney said, it is not recorded consistently. The boards might not—they probably will not—have information on the second category, although there is some published data that we could pull together for the committee if that would be useful.
I think that it would be helpful to have that information. I do not know about other members, convener, but I would certainly like to have it. It would be unfortunate if people were being pushed into the private sector unnecessarily when they could get perfectly good treatment within a reasonable time in the NHS.
On tariffs—
And I will pass it on to Jillian Matthew.
Will the final PwC report provide us with a comparison between the costs of the Netcare project and costs within the NHS more broadly?
When is the report due to come out?
The information would need to be strictly comparable. My recollection, which I think is confirmed in exhibit 7, is that Netcare took only the quick and easy jobs—the ones that it could make money on quickly—and that difficult and dangerous ones were sent back to the health boards to be done under the NHS. I do not know that the two will be strictly comparable.
That is right. Both are included.
In part, as I said before, that might be due to the fact that it is now possible to carry out more complex and costly procedures that could not be carried out before. Another issue is the increased cost of medical cover, as the cost of buying a given number of hours of a consultant’s time is different under the new consultant contract from what it was under the previous arrangements. The introduction of the European working time directive has also had an impact on the training arrangements for junior doctors, which means that the medical workforce has a very different feel to it from what was the case a few years ago. All those things will make a big difference to productivity.
Exhibit 3 certainly shows an interesting indicator. If that divergence continues, committees of the Parliament might begin to think that we are not getting benefit from the extra money that is being spent, especially when we see such gaps emerging. However, I do not think that that is the picture that is emerging from Audit Scotland’s explanation, which suggests that activity has also increased along with spend. Nevertheless, people looking at that graph might conclude that, if the gap widens, we are not getting value for money. However, that might not be the message that exhibit 3 is telling us.
We know quite a lot about hip fracture, because there is a long-standing hip fracture audit that was first set up in Scotland and is a real Scottish success. It has looked at good practice on everything, such as what should happen to somebody when they are admitted to hospital with a hip fracture, how quickly they should be operated on, and antibiotic and anti-blood clot treatment. A lot of work has gone on to ensure that that good practice is applied throughout the system.
I was referring to the general point that we know that ill health is associated with deprivation and that the more deprivation that there is in an area—in Greater Glasgow and Clyde, for example—the more likely it is that people are in poor health generally and may not cope as well at home after a major operation such as a hip or knee replacement. They may not have as much family support around them and their housing may not be as suitable—a whole range of things comes into play that may make it more likely that they do not do as well after an operation as someone who lives in a bungalow with easy access to a telephone and neighbours who are willing and able to help out. It is the broad set of circumstances around deprivation that we think comes into play.
We did not look in great detail at the rehabilitation side; we were very focused on looking for potential efficiencies and at the acute care that was provided—surgery, in particular. However, we touch on the issue in the final paragraph of the report—paragraph 103. We found that, as you say, convener, there is variation in the rehabilitation services that are available, particularly for older people. That will obviously have an knock-on impact on the length of time that people need to stay in hospital and the procedures that can be carried out as day cases. You are right: rehabilitation has a set of impacts on how other services are developed. It is not something that we looked at in detail, but we certainly touched on it and took account of it in the report.
“Protecting and improving Scotland’s environment”
Committee members have before them a response from the accountable officer. Are there any comments or thoughts on that response? It covered many of the issues that we raised. There might well be matters of interest to the Transport, Infrastructure and Climate Change Committee but I am not sure that we need to do anything further. Are members content to note the report and refer it to our colleagues on that committee?
Just before we turn to item 4, which is to be taken in private, I will comment on changes in the committee, which it was remiss of me not to note at the beginning of the meeting when I referred to Audit Scotland. Members will have noticed that Tracey White has now left the committee to go to the Parliament’s legislation team. She is replaced by Jane Williams, who is now in place as our committee clerk—welcome, Jane.