The third item on the agenda is a second evidence session on national health service board budget scrutiny. Last week, we took evidence from the directors of finance at NHS Greater Glasgow and Clyde, NHS Ayrshire and Arran, NHS Tayside, NHS Dumfries and Galloway and NHS Western Isles. Today, we welcome Paul Gray, the chief executive of NHS Scotland and the director general of health and social care at the Scottish Government. He is accompanied by Dr Catherine Calderwood, the chief medical officer; John Connaghan, the NHS Scotland chief operating officer; and John Matheson, the director of health finance, e-health and analytics at the Scottish Government. I welcome you all.
I understand that Paul Gray wants to make a short opening statement. After that, we will move directly to questions.
I thank the committee again for the opportunity to discuss the budgets. We have just concluded the financial year 2014-15 and, subject to audit, we can report that health boards have delivered services within financial plans for the seventh consecutive year. In doing so, delivery of efficiency savings has been a key part of maintaining financial balance. In 2014-15, boards achieved savings of £284.9 million, which is 3.1 per cent.
We start from a strong base in NHS Scotland budgets. We plan for the long term and the short term, and we have clear financial planning assumptions. I assure the committee that budgets are not developed in isolation. They form part of health boards’ planning for service delivery and workforce.
Our methods of funding are designed to provide equity as well as stability, and to incentivise the right behaviours on efficiency and planning. Boards’ plans for 2015-16 will deliver a balanced position. However, we recognise that it is becoming increasingly challenging to do so, and that challenge will continue. That is why we have a strong focus on improvement and efficiency, and it is why we are continuing the very important work on the integration of health and social care.
As always, convener, if there is information that the committee wishes to know that we do not have immediately to hand, I will undertake to provide it as quickly as possible. I will also make good use of my colleagues, who have expertise in particular areas in which the committee may have an interest.
I am grateful for the opportunity to make that brief statement.
I will ask about the data that the Government collects and garners from health boards, and whether that is provided in a consistent, meaningful and comparable way.
I will mention some information about anticipated uplifts in hospital drugs prices. Other members might wish to talk about that in terms of cost pressures in the NHS, but that is not my reason for giving an illustration of the figures. In the meeting papers, there is a table showing the anticipated price and volume changes for hospital drugs for 2015-16. NHS Ayrshire and Arran has an assumed price uplift of 2 per cent and an assumed volume uplift of 22 per cent. By comparison, NHS Dumfries and Galloway has an assumed price uplift of 8.7 per cent and an assumed volume uplift of 2.5 per cent. Those are just numbers and in one respect they are meaningless, but when the committee does its budget scrutiny and when the Scottish Government takes a view on the local delivery plans of each health board, how can we be sure that the figures are collected, collated and analysed in the same way?
From looking at the figures, I have no idea whether they reflect the cost-pressure mitigation of drugs going from patent to generic, whether they take account of the £80 million new medicines fund that the Scottish Government has supplied or whether they include horizon scanning of new drugs that are likely to be approved by the Scottish Medicines Consortium and then go through to the area drug and therapeutics committees. I do not know.
The Government has to look at each health board’s local delivery plan across a variety of areas. I apologise for starting off on the matter of process, but we are involved in a budget scrutiny process. How do you ensure consistency and comparability to interrogate the figures of the local delivery plans from each health board?
I signal to my colleague John Matheson that I will bring him in on this shortly, and Dr Calderwood might want to comment on any clinical aspect. I will focus on the example that you used, although the question has broader applicability to other areas where the figures may or may not be comparable.
Boards make an assessment based on their local demography. The patients that they expect to treat and the age of the population are two factors. For example, in NHS Greater Glasgow and Clyde—which was not one of the examples that Mr Doris advanced—certain drugs are used more frequently and at higher cost because of the type of patients in the board area. It is therefore not a concern to us if different boards make different assessments. However, you point to quite sharp variations in the assessment both in terms of the likely cost pressures and the likely numbers.
We look at the budgets across the piece to assure ourselves that boards have made rational assumptions, but we do not seek to second-guess the boards and the clinical advice that they will have received from their medical directors and through the clinical governance and assurance processes that they have in place.
John Matheson may want to say more about that, and Dr Calderwood may want to come in, too.
09:30
Mr Doris is right to highlight the issue of drugs because, after staffing, that is our next highest spend area—we spend £1.4 billion on drugs. We have a collegiate approach across boards and discuss planning assumptions as we move forward into not just the next financial year but future financial years. We do that through the corporate finance group. We look at pay assumptions, inflationary assumptions and the impact of pension and national insurance increases. Mr Gray is right to the extent that there will be a differential approach, depending on how efficient boards have been. Mr Doris picked up specifically on where the boards are positioned on branded and generic drugs, and we expect variation in that across boards.
We expect boards to include in their considerations the new medicines fund and any pressures. Hepatitis C provides a positive example of a differential approach across boards. There is a high prevalence of hepatitis C patients in NHS Greater Glasgow and Clyde—it covers 25 per cent of the population but it has about 40 per cent of the hepatitis C patients—so the new drug that has been brought out recently that cures hepatitis C patients is having a significant impact in NHS Greater Glasgow and Clyde. We would expect a differential position on that.
I am more concerned about the total trend in expenditure than about the split between price and volume. I am also concerned about how proactive boards are in looking to make further efficiencies within that £1.4 billion spend. For example, we are being proactive around the introduction of the Scottish therapeutics utility tool, which is made available to general practitioners to review repeat prescriptions. It is focused on reducing harm and variation, but it will also create financial savings.
There is a complex matrix, and the differential is not a surprise to me. For me, the key is the robustness of the estimates. Throughout the year, we go back and review with boards how accurate the estimates have been.
I will give another example. Sixty per cent of cancer patients are treated by the Beatson hospital in NHS Greater Glasgow and Clyde. You will know that, as a subset of drugs, chemotherapy drugs are among the most individually expensive. Again, the population in the area needs those expensive treatments. One or two individuals in a health board area may be on very expensive immunomodulatory drugs. We would not know the clinical details of that, but it might be enough to push up an individual board’s budget quite a lot.
I thank the witnesses for clarifying those understandable variations in drug costs. I get that point. We know about NHS Greater Glasgow and Clyde, because the committee visited the new robotics centre in the south of Glasgow. We know about the health board’s ability to deal with polypharmacy and about the efficiencies in the system. We get the idea that there can be variations based on performance and best practice, but that was only half of my question.
The other half of my question—which I do not think the witnesses addressed—was about whether there is a matrix or framework whereby NHS boards report to the Scottish Government in a consistent and comparable manner and what the methodology for that reporting is. Is there scaffolding—for lack of a better expression—or a framework around the returns that boards have to give to the Government? All that we have is numbers, and there are variations. I take on board all the reasons for the variations, but we do not have an explanation of whether the boards collect the figures in a consistent and comparable way. That is what we need to know. If such collection has never been done, it is not a matter of blame, but I want to get to a position in which it is done.
I ask the witnesses to address the broad issue and not just the issue of drugs. The broader question is about making comparisons. Every time that we make a comparison, we get a long explanation about why there is a variation in Glasgow or a rural area. The important point is the consistency of the information that is being put before us and whether boards use the same methodology to collect the information. In some cases, boards do not collect the information at all.
That is entirely understood.
John Matheson will help us to understand how we collect the information and the framework that is used, both of which are consistent.
I will make this succinct.
There is a corporate finance network, in which the senior directors and deputy directors of finance come together to review the planning assumptions and look at the consistency of approach across pay and prices.
We get individual returns from boards and respond to them. For example, we might say to NHS Ayrshire and Arran that the average across Scotland for drug inflation and volume increases is X, and it looks as if the board is an outlier. We will ask the board to review its position, and it will either change its position or confirm that there are specific reasons why it is an outlier.
There is a basic framework in place through the corporate finance network, which brings the planning assumptions together for the next year and the two or three years after that. A review mechanism is built in whereby the returns are played back to the boards to allow them either to confirm or to moderate their assumptions.
I will ask you a final question about this, and I will then come off process and allow my colleagues to ask different questions. The question is, however, important.
I am partially reassured that there is a corporate finance director framework, and dialogue between the finance experts in each of the health boards and the Scottish Government on outliers. I understand all that. My point is about the reported figures that the committee sees. Are you saying that those are collected in the same way to the same framework and that therefore we can compare them directly?
For example, NHS Ayrshire and Arran has a 2 per cent assumed price uplift for hospital drugs and NHS Borders has a 13.6 per cent assumed cost uplift. Can we say that the difference must be because of demography, and not because Ayrshire and Arran has taken generics into account and Borders has not, or because Ayrshire and Arran has done a better horizon-scanning exercise on future cost pressures than Borders has? In other words, are the numbers collected in a consistent way, so that there can be scrutiny other than waiting to see what is collected and asking outliers to explain themselves?
I will not come back for a follow-up question on that point, because I want to come off process, but it is quite important. I have picked drugs because that is what the information in front of me is about, but it could be any part of the NHS. Is the process giving us good budget scrutiny? I understand that there is perhaps good budget scrutiny between the Government and the health boards, but the process should be a three-legged stool with this committee as well. We want to be part of it.
I recognise the critical role of this committee.
The aim here is that the core planning assumptions, which would include those factors that you identify, Mr Doris, if we focus specifically on drugs, are included within the planning assumptions of the boards. Any differentiation is a differentiation in terms of the impact of those core planning assumptions and not the absence of them.
Okay. I will reflect on that rather than ask a follow-up question, convener.
Would it be helpful if we set out for the committee in writing the basis on which the financial plans are constructed, scrutinised, and reviewed at the end of the year? Would the committee find that helpful? We would be very happy to do that.
I am sure that we would find that helpful.
The follow-up questions would be how important the information that you are gathering is and how important it is to push forward your strategic plan.
How do you build in risk, such as politicians complaining about access to very expensive end-of-life and cancer drugs, which the health boards were squealing about? How do you build in the risk that politicians will announce an £80 million fund for rare diseases that is then in the newspapers? How do you build that risk into all of this strategic and financial planning?
I will make an offer in addition to Mr Gray’s offer. I would be happy to explain why there appears to be a differential outcome for a couple of boards, if that would be helpful.
Yes.
In relation to the £80 million new medicines fund, the health boards will look at their individual cost profile against that, we will have a horizon scan from the SMC of what drugs are coming through the pipeline over the next financial year, and there will be the impact of individual patient treatment requests and of orphan or ultra-orphan drugs. As Dr Calderwood pointed out, because those drugs are low volume and high cost there is a very different profile for them across Scotland. For example, eculizumab—for cystic fibrosis—is given to a very small number of patients across Scotland, but the cost of the drug is several hundred thousand pounds.
It may be useful to compare reality and the pressures that are on the system against those budget plans. I have been on the Health and Sport Committee for several years and, for a number of years now, we have been talking about controlling the price of prescribed drugs. We are still at it, and we have estimated that drugs going off patent would generate X amount of money and that that would reduce the drugs bill, but it has not happened to the significant extent that we expected.
However, we are focusing a bit too much on drugs here. Maybe we will get a wee bit more coherent as we move on. We are trying to see where the budget planning is pushing along the priorities and long-term strategies of Government for moving the delivery of care away from clinical settings and into community settings. We have heard about all the pressures that affect budgets and, obviously, some of the priorities. We are trying to get to the heart of that.
May I just make one point? We are quite rightly focusing here on the cost of drugs, but our focus when we look at how drugs are utilised is as much, if not more, on the variation in patient harm and so on, to ensure that we have a clinical focus in how we review the drug expenditure.
It could be drugs, or it could be workforce planning.
Indeed.
We assess the health of the health service on the basis of how many doctors and nurses we have. That is an old-fashioned idea now, but we still do it. We spend inordinate amounts of money recruiting people outwith the recruitment and budget plans. That is what we are struggling with here, as a committee.
I begin by congratulating John Matheson on his honour, which is much deserved.
I want to focus on the question of the incremental cost of achieving targets. There is no doubt—I think that the whole committee would agree—that targets have served us extremely well since the Parliament was formed. They have driven forward performance in a way that had not previously been possible.
However, it was quite clear from both a freedom of information request that I made and the evidence that we heard last week that there are some problems. First, in response to the FOI request, the overwhelming majority of finance directors could not tell me the incremental cost of achieving targets—the cost of pushing that final group through. Last week, we heard from Derek Lindsay of NHS Ayrshire and Arran an example of where the board had to pay consultants three times the normal rate to get them to undertake a waiting list initiative.
All the finance directors agreed last week that the cost of achieving that final element in the target, particularly when it is a 100 per cent, legally required target, is a huge cost to the health service that is not a wise way to spend money. Do you think that this committee as a collective, in a way that has nothing to do with party politics, should be joining the call from the Royal College of Nursing this week to look at whether those targets should be modified for this period of austerity, so that we can spend our money more wisely? What are the costs, do you ask for them and is the money spent wisely?
09:45
Dr Simpson, you are right to say that it is hard to determine the incremental cost of meeting the last 1 or 2 per cent of any particular target. That would apply to the treatment time guarantee and doubtless to other targets too.
If someone is being paid three times the standard rate, he or she has been asked to work at the weekend and that is the rate that applies. If a waiting time or other high-profile target is being addressed through an initiative, some costs will certainly be incurred and it is possible to calculate what those are. However, the overall cost of meeting the last percentage points of a target is not something that we routinely collect.
You ask whether I think that the committee should join the RCN and others in seeking a review, particularly of the treatment time guarantee. It would be for the committee to decide its own position. As the chief executive of the national health service, however, I must and will be committed to meeting the treatment time guarantee for as long as it is a legislative requirement. I cannot do otherwise.
If the committee, on the basis of the evidence before it, felt that it ought to press for a change in the legislation, that would be a matter for the committee. The last percentage points of the treatment time guarantee target cost money to meet, and some clinicians have questioned with me whether, at the far end of the target, it is clinically necessary to meet it in every single case. Those points having been made, I must nonetheless proceed on the basis of the legislation.
It goes back to our original question.
The issue is the data collection. The committee cannot make a recommendation unless we understand what is involved. Until we get some modelling, which I am really surprised is not being done, of the incremental costs at the far end of meeting a target—or not meeting it in the case of the 10,000 Scots who did not get the legal guarantee last year—we cannot make a recommendation.
We are not even reaching the treatment time guarantee target. I know that the fractions are small. We are 99 per cent there, which is fantastic and a great achievement. To force the system to achieve that final 1 per cent, or indeed not achieve it, is costing us a fortune that could be much better spent in other areas. Nevertheless, unless the centre can supply the data and get the boards to do the modelling, there is no way we can make recommendations.
I am happy to take from the committee a request that we first establish what we have available. I will discuss with ministers, because ultimately it will be a decision for them, what more we might do to collect information about the incremental costs of meeting the last percentage points of the target. I am happy to take that away.
When we decided to improve the waiting time targets, did the people who were constructing the budgets not say, “That’s a great idea, minister, but this is what it will cost,” or did that not affect this budget process at all? Did they just say that that was fine, with no information about cost and outcome at the heart of the decision to go further? Is that what we are hearing today?
What I am saying is that I cannot speak for the advice that was given to ministers at the time. Of course, advice to ministers is private, as the committee knows. The decision was made through a parliamentary process. The legislation was scrutinised in the normal way. There would no doubt have been the normal costing information associated with that.
What we were not asked to do once the legislation was implemented was collect information on the incremental cost of meeting the last few percentage points. Therefore we do not have a system in place that routinely does that. I take it that the committee is telling me that it would be interested in having information on that. I will raise that point with ministers and come back to the committee quickly on it.
I will make this very brief, because I have already had an opportunity to come in. On Dr Simpson’s point about a 100 per cent treatment time guarantee, whether it is 100, 95 or 90 per cent, as soon as you set a target with a number you will always at some point be just 0.5, 1 or 2 per cent away from meeting it. If targets are reduced from 100, 95 or 90 per cent, is the principle not just the same that to meet the target in absolute terms requires additional costs to be met? It is not that the target sits at 100 per cent; it is that, as soon as you put in a target, when you are just short of that target there is one final heave required to get over the finishing line. Is that a reasonable thing to say? We should not just focus on the treatment time guarantee; we should look at the additional cost to reach any target. It is for the politicians to decide which targets we believe are most important.
Can we broaden this out? We heard that it is not just about money. We heard that these targets were driving the priorities more than the planning frameworks. It is not just about money; it is about how the targets are diverting us from some of our other strategic objectives and policy. That is what we heard last week.
I will bring in Mr Connaghan in a second, convener. The chief medical officer might have a comment on the clinical aspects of this, but let me try to cut this up into three parts. First, there is a difference between a 100 per cent target and a 95 per cent target, such as we have in accident and emergency. What we are saying for A and E is that it will not always be clinically appropriate to have someone seen, treated and discharged from A and E within four hours. Most of the time it will—the clinical advice is that it is appropriate in 95 per cent of cases. In the past few days, a person in one of the A and E departments in Glasgow was there for well over four hours. Throughout that time they were receiving appropriate treatment and care, but they were too unwell and unstable to be moved; it would have been wholly inappropriate to take them out of A and E within that four-hour period. A 95 per cent target, with some flexibility for clinical judgment, is different from a 100 per cent target.
Secondly, the cost of meeting a 95 per cent target will be driven somewhat differently from the cost of meeting a 100 per cent target. There is a degree of flexibility for clinical decision making in the A and E target that is not present in the treatment time guarantee.
Thirdly, I am slightly hesitant to say that targets are one thing and priorities are another. It is a priority to see, treat and discharge people from A and E within four hours. That is a priority as well as a target—although we now call it a standard. I would not like to go as far as to say that targets are deflecting us from our priorities. However, I take the point that the committee is making that, if the expenditure to reach the last fraction of a target is proportionately excessive and does not deliver clinical benefit, that may be something that we should look at.
It is probably worth remembering where we were back in 2005-06. At that point, the NHS had what we called a performance assessment framework in which there were more than 200 individual targets. Boards were complaining that they did not know what the priority was—they needed some focus in what they were doing—and out of that came the system of health improvement, efficiency and governance, access and treatment, or HEAT, targets, which was established in 2006-07.
As of today, having listened to the advice that we have taken from the committee and through consultation, we have 20 standards in the NHS. I agree with the committee that they drive investment in certain respects. Those 20 standards can be subdivided into seven broad categories: cancer standards, mental health standards, waiting times, infection rates, finance and governance, emergency services and some standards broadly around health improvement. Those are all-important for both the health of the population and the efficiency of how we deploy our budget.
When we engage with bodies such as the College of Emergency Medicine on what is appropriate, they invariably say that they really do not want to move away from the four-hour A and E standard, because it is important. We do take advice on our standards.
The point about the incremental cost is a moot point, and I have some sympathy with Mr Doris’s view. If we were to make the target 15 weeks instead of 12 weeks, there would still be an incremental cost associated with the 15th week—if I can put it like that. The tighter a particular standard is drawn, the more there is an argument about incremental cost. As you heard from the director general, we will supply some information on that.
The four-hour A and E waiting time target is a process measure—it does not tell us how good the outcome is at the end of that time. However, it is based on evidence that the longer someone spends in A and E, the poorer their outcome will be and the more harm will potentially occur. The targets are proxy measures that are driving clinical improvements.
We do have outcome measures—the cancer standards are more along those lines. We know what percentage of patients survive for five years, for example. However, the targets are proxies for our quality-of-care measures because it is very difficult to measure the quality of care. Not everyone will have a good outcome, but we want them to have a good quality of care in our NHS even if we cannot prevent a poor outcome.
We need to understand that the four-hour waiting time is based on good, sound clinical advice. It sounds like just a number, but the targets are always being developed with patient care and patient outcomes behind them. With the RCN having recently raised the issue of the need to look at the targets, we know that it is an evolving process. As Mr Connaghan said, we have changed over time, and I think that we would always be willing to revise targets and standards partly because the way we work in medicine changes.
That engagement has been important in making the point that there has been progress. I recognise that, at the moment, there are a number of targets—there are also HEAT targets, performance targets and whatever. There seem to be an awful lot of them. However, compared with what we had, there has been a reduction in the number of targets. As we picked up last week, gathering this information does not really tell us much. It can tell us, for example, how many people died in hospital as opposed to in the community, so that people can boast about the fact that more people are dying at home, but there is no reference at all to the quality of the care or the engagement.
I hope that you see where the committee is going with this. Can there be more clarity? Do we need more clarity and focus? Dr Calderwood made a good point in asking how we can measure quality and the impact on patients in all this.
I will let Richard Simpson back in, because he might want to speak to some of the other headings, but I will let Richard Lyle in first.
10:00
A number of years ago, I wore glasses because I had cataracts. I then had cataract operations on both eyes over two weekends at a time when the number of people waiting for cataract operations was halved.
With the greatest respect, I have to ask this question, because it is on something that has always annoyed me. Does it annoy you when politicians from whatever party interfere in the NHS and say, “Change that target, put that target up and put that target down”? How much does that annoy you? [Laughter.]
I will answer for all of us, in the interests of diplomacy.
If it was my stock in trade to be annoyed by politicians, I would not be a civil servant. Politicians are elected, and I respect that. I respect the democratic right of the people of Scotland to elect the politicians of their choice, and I respect the right of the politicians to decide. We are here to advise; politicians are here to decide. I am perfectly happy with that. If I allowed my personal views, or what might annoy me, to enter into my judgments about what I do, I would not be doing my job professionally.
I welcome the challenge and scrutiny of committees such as this, and I welcome the challenge that politicians of all parties provide. Generally speaking, every politician that I have met has a motivation to make things better. They may have different views about how that should be done. I respect the right of the politicians to take the positions that they take and I will work with that.
That was a good answer—a politician’s answer.
Along that line, at the end of the day we have targets, but should we not ask politicians from every party to sit down and agree where we are going with our health service? It annoys me intensely—I have to say it again—that the NHS becomes a political football that every party takes a swipe at; we are all in that game. Based on the points that Richard Simpson has correctly made, should we sit down and give you clear direction that every party signs up to and, once the parties have signed up to it, stop throwing bombs at the NHS?
Certainly, the more consensual the decisions about the NHS are the better, as far as I am concerned. I do not deny that it makes my life easier if there is agreement about what the propositions, solutions and outcomes should be. That said, I would not want to stifle healthy debate about the future direction of the national health service. It is a complex and multifaceted system that does not operate in a vacuum; it operates in the context of all the other public services that are provided, the demographic trends that we face, and health and social care integration.
To suggest that there will ever be one simple solution to the problems that we face would be naive of me. I would not want to stifle debate about the options that are ahead of us, but at the end of that a consensus will certainly make it easier to implement.
I want to widen the scope a little to look at how you evaluate and account for the preventative care aspect. Mr Gray, you and your colleagues have mentioned improvement several times. When you are looking at that, does improvement equal efficiency and does efficiency still look after patient care? At the end of the day, we would like to prevent people from going into hospital and to look, perhaps, at other integrated services. How do you account for that broad aspect of prevention, given that, as Mr Gray said, the variables across all the health boards are complex and multifaceted?
Evaluating the efficiencies or savings that are delivered by preventative interventions is hard, because it involves making a judgment about what did not happen as a result of the intervention that was made. Nevertheless, there is evidence across a range of preventative spend that early intervention is cost effective.
For example, it could be argued that the early years collaborative and the raising attainment collaborative are preventative measures. They are helping people to intervene with a child and family early in the life cycle of a child in ways that are co-produced rather than superimposed. There is clear evidence that, by doing that, the life chances of children are improved.
I cannot say explicitly or absolutely that there will be so many fewer visits to hospital, so many fewer interactions with the criminal justice system and a better educational outcome for every child. However, I can say that the evidence suggests that early intervention in those circumstances means that the life circumstances of children are improved, and that is something that we want.
One example in a narrow health setting would be the hospital at home service. I have seen that in many places, but I will pick Lanarkshire as my example today. The service prevents elderly people from going into hospital and I have spoken to patients and families who have benefited from it. The outcome for the individuals is definitely better. Mr Robertson asked whether improvements are all about efficiency and what we think about outcomes. There is no doubt in my mind that the outcome for the individuals is better, even to the simple extent of a lady being able to give an account to me of spending Christmas at home with her family instead of spending it in a hospital bed.
I understand all those points, Mr Gray. However, I am trying to ascertain how you account for that from the budget perspective. How do your directors of finance model that into the framework across all the boards?
I will stick with my example of hospital at home, but the point can be applied more widely.
I have asked that further data be collected not just on the outcomes, although they are really what we are striving to achieve, but on the relative costs. In the example that I gave, we are reducing the pressure on accident and emergency and unplanned admissions to hospitals, but we are paying the cost of having, in this case, a senior consultant geriatrician and a number of other clinicians working alongside that individual in Lanarkshire. That cost has moved out of the hospital into the community. We are not yet absolutely clear whether the net cost is the same or lower, although we do not believe that it is higher. I am being honest with you about that.
I will ask Mr Connaghan and then Mr Matheson to add to that.
For the past few years, we have published a number of case studies in which efficiency and productivity gains have been realised while benefiting patient care. Mr Robertson asked how we account for such things. The annual report for 2014, which is about to be published, contains about 50 case studies, most of which have some quantification.
A small example is a case study in NHS Lothian about how to promote quality and cost effectiveness in the use of wound dressings. This is not just Lothian blowing its own trumpet; it is a series of examples that are applicable to most boards. We encourage most boards to adopt those good principles, and there are other examples. We have been publishing such annual reports for about four or five years.
I will make one generic point and will then give two or three specific examples. The overall strategy that we have in NHS Scotland is the quality strategy, and its thrust is safe, person-centred and effective care with people being treated at home or in a homely setting. Our sub-strategies all point in that direction and support that. From a preventative perspective, prescription for excellence looks at how we can strengthen engagement with community pharmacists to reduce the number of unnecessary admissions that are due to medication errors. At the moment, the figure is about one in seven—Dr Calderwood can correct me if I am wrong. More proactive engagement with community pharmacists would result in a reduction in harm.
Within our overall financial strategy, we identify specific sums of money to take forward that preventative agenda. For example, we have a specific investment in telehealth and telecare, which looks at home monitoring and the use of technology to delay admissions. Another example is in the Scottish Ambulance Service, where we have just invested a sum of money as part of an on-going programme to upskill paramedical technicians to enable them to assess and stabilise people in their homes instead of taking them to A and E departments. Strong community engagement is then needed, through community nursing, social care and so on, to allow those people to be kept in their homes. Those are two specific examples in the context of our strategic direction.
I dare say that, if there is community optometry, for instance, and people have regular eye tests, that can prevent trips and falls. However, it is all pretty subjective, is it not? What monetary figures do you assign to the strategy? Finance directors will have to come up with costings for the strategy in their budgets.
We are looking for the definition of investment that is specific, appropriate and sufficient to drive more people being treated. There are no targets to ensure that X number of people will be cared for in the community, at home or close to home or that the number of hospital admissions would halve if people could get follow-ups through the system. I suppose that what we are seeing is the absence of a number of features that we take for granted in the NHS setting—prioritisation, quality of outcome for the patient, guidelines and standards that apply, targets to drive the activity and budgets to support it. Where are the equivalent features in the community and the integrated boards? Are we investing enough to drive the change over a period of time?
The outcomes for the integrated joint boards are set in legislation—they are clear. The budgets for the integrated joint boards are subject to scrutiny and this is the shadow year. Going back to Mr Doris’s earlier point, there is variation in the budgets of the IJBs that is not all explained by the demography and geography of the IJBs; it is also explained by the fact that there are certain things that they must include in their integration scheme and certain things that they may include in it. Different integrated joint boards will decide to include different things.
I realise that I am describing to you the things that always make comparison harder, whereas you are asking how we can make comparison easier. There is no straightforward answer to that, as different factors apply in each board and in each integrated joint board. However, each board operates to the same financial standards, each territorial board operates to the same performance standards and each integrated joint board operates to the same set of outcomes, which are set in legislation. To that extent, there is commonality.
The question, which is legitimate, is about how I assure myself, as the accountable officer for all this, that the different portions of money—the different budgets that are set in different places—are all going to add up to the outcomes that we want for the people of Scotland. The answer is that I do that through a series of assurance processes that already exist. I have to accept some of the assurances that I get on clinical and financial matters from the people who are expert in those matters. Nevertheless, I can look at a series of assurance and governance mechanisms that help me to draw that together into a single picture. I am confident that what we have in place currently provides me with sufficient assurance. I am equally confident that it could be better. There are areas where we could improve.
In the year of the shadow integrated joint boards, we will look to review and analyse the propositions that the integrated joint boards have put forward and to learn from them so that, when we come to the first full year of operation in 2016-17, we will not simply walk into it as though this year had not happened.
Dr Calderwood has a specific example on maternity services, which may be of assistance to the committee.
10:15
I am delighted that Mr Robertson has asked about preventative spend. As he may know, I am an obstetrician, so I am always telling my colleagues that, if only they invested in the pregnant woman, they would have a healthier baby, who would grow into a healthier child and adult. In fact, I could solve the problems around the costs of the NHS in future.
You have got the job.
Thank you.
I am sure that the committee is familiar with quality-adjusted life years and the question of how much we need to spend in order to have one more year of quality life. The prevention of pre-term delivery is the ultimate opportunity. If babies grow up to live long and healthy lives, they live very long lives. The prevention of pre-term delivery costs only £300 per QALY, whereas we would deem up to £10,000 as offering value for money.
The investment is difficult, however, as it is multifactorial. The Scottish Government has invested in a maternity safety collaborative, which involves reducing all sorts of problems in pregnancy, such as smoking, which would, in turn, prevent pre-term delivery. The difficulty in measuring that is that, if we also reduce all sorts of other issues, there may be knock-on effects on pre-term delivery.
The boards have invested £1 million across Scotland in maternity champions, who seek to tackle all those outcomes for pregnant women. If we went back to them and asked how much they saved, it would be difficult to quantify an answer. We can already see a very impressive reduction in the stillbirth rate. We know that the smoking ban across Scotland has generally reduced the pre-term delivery rate. However, it is extremely difficult to say that we spent X and gained Y. Nevertheless, I commend Mr Robertson for continuing to ask that question.
I am trying to get at the matter of efficiency. Every board is asked to have efficiencies—a reduction, I suppose. I am concerned about how they prioritise and what falls off the end, or what is not happening to attain those efficiencies. To get the outcomes that we are looking for, are we not delivering a particular aspect of care to a patient? When you are asked to prioritise, does something have to give? If so, what is it? Is it around the preventative spend or through the joint integrated boards? I am trying to work out what happens to the spending. We have finite resources, and everybody has their own budget. Every board is being asked to make efficiencies, but how do they prioritise?
I will ask Mr Matheson and Mr Connaghan to come in on that shortly, but I will first share with you an area where I am currently taking steps to see if we can improve. I am concerned that, in the pursuit of efficiency and delivery, we are underplaying our hand on developing leadership capacity in our workforce.
Does that equate to improvement?
Well, it would, you see. Leadership capacity is, in my view, one of the keystones of prevention. It prevents things from going wrong. For example, we have had a very helpful and robust conversation with the Academy of Medical Royal Colleges and Faculties in Scotland. In part, that has been about the extent to which consultant contracts allow sufficient time for consultants to develop themselves and their leadership capacity.
Although I have not sought to impose a particular solution on health boards, I have told them in writing that I expect them to be flexible in setting up and reviewing consultant contracts. I attach great importance to senior colleagues in the NHS, whether they are clinicians, administrators or whatever, having the time and space to develop and exercise proper leadership. If they do not, the impact of that can be high. That area is perhaps overlooked when considering prevention, but I see a strong link between leadership capacity and prevention.
I made an FOI request 18 months ago, which I am just repeating, on the consultant contracts. The standard consultant contract is split 7.5:2.5—7.5 sessions are to be spent on direct clinical care activities and 2.5 sessions are on supporting professional activities, or SPA. That is the nationally agreed contract.
However, 60 per cent of all the consultants appointed since 2011 are on contracts that are split 9:1. How does that fit with your concept of leadership, if we are requiring our consultants to have only one session for audit, research, leadership development, continuing professional development and training of staff if they are not in a teaching hospital? That really does not fit with what you are saying. I entirely agree with what you say about leadership, but the approach is not working.
In the same FOI request, I asked how many consultants are converting their contracts. It might be argued that, as consultants are starting younger now, they do not have the same breadth of experience, so they need to do the clinical work for a year—that is what Tayside NHS Board told me when I raised the matter originally. I asked how many consultants were converting their contracts to 8:2 or 7.5:2.5 after a year or two. There is very little sign of conversion.
I agree with you about the importance of leadership, but we should start by monitoring the contracts of those clinicians. They are complaining quite strongly about being overworked and stressed, and we have the highest number of consultant vacancies that we have had for a long time in the health service. You cannot control that from the centre; it is the health boards’ responsibility. However, we have the national contract. How do you monitor it, what advice do you give the boards and how does it fit with your leadership plans?
The simplest thing that I can do is share with the committee what I wrote to the health boards and what I agreed with the Academy of Medical Royal Colleges and Faculties in Scotland. I would be happy to share that. Dr Calderwood may have something to say in the meantime about the approach that we are taking to consultant contracts and to ensuring that consultants have sufficient time to develop themselves and the people around them.
My colleagues have been raising the matter with me, particularly in some health boards where the national contract has been applied more stringently. We need to remember that, although 60 per cent of consultants appointed since 2011 are affected, that is a very small number of the total consultant body.
We also need to remember that departments now have many more consultants. That perhaps provides an argument that not everybody needs all of the time that was needed previously to do the extra things. For example, in emergency medicine, there has been a 170 per cent uplift in consultant figures over a very short time.
We are talking to the clinicians about the standard contract including one SPA session. However, if consultants come to an interview or job plan and say that they are, for example, teaching a session and involved in college work X, Y and Z, which can be defined as time that is being spent properly and that the NHS is getting good value for, they can take that negotiating stance with their health boards.
We worried that people were being automatically given that time, which is a lot of additional time in a week if it is not being used efficiently and effectively. There was evidence that the time was not being used efficiently—people were going home early or doing other things with it. With proper job planning, those sessions can be allocated, but only if they will be used properly for additional improvement to patient care through teaching and so on.
Does anyone want to come in on wider workforce planning and the overall strategy to treat more people at home or closer to home? Some thinking has been going into that. When consultants are not at the hospital—because they are at a conference or a training session, for example—that impacts on the rota, weekend cover and so on. Such issues may make the job less attractive in smaller health boards, as I recall from my experience in Inverclyde.
What is the response through workforce planning? How do we view the total workforce, not just the consultant end? It is not the consultant who provides day-to-day, hour-to-hour care at home. What is happening there?
About a year ago, I gave evidence on the same topic. I said that we needed to consider workforce planning as part of a triangulation that involves looking at what service we want for the future and at the available resources. We have a comprehensive framework—if we have not given that to the committee, perhaps we should do so.
At the broadest level, the framework has three big principles: designing the future workforce, which means having an understanding of what impact new services will have on the current and future workforce; developing the workforce—Mr Gray referred to one element of that, which is leadership; and delivering the future workforce. I will not go into the details of the framework now, but it lays out a clear step-by-step methodology that we expect each NHS board to follow. We call it the six steps methodology and it is contained in the guidance.
Does that focus on the NHS workforce? Does it recognise that the new strategy will include the private and voluntary sectors, too?
It will also include the integrated joint boards.
Does the framework include what I mentioned? Does it talk about the NHS workforce or does it take a broader view of the workforce and the strategies?
The guidance that we have concentrates by and large on the NHS workforce. It refers to the fact that planning for other groups, including voluntary services, should be taken into account.
Mr Gray, can you tell us what else is going on to join that up?
When I came into the role of chief executive of NHS Scotland, I became chair of the leadership advisory board. When I took over that board, it was a health service leadership advisory board. I changed that. The second meeting of the new leadership advisory board is tomorrow and will include representation from social work, social care and the third sector. I changed that deliberately because I did not see how we could construct a leadership development offering that was narrowly restricted to the national health service.
In the directorate that is responsible for the integration of health and social care, under the leadership of Geoff Huggins, we have a specific work strand on workforce development, which recognises that we are asking colleagues from health, local government and the voluntary sector to work together in new ways and that simply saying that it is a good idea and that we hope that they will get on with it is wholly inadequate. We need to provide workforce development across all the elements of the workforce.
10:30
Are there budget allocations to drive that?
Yes.
Is that additional money?
To use a phrase, it will be within existing allocated budgets.
How do we assign the budgets for that efficiency? We did not get to that and I am not clear about it.
I am sorry; I am not getting that.
Dennis Robertson is asking for an answer to his question about how budgets for integrated boards are assigned; there are some differences on that issue. I think that you responded that this is a shadow year, and you acknowledged that there are some differences, but I do not think that that satisfied him. Does Dennis Robertson want further clarification?
I asked the question because we have considered all other aspects. Efficiency equals improvement, and I am trying to find out how we assign the budgets. This is about priorities. Does something fall off the end if we need to prioritise because we have set efficiency targets?
In the leadership discussion, I was giving an example of something that I was concerned might be given less priority because of the pressure on delivery. I had a discussion with the Academy of Royal Colleges, and concern was expressed that newly appointed doctors and consultants would be given less time for personal development because the focus was on getting people through A and E or the hospital, and that would not be to the doctors’ benefit. Mr Matheson will speak in a moment, but efficiency is not all about stopping doing things; sometimes it is about doing things in a completely different and innovative way and changing completely how we deliver a service.
To give one simple example, a gentleman in Cumnock with chronic obstructive pulmonary disease would have received regular visits from a clinician or gone regularly to a place where he could be cared for. He can now have most of his care, and the diagnosis of any difficulties linked to his condition, conducted through telehealth and a videolink. I have seen that in operation; it is far more efficient and far better for the individual concerned. That was not stopping doing something; it was doing something in a completely different way. The efficiency gain accrues to the individual and the service. Does Mr Matheson want to say more about that?
To me, efficiency is doing what we do at the moment in a way that is not necessarily cheaper but is more cost effective. Innovation is doing things differently and in a more radical way. For efficiency, we consider procurement, not just of drugs but of general supplies. We have a national procurement service, and the NHS in Scotland is considering health and social care integration and how expertise can be used more broadly across the public sector. We consider locum expenditure, both nursing and medical, and how it can be reduced. When I mention financial performance and efficiency, I mean quality-driven financial performance. If we get the quality right, the money tends to go in the right direction.
In Scotland we have eight innovation centres, including two in the health service. The digital health institute has just moved from the centre of Edinburgh to Eurocentral in Lanarkshire. There it will set up a simulation laboratory with a ward and a home environment, which will allow small and medium-sized enterprises to come in and show their products and innovative practices in a real-life environment. That will allow clinicians to take a view on the applicability of those things.
We have delivered £1.4 billion of efficiency savings in the NHS in Scotland over the past five years, and that has been reinvested in the health boards. Mr Gray mentioned the performance at the end of 2014-15, which was just under £300 million, and boards have identified a further £300 million of efficiencies and innovative practices going into 2015-16.
We will look at that closely to ensure that that is about sharing and delivering best practice, so that the efficiencies identified are consistent with and do not step back from our strategic direction. The efficiencies made have been positive, but we must be more innovative about where we look for solutions.
On the 3 per cent efficiency savings applied across the board, we have heard this morning that many of the boards have different challenges. For example, NHS Greater Glasgow and Clyde has a specific hep C challenge, which includes costs, while other boards could make savings on prescribed drugs, productivity, staffing and so on. How will boards such as Glasgow, which faces a disproportionate pressure, meet the required savings? How does the Scottish Government discuss with the boards the varying pressures that they face in the context of the efficiency savings?
If I gave the impression that there is a set target, I apologise. I was talking about the overall position in NHS Scotland. Boards have individual targets and, across Scotland, that averages out at around 3 per cent.
We assist boards to make efficiencies by identifying best practice. Mr Gray mentioned the Cumnock experience. We have a number of European projects that are looking at and sharing best practice on comorbidity. We look to ensure that boards are aware of that best practice.
Prescribing is a good example. To return to Bob Doris’s point about generic prescribing, we have excellent performers in that area, and we share that best practice with the rest of Scotland. We allow people to learn from best practice.
The efficiency savings are identified at local level. When we see something innovative, we ensure that other boards are made aware of it, and the corporate finance network and other fora are part of that mechanism.
Is a target in place for each board to achieve savings of 3 per cent?
There is an overall target across NHS Scotland, but individual boards determine their local needs—
Coincidentally, that saving is 3 per cent across the health boards.
The percentage is not coincidental; that is what the saving rate has been over a number of years. We do not say that individual boards must achieve a 3 per cent target.
What happens if they do not? What happens to the process if a board says, “This year, I’ll not be saving 3 per cent. I’ll not be saving anything, because I’ve got all these prescribing costs”?
That situation has never occurred. It would mean that a board would not achieve its statutory financial targets.
We ensure that boards have all the information on best practice—not just in Scotland, but internationally—available to them on how they can improve the efficiency of the services that they provide cost effectively.
Glasgow has been mentioned twice. The board there has disproportionate costs in relation to the Beatson west of Scotland cancer centre, as well as the high cost of cancer drugs. It also has disproportionate costs because of the high levels of hep C in its population. We know that some of the measures that are taken will be preventative, so there will be long-term savings. How does the Glasgow situation play into the financial plan and the target? Is there a variance in the target? Is it flexible? Is there a recognition of Glasgow’s situation?
There is flexibility. We give a differential supplementary allocation to recognise that, for example, the high-cost drugs for hep C are atypically weighted across the country.
Mr Matheson has answered the question on hep C much more eloquently than I was going to put it. I understand that a lot of the new curative, revolutionary hep C drugs are coming to health boards through the new medicines fund. Will that deal with cost pressures?
I have listened to the talk about efficiency savings. I understand that it has been the case for the past few years that, if a board makes a 3 per cent saving by redesigning services, the moneys that are freed up stay in the health board. Is that correct?
That is absolutely correct and has always been the case. I made the point that the £1.4 billion of past efficiency savings have been retained and reinvested by health boards.
That is fine.
I was interested in what Dr Calderwood said about the health economics of preventative spend. The interplay between finance and economics is an interesting one. We usually look at budgets and targets on a yearly basis, or perhaps at shorter intervals, yet the results from preventative spend often manifest themselves over longer timeframes. I am also mindful of Paul Gray’s comment that it is difficult to do a financial analysis of the benefits of preventative spend.
My question is twofold. First, how do you decide how much of a budget to allocate to preventative spend in any given year? Do you just think of a number and double it or is there some rationale or calculation? Secondly, is there a higher, strategic-level overview of the planning of spend beyond the year-to-year finessing of and reacting to targets?
I will bring in Dr Calderwood, Mr Matheson and Mr Connaghan, if he wishes, on that.
We expect all expenditure in the NHS to be based on evidence. On the question about whether we just put our finger in the air and say that we will spend 3 per cent or 26 per cent on preventative spend, the answer is that we absolutely do not do that. If a health board advanced a proposition for preventative spend for which there was no evidence base, we would say no. I can be perfectly clear about that. That is my answer to part one of the question.
On part two, Mr Matheson will speak in a moment about our long-term financial planning. We do that planning every year, not just for one, two and three years ahead but for five and 10, and we take it very seriously. We look ahead based on the demography and trends that we expect. In our case, those are the pressures of an ageing population and multimorbidity. We plan for services not just for now but for the future.
One of the things that I hope that the integration of health and social care will do is to help with the somewhat artificial barriers that meant that, if a saving was made in one place, the benefit accrued in another. Someone might therefore have asked why they would make a saving to benefit another organisation. I try hard to see public sector money as a whole rather than in a series of pockets. If I do something that helps the police service, I do not regard that as a bad investment. Rather than saying that I will not do something because it will save me nothing, the conversation has to be about what the police might do to help me in the future.
Dr Calderwood might want to come in on the evidence base for preventative spend, and then John Connaghan or John Matheson on the longer term.
The public health aspects of preventative spend are all long-term strategies. Although the money is allocated year on year or three yearly, the Scottish obesity and smoking strategies and so on all have long-term goals, some with targets attached to enable us to keep working towards them. It is difficult to measure the financial impact on a person-by-person basis. We always go back to asking whether a measure will make a difference. The decision is definitely based on clinical evidence and, more and more, we have health economic evidence for everything that we do.
Let us take the example of our recent investment in in vitro fertilisation treatment for fertility problems. I was tasked with looking at the clinical evidence on what it would do for the success of the treatment if we were to change the criteria. Women who do not smoke and women who have a healthy weight have much more successful IVF treatment. It could be asked why something would be given to somebody that would not be as successful if we know that something else would work more effectively. That treatment is relatively invasive. Some of the work is done on the basis of better clinical outcomes, but investment in preventative measures in society as a whole, particularly around obesity and smoking, is a much better use of our money in all sorts of other parts of the health service.
10:45
I will give a practical example with some figures that might be useful.
I think that Mike MacKenzie is asking about a rational allocation model. One objective of enhanced recovery for patients who have undergone surgery is that they will spend less time in hospital and be able to spend more time at home. That work is led very impressively by our clinicians. It started in the Golden Jubilee hospital national waiting times centre a few years back. It was about mobilising patients almost immediately after joint surgery such that they were up and about and could go home earlier. There are also clinical benefits in reductions in catheterisation for patients. The results of a three-year pilot show that catheterisation halved in a select group of patients, and blood transfusion requirements have also halved.
Since that pilot started back in 2010, most boards have started to adopt enhanced recovery pathways. That will drive investment decisions on where they will put support in to achieve enhanced recovery. It will also drive future investment decisions on how much they want to spend on surgery—orthopaedics and so on—and how to recycle some of that money.
That is a practical, clinician-led change that started with a pilot. The investment in that pilot has been proven to have paid for itself many times over as we have rolled it out through the country. As we roll it out, different boards are at different starting points. Some change in clinical practice is involved. I use that as an example of why we can say that boards sometimes have differential savings targets as they go through the year, as boards might have started later, but are still pursuing the aim. We expect all boards to eventually get to a much more acceptable clinical model.
Thank you. That is useful.
I have a couple of comments to make on that. First, because we have annual financial targets on breaking even within a 12-month period, there is a potential tendency to have a short-term approach to financial planning, which is not sensible. A medium and long-term approach is needed.
The corporate finance group looks at planning assumptions over the next four or five years. Some of the major pressures that we currently face are from the pension increase in 2015-16 and the national insurance increase next year. We have known about those for the past four or five years. Finance directors have known about them and have included them in their planning assumptions. We have a 10-year capital plan, which was signed off by the previous cabinet secretary, and that will take us forward over that horizon. On the strategic direction, we have our 2020 vision and a financial plan that underpins that.
The other factor, which is an important one, is about not micromanaging the boards’ financial planning and financial allocations. About three or four years ago, I introduced the bundling of discretionary spends so that the boards have flexibility in how they spent in that area. I have given the three island boards total discretion in 2015-16 for the first time. Rather than having just a reduced number of bundles, they will get one bundle of funding. They will still have to meet the targets and standards that are associated with those allocations, but they will have flexibility within that.
That has been generally welcomed by the island boards, and I would like to see that model going forward. It gives boards financial flexibility at the local level. If they do not need to spend money on alcohol services because they are meeting their target on brief interventions, they can divert that money into other local priorities.
I am struck by the idea of the rational allocation model, which is quite a sophisticated one. However, rather than this being a subjective and anecdotal discussion in which we all speak from the point of view of our hobby-horses, it would be good if you could share with the committee in writing some of the thinking or calculation that goes into the operation of the rational allocation model. It strikes me that that should be used in the context of guidance.
I take your point about the island boards, discretionary spending to suit local circumstances and challenges and so on, but it would be comforting to know that rational decisions are being made in the short term and the long term, bearing in mind the possibilities for preventative spend and the tension that will inevitably creep into any budgetary discussion about spending for the here and now and spending for longer-term benefit.
I would be happy to write to the committee on those points if that would be helpful, unless you would like Mr Matheson to say something about them now.
It might be useful to have something in writing. You mentioned the 2020 vision, but I noted from recent statements from the cabinet secretary, including in the chamber last week, that people are starting to talk about the period beyond 2020 or even 2030. I do not know whether that has been tweaked for financial reasons or some other reason, but it would be useful to have a written note about the points that Mr MacKenzie raised in the context of discussions about the period beyond 2020. That would inform the committee and satisfy Mike MacKenzie.
Earlier, Mr Gray talked about the public pot being one pot and not several. It might be that this was discussed earlier and I did not pick up on it, but I would like to hear more about the strains between the different sides that are involved in setting up the integration joint boards. Have there been any difficulties with people being a bit overprotective of budgets?
All the integration joint boards delivered their schemes on time, by 1 April this year. I am absolutely certain that the health and local government components will have thought carefully about what elements of the budget they would put into the process. However, I would be hesitant at this stage about suggesting that either side has taken a protectionist approach. In the course of the year, we will look at the budgets with the partnerships. Ultimately, we have to give ministers an assurance that the budgets are sufficient to deliver the outcomes that the partnerships have been set up to deliver.
It would be fair to say that local government and health boards face pressures as a result of the demographic trends and the expected change in the health status of the population over time. However, I have seen good evidence of joint working. The rate of delayed discharge in Fife has come down considerably. I am certain that there have been some fairly tough discussions between the health board and the council—I know that there have been—but they have been committed to achieving a solution.
I do not mind if people have robust discussions. Frankly, it is sometimes worse if people feel that they all have very good relationships with each other and nothing much actually happens. I would rather that people got to the nub of a difficult issue, and I do not see that as protectionism or as in any way deviating from the overall standards that we set. It is important that people have robust discussions and I can see that, when they have them, results are produced.
That was a rather long answer to a short question.
Thank you for that.
I was going to ask about efficiency savings, but that has been dealt with, so I will change tack. Before I do that, however, I want to flag up for future discussion the emerging serious issue of the recruitment and retention of doctors in general practice. I know that there are other ways of delivering general practice, but that is becoming a serious issue in parts of Scotland, and we need to look at it.
I want to raise the issue of palliative care. Some boards said that it was not possible to separate general care from palliative care, while others gave information on either specialist care or general care. Is it possible to get data on palliative care costs? How can we improve the availability of that information? If there is no financial data, how can Government assess whether appropriate resources are being devoted to palliative care?
My next question is on the health boards’ agreement to provide 12.5 per cent of Children’s Hospice Association Scotland hospice funding, which is co-ordinated by NHS Tayside. I do not think that that agreement is being met by a number of health boards. Will you also comment on that?
I got some information on the CHAS funding this morning, but it is not in my pack. I will have to write to the committee about that, because I did not think that it would come up. Getting that information would involve me switching my mobile phone on. I will not do that right now, but I will write to you on that question.
When someone receives palliative care as an element of other care that they are receiving, it is genuinely difficult to separate that out. We discussed that in an evidence session recently. I am clear that we could do more to separate it out, and in the evidence session I undertook to consider that further. However, the way that information is recorded at present does not make it particularly easy to separate it out, so you are right to ask how we know whether the resources are sufficient.
This is a slightly different point, but one of the ways in which I am seeking to advance the issue is by ensuring that more individuals have anticipatory care plans so that we will be much clearer about what individuals are looking for, particularly as they come towards the end of their lives.
Dr Calderwood, do you want to add anything on palliative care?
Nanette Milne may already be aware that there is a commitment to a strategic framework for action on palliative care. I concur with Paul Gray that the difficulty that she points out regarding data and the way that we are collecting it, or rather not collecting it, means that we are not able to understand what is going on in different boards, which is perhaps why they cannot articulate the situation to your committee.
Stakeholder events and engagement events are planned in different parts of the country as part of the development of that strategic framework, and I will be keeping a very close eye on that to ensure that your concerns are brought up in discussion and we find a better way forward.
That is helpful. Anticipatory care planning is important. We know from organisations such as Marie Curie Cancer Care that many people who ought to be receiving palliative care are not receiving it. They need to be identified very early so that that care can be planned for. I look forward to receiving more information on that.
Does that amount to a commitment to try to establish some sort of database of what is available?
Yes, convener. We need to improve the information that we have. As Dr Calderwood said, through the strategic framework for action, we are seeking to improve the delivery of anticipatory care, our understanding of what people want through their anticipatory care plans and the information that we have, in order to assure us that palliative care is being delivered appropriately in appropriate settings. We absolutely want to improve things.
11:00
I have seen some briefing papers, possibly from 2008, that show almost an audit of how many beds there were, who provided palliative care and so on. Is that baseline worth anything? Are we building on that or are we starting something completely new?
We need to refresh what we have. The 2008 information is good as far as it goes, but it will not take us much further forward. I wrote to the committee about the issue fairly recently. In my previous evidence session, Mike MacKenzie asked how many people had palliative care plans and how many people needed them, and my answer was that I want, as far as possible, everyone to have a palliative care plan. For certain situations, including someone dying suddenly, an anticipatory care plan would not be either necessary or helpful. However, the evidence, such as it is, suggests that roughly 70 per cent of the population would benefit from having one. We are quite far away from that.
Will you keep the committee up to date on that?
Yes.
Are there any other questions?
Members: No.
Good. [Laughter.] That concludes the session. Thank you very much indeed for your attendance and the evidence that you provided.
I will suspend the meeting to allow us to set up for the next panel.
11:01 Meeting suspended.Previous
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