“NHS Financial Performance 2012/13” and “Management of patients on NHS waiting lists—audit update”
Agenda item 2 is two section 23 reports: “NHS Financial Performance 2012/13” and “Management of patients on NHS waiting lists—audit update”. At our previous meeting, we heard from Paul Gray, the director general for health and social care, who is here again, as is the Cabinet Secretary for Health and Wellbeing, Alex Neil, who is accompanied by John Connaghan and John Matheson, who have been at the committee previously, and Professor Jason Leitch. I welcome them all to the committee.
Yes, if that is okay.
You have never been shy about talking, so on you go.
I learned that from you, convener.
Thank you, cabinet secretary. It is worth emphasising what I have said about excellence in the national health service—it would be wrong to take any criticism as a criticism of the efforts of individual staff or to question their commitment to a publicly funded NHS. The issue for us is to look at the strains and stresses on the NHS and to consider whether the Government is properly factoring them in, so that we can assess whether we are adequately resourcing the service and planning for future demand.
The treatment time guarantee was set down by Parliament in the Patient Rights (Scotland) Act 2011 and is now a legal duty on the national health service. By definition, if a health board is not meeting the treatment time guarantee it will not meet the requirements of the legislation. That is why we are insisting that every health board meet the guarantee, and I have made it absolutely clear to the two health boards that have had the greatest challenge in doing that—NHS Grampian and NHS Lothian—that they have no option in the matter; it is a legal requirement and they must get themselves into a position, as they are doing, to meet the guarantee.
Do you agree with Mr Gray that it may not be possible to ensure that there are no breaches of the guarantee?
In a system that deals with the number of patients that we deal with every year, there will always be a substantial risk. For example, in a small hospital where there is only one consultant in a particular discipline, if that consultant becomes ill suddenly and is absent for a period of time, there is a chance that the guarantee may not be met. However, until now, across the health service as a whole, we have achieved a rate of more than 98 per cent in relation to meeting the treatment time guarantee, even with the problems in Grampian and Lothian. I think that, by any standard, most folk would accept that that is a credible performance, but the law says that we must reach 100 per cent and we will get there.
Why put into law that particular target but not, for example, the right to be treated in accident and emergency within a defined time period?
That relates to legislation that the Parliament passed three or four years ago, and obviously—
The legislation was promoted by your Government. Why that target?
The legislation was also supported by other parties.
But it was promoted by your Government, so why that target and not others?
I will explain that if you will let me finish my sentence. It was the wish of the Parliament to pass that into legislation, and it emanated from the terrible waiting times that we had prior to 2007. As a former Deputy Minister for Health and Community Care, you will remember that, way back in 2001-02, waiting times for some procedures that are now down to 12 weeks were measured not only in months but, in some cases, in years. The public’s primary concern was that waiting times and waiting lists were far too long, and that was the top priority.
Tell me, then, what is meant by a legal right to treatment.
It means that everybody who has been referred for treatment has to have that treatment within the 12-week period. There is also the 18-week target, which is from the initial contact with the general practitioner to treatment, but within the 18 weeks we have the 12-week target, which is from referral for treatment to the treatment. That is what it means, and that is, in law, what every patient is entitled to expect.
If the patient does not get that, what happens?
A whole range of things happen. First, there is redress under the legislation that pre-dated the 2011 act. Patients can go through the formal national health service complaints procedure, and if they are not happy with the outcome they can go to the Scottish Public Services Ombudsman. In addition, they can, if they so wish, resort to law.
You said that patients have the right to use the complaints procedure and to go to the ombudsman, but those things would be there anyway, for example for those whose accident and emergency waiting time guarantee is not fulfilled, or whose out-patient requirements are not met. They are there for anyone. A legal right is not required. What is different about the legal right compared with other aspects of complaints procedures?
The additional rights in respect of the treatment time guarantee that were built into the Patient Rights (Scotland) Act 2011 are as follows. First,
But that brings us back to the question why we should bother putting the provision in legislation in the first place when it is so complicated, there is no evident easy route for patients to exercise their legal rights, and there does not appear to be any impact on the health boards that fail. It becomes a farce because, even if people know their legal rights, they are not able to exercise them. Paul Gray has said that the option is then to go to judicial review.
To describe the situation as a farce is ridiculous. The farce was when people had to wait months for treatment.
We accept that.
They are now getting their treatment within 12 weeks. We inherited the farce of long waiting times and long waiting lists, and at the time our priority was to deal with waiting lists and waiting times. We have done that so dramatically that we now have by far the best waiting times in the whole of the United Kingdom. If you compare us with Wales, where the waiting times and the accident and emergency turnaround times are way out of control, you will see that the Scottish health system is doing brilliantly. To describe that as a farce is a bit ridiculous.
I am asking for information on each of the categories that you listed. I want to know how many times each health board has actioned each.
We will provide that.
That is fine, if the information is there.
No one has come to me and said that their legal rights have not been met when they have had a problem with the treatment time guarantee. Every patient who has come to me as the constituency MSP for Airdrie and Shotts has been told why there is a problem.
That is helpful.
Do you mean as an MSP or as the cabinet secretary?
Either.
As an MSP, I certainly have not had to do so, and as the cabinet secretary I do not recall having had to do that. However, we will double check to ensure whether any of us has had to do that, and we will certainly provide the information. I am determined to ensure—it is in our interests to do so—that every health board in Scotland abides by the law.
Could you also provide us with the details that are given to each patient on how they can exercise their legal right? Is that in the form of a leaflet, or is a letter issued to them?
I have two points on that. First, information is given to patients at every stage. For example, if a patient is unable, for their own reasons, to attend within the 12 weeks, they are told what will happen and what their legal rights are. As the primary legislation says, if for any reason a health board is unable to fulfil the guarantee, the patient has to be told. At that stage, the health board has to tell the patient why that is the case, when they can expect to get their treatment and whether there is a choice of locations where the treatment can take place. We will give the committee a flow chart that shows, right through the system, from the time that a patient goes to their general practitioner, what should happen in law if the treatment time guarantee is not met and what information they should be given.
What sanctions are taken against health boards if they do not meet the target?
If a health board does not meet the target, we sit down with it, as we have done with NHS Grampian and NHS Lothian. Rather than take a legalistic approach, our preferred approach is to work with a board to get it into a position whereby we can ensure that it will deliver. In the cases of Grampian and Lothian, that involves a fairly substantial investment programme. For example, the investment programme in Grampian includes the commissioning of three new theatres in the area between now and the summer of 2014 to ensure that the board can deliver on the treatment time guarantee. Most other boards have met the guarantee in most months, although there might be the odd month in which they have not met it. Overall, as I say, even with the problems in Grampian and Lothian, we are still at more than 98 per cent. I think that, as far as the public are concerned, that is a fantastic achievement.
I will ask briefly about patients’ rights, and then come on to an audit question. The 12-week waiting time guarantee is entrenched in legislation, and the convener explored how people can exercise that right. However, in relation to the responsibilities of Government and health boards, would new primary legislation be required to withdraw the target? My reading is that the 12-week target is a Government target that is entrenched in law so, if a future Government wished to disavow the target, it would have to pass primary legislation. Is that the case?
To abolish the treatment time guarantee, the primary legislation would have to be changed. An act of this Parliament created the treatment time guarantee.
That is a pretty strong protection, so it is important to put that on the record. Time and again, whenever I raise issues in relation to targets on waiting times or whatever, I always take the view that, when targets are missed, it is important to identify that that has happened, but it is more important to consider what is done to address the issue. That is a clear role for the committee in auditing the process. My questions will refer to that and to budget decisions.
Absolutely. We will send you the full list but let me give you some examples, starting with Grampian and Lothian, of what we are doing.
That would be very helpful, cabinet secretary. When the committee returns to the issue this time next year or whatever the appropriate time might be, the question in my head will be whether, given the levels of investment that you have identified, there has been any improvement. If there has, that will be fantastic and we will recognise that; if not, we will certainly ask questions about why the money has not been used in the most appropriate and effective way. If you can provide the committee with a list setting out a financial sum for each health board and a summary of their action plans using those finances, we will be able to audit whether that money has been used effectively to meet their 12-week guarantee.
We will do that.
I am glad that the whole committee shares that commitment.
A recurring theme that the committee has noticed is the availability and quality of information on which decisions are being taken. Clearly there is a deficiency across the public sector in the way that figures are being produced—and indeed a question whether they are being produced at all. Page 24 of the report says:
The NHS’s electronic benchmarking system is up and running. Indeed, yesterday, John Connaghan, who has overall responsibility for performance and delivery, and I were going through a number of areas, looking at the benchmarking of certain procedures and how well some boards were doing compared with others. Now that the system is up and running, we are benchmarking regularly to compare boards and find out where some could do better.
That sounds like good news.
Absolutely. We have put in place very robust whistleblowing policies and procedures. For a start, we have the whistleblowing line. Ironically, we get more calls from the rest of the UK than we do from Scotland, but we cannot do anything about them.
I will continue the same line of questioning, if I may. I welcome your comments, cabinet secretary. I think that people will be encouraged, at least, by your intention in this regard. However, I am not quite sure that what you describe is happening in practice. Were you pleased to see the decline in the use of unavailability codes, which the Auditor General flagged up in her report?
A lot of the unavailability is patient unavailability. In terms of the treatment time guarantee, patients have the right to say that they are not available because, for example, they are on holiday or on some business. We have tightened up the system enormously compared with the previous system. We have implemented the Auditor General’s recommendations to ensure that unavailability codes cannot be abused in any way or used to hide anything that is going on that should not be going on in measuring the time that it takes for people to get their treatment.
Can you clarify that you agree that the codes were misused by NHS Lothian?
I do not think that there is any doubt about that. I think that the report into NHS Lothian made that absolutely clear. Obviously, we have all learned a lot of lessons from the NHS Lothian experience. As you know, we have been working in a very detailed way with the Health and Sport Committee to ensure that we now have a much more robust system for ensuring that we have validated statistics and information to measure waiting times for patients.
I am glad that there is a new system. The Auditor General highlighted in her report that the general use of unavailability codes began to decline after it was identified as a problem in NHS Lothian; she also pointed out that that was not because it was revealed by scrutiny. In other words, she could not reveal the misuse of unavailability codes through audit, and it was revealed by a whistleblower. Do you accept that that is what happened?
I think that we all know that what happened in NHS Lothian was an abuse of the system. We have taken appropriate action. For example, the chief executive at the time is no longer with NHS Lothian. I think that my predecessor took very decisive action to deal with the NHS Lothian situation.
I just ask again: were you pleased by, and do you recognise the importance of, the whistleblower in revealing the misuse of unavailability codes?
Absolutely. I have just said that I want people who see malpractice to whistleblow, because I am not here to defend malpractice in any way, shape or form.
In that case, why is a confidentiality agreement inserted automatically in every single settlement arrangement or compromise agreement within the NHS?
That has been standard procedure for a long time. As I said, I am looking at how we can be more robust. I am quite happy about looking at whether we can relax some of the procedures in terms of confidentiality agreements. There are of course legal implications. We need to be very cognisant of employment law and various other things. However, the one thing that I should stress is that even where there is a confidentiality agreement, the information on whistleblowing-type activity is specifically included in the agreement. It is written in that the person cannot in any way have action taken against them.
In that case, do you recognise that in a confidentiality agreement it is illegal for someone to even declare that there is a confidentiality agreement?
That is one of the areas that I am looking at. Obviously, this is historical because confidentiality agreements have grown up over time. I am looking at whether, even leaving aside the gagging issue, they are too restrictive. I am reviewing that at present.
You suggested earlier that very often the agreements are inserted at the request of the individual concerned.
Yes.
In how many cases do individuals request confidentiality agreements?
Over the past three years we have signed 150 or so confidentiality agreements.
It is 148.
Sorry. I was two out. I do not have to hand the exact number of cases when an employee asked for the confidentiality agreement, but I am happy to see whether we can provide that, provided of course that doing so would not breach part of the confidentially agreement.
Interestingly, in your written response to the committee, you said that of the 148 settlement agreements over the past couple of years
What is automatic?
Well, perhaps I should ask Mr Gray this. I asked Mr Gray this question at our previous meeting, and it was in a letter that the committee sent to you, cabinet secretary. There have been 697—almost 700—of these agreements over the past five years. The specific question that we asked was how many of those contained confidentiality agreements.
I will let Paul Gray answer that.
Mr Macintosh, as I explained in my letter, the data is held by the boards. In an attempt to be helpful to the committee, I asked them to go back to the 2011-12 financial year for the data. I genuinely do not want to put in front of the committee information that is inaccurate or unvalidated, but my understanding is that the 697 agreements referred to included a number that were not in fact to do with settlements outside the normal early severance scheme. There was some confusion in relation to the response on that number, which I think was given via a freedom of information request.
I am sure that the committee is pleased that you found out about the 148 agreements going back over the past couple of years. Can you conduct the same exercise going back to 2007-08 for this committee?
If I can, I will.
Thank you. Given that 147 of the 148 agreements in the past couple of years have contained confidentiality clauses, how many of the 697 agreements over the past five years do you think contain confidentiality clauses?
I am not prepared to answer that until I have done the exercise, Mr Macintosh. I would like to put accurate information in front of the committee.
Given that 147 of the 148 agreements contained confidentiality clauses, do you think that it is almost a matter of automatic policy?
It appears to be so.
So do you think that maybe the vast majority—maybe 99 per cent—of the 697 agreements contain confidentiality clauses too? Is that a likely scenario?
I would be speculating, but it is probable.
The cabinet secretary stated earlier that very often such clauses are inserted at the request of the individuals concerned. Can you give me any examples of that?
I said that sometimes they are inserted at the request of individuals.
No, cabinet secretary, you said that they are very often inserted at the request of the individual concerned. Those were your exact words—“very often”. How many examples do you think you will be able to find of individuals requesting such clauses, given that they are automatically inserted in every agreement?
It would be very difficult to get a precise figure, but we will see whether we can give some indication to the committee of the number of requests—
Cabinet secretary, why did you say that the clauses are very often inserted at the request of the individual concerned if you cannot back that up with any evidence whatsoever?
I am just going by the anecdotal evidence that I have collected in my 18 months in this job. When I have spoken to individuals as well as to people on the health boards, I have heard that sometimes there is information that the individuals themselves do not want to be disclosed.
So—hang on a second—we have gone from the statement that they are “very often” inserted at the individual’s request to the statement that you understand, anecdotally, that they are “sometimes” inserted at the individual’s request. Is that right?
I am saying that confidentiality agreements should not be abused. They cannot legally include gagging orders. When people leave the national health service under difficult circumstances, traditionally—going right back through many previous Administrations—confidentiality agreements are drawn up. That is not new; it has been done for many, many years.
Health secretary, you are saying that this has been going on for years and that—
The confidentiality agreements have been standing practice for a long time.
You say that you have no statistical information but that you would like to try to gather some. Perhaps I can refer you to my own parliamentary questions on this issue, because the use of compromise agreements in the NHS has been rising over the past few years, particularly since 2007. Perhaps you could refer to the answers to those questions. The point is that this involves an extensive use of public money. How much money do you think is spent—or could you find out how much is spent—enforcing or including these confidentiality clauses in NHS contracts?
As I said earlier, I am happy—unlike any of my predecessors—to get any information on the costs to the Auditor General and to the committee to allow the committee whatever information it needs to do the proper scrutiny. I am further reviewing the role of confidentiality clauses precisely because I have concerns that they may be unnecessary or overrestrictive in many cases. One of the reasons why the number has gone up is that there has been a substantial increase in the number of people who are employed in the national health service since we came to power.
Will you find out exactly how much is being spent on enforcing gagging clauses?
If the figure can be obtained, we will be happy to share it with the committee. I honestly doubt that it can be obtained, but we will ask the central legal office.
I may ask you later to comment on the cases of Dr Jane Hamilton and Mr Rab Wilson, who has petitioned the Parliament.
We can give you that information—we will try to get it for you.
Do you believe that any of the 697 people who have signed confidentiality agreements has made a protected disclosure?
We will come back to you on that. I will not give you information that I have not checked out beforehand.
Does the use of these clauses encourage an attitude of transparency in the NHS, which you spoke about earlier?
One of the reasons why I—unlike any of my predecessors—am reviewing their use is that I want to ensure that they are not being used to hide what should be transparent. I am sure that many such agreements were signed when Mr Henry was a junior health minister.
Not by me.
Well, the agreements were not signed by the minister, but they would have been signed at that time.
Does the health service in Scotland have anything to learn from the Mid Staffordshire NHS Foundation Trust scandal in particular?
Absolutely. We have responded not just to the Mid Staffordshire situation but to subsequent reviews, such as the Keogh inquiry and the Berwick inquiry that followed it. Professor Leitch was a member of the team that was chaired by Professor Don Berwick, who describes the health service in Scotland as the safest in the world.
Is legal protection for whistleblowers as strong in Scotland as it now is in England?
I am not legally qualified to make a judgment on that. You will have to ask a lawyer.
Before I bring in Tavish Scott, I note that Mr Connaghan told the committee twice that he was the whistleblower in the NHS Lothian situation. Why did a senior member of your management team have to use the whistleblowing process to rectify a problem?
Mr Connaghan said that he identified the problem in reviewing the management of information. I am happy for him to expand on that.
Before he comes in, I will give you his exact words.
I have read them.
He said:
As I said, my interpretation of that—John Connaghan can speak for himself—was that he, as the person who has primary responsibility for reviewing performance in delivering information, identified that there was a problem.
I am happy to amplify that, convener. In any such complex situation, there are a number of layers. It is true to say that unfair offers by NHS Lothian of treatment by an English healthcare provider were identified, so we need to acknowledge that the very first issue was raised by a member of the public, probably around October 2011.
Was there someone other than you who was the whistleblower?
I am not quite sure, but I certainly recall what we did in the team that uncovered the deliberate manipulation. I am not aware of anyone else who wrote to NHS Lothian at that time to say that that area needed to be subjected to detailed internal audits; I referred at the previous committee meeting to my letter of 6 January.
Does the health service keep a record of whistleblower complaints?
In the sense that we have a register?
Yes.
We do not per se, because the whistleblowing takes place primarily in the boards. Each board would be able to tell you how many times someone has raised an issue internally.
But there is a whistleblowing procedure—is that correct?
Yes.
When someone uses the whistleblowing procedure, is a record kept of the complaint that is made?
Each board will have its own record, yes.
Right. So NHS Lothian will have a record of the whistleblowing complaints that have been made.
It should have, yes.
Will the records show that, on the matter that we are discussing, Mr Connaghan—and not anyone else—was the whistleblower?
No, convener—you know fine that that is not the case. Mr Connaghan was operating as the director for delivery and performance, and he was using the word “whistleblowing” in a slightly different context.
No, no, no—
You are playing with words, quite frankly.
I am not playing with words. You are trying to introduce words that were not there, such as “in essence.” Ken Macintosh asked Mr Connaghan a very specific question—he asked:
I did not say that boards keep a register; I said that they will have a record of every case.
Okay—they will have a record. So we can go back to NHS Lothian and ask for that record, and ask the board to confirm that Mr Connaghan was in fact the whistleblower. He did not say “in essence”—he said, “I was the whistleblower”, twice.
Fine—why don’t you do that, then?
I will make a suggestion. I said that the NHS situation was complex, like peeling back the layers of an onion. It may well be worth your while asking NHS Lothian to give you a sequence of events.
Okay.
Never let it be said that this committee is not full of entertainment and liveliness.
Yes.
How much will the use come down by? Do you accept that there will always be some degree of private sector involvement in NHS Lothian?
Not just in NHS Lothian. There are certain types of services that are available only in the private sector, for various reasons, so there will always be a small private sector contribution in the health service in Scotland.
But it is a statement of fact, as you have indicated, that the private sector will have a small but significant role in continuing to manage the complex issue that NHS Lothian and other boards are facing.
Yes. Indeed, as part of the local delivery planning guidance, I have asked every health board to review their use of the private sector with a view to reducing that use, particularly where the capacity exists in the national health service in Scotland. There is little point in our using taxpayers’ money to double fund capacity, in effect, if capacity exists in the health service.
Will you be so good as to keep the committee updated with that programme?
Absolutely.
I have a question about the difference between the 12 weeks and the 18 weeks that you helpfully mentioned in your earlier remarks to the convener. Does the NHS keep statistics on the period between 12 weeks and 18 weeks?
We measure the whole thing, and ISD regularly publishes validated figures on waiting times. We publish information on how many people are seen within the 18-week period. There is a threshold of 10 per cent, and in recent times we have consistently met that, with over 90 per cent of people being seen within 18 weeks.
But there is no legal attachment to the 18-week period. It is purely—
That is correct. The only legal attachment is to the 12-week period.
It may be that most patients are seen within 18 weeks—90 per cent are, according to your figures. However, do you accept that, for most patients—for you and me and our constituents—the period between first seeing a GP and seeing a consultant is just as important as the 12-week period that is covered by the legal guarantee?
Absolutely.
So why not have a legal guarantee for the full 18-week period?
Again, we are going over the discussion that took place during the passage of the bill.
I am well aware of that.
As you know, there were various opinions at that time on whether we should have any targets. Some people took the position that there should be no targets in statute. The Government’s position was that, because of the particular concern around the period from referral for treatment to receipt of treatment, we should put a target for that into statute, but that was the only target that we would put in statute. That debate was had at the time, at stages 1, 2 and 3 of the bill.
I understand and accept that. I did not agree at the time, and I made my position clear, but—
I do not have any quotes from you, Tavish.
Don’t tempt me. I presume that you accept that, when ordinary folk go to their GP to get sorted out because something is wrong with them, that is where it starts.
Of course. Aye.
You have made some strong statements this morning about wanting to review particular areas of NHS policy. Ken Macintosh has just raised that with you. If you believe in the point about a legal guarantee, is there not a public expectation and desire, which you have been keen to mention this morning in relation to the 12-week period, for a guarantee for the full journey from the point at which the person sees their GP?
Absolutely. If people go to their GP and the GP says that they need to see a consultant, they will obviously want to see the consultant as soon as possible, particularly if certain conditions that are potentially life threatening are suspected. As you know, we have the specific 31-day and 62-day targets for cancer. That reflects the degree of anxiety felt by anyone who has suspected cancer. We do not have a parallel target for every condition under the sun. If you have a wart on your finger that needs to be burned off, the anxiety about that will be a lot less than the anxiety about other, potentially serious illnesses. We have the generic 12-week and 18-week targets, and then, for example, we have the two cancer targets of 31 days and 62 days.
But the Government has no plans to bring forward legislation in relation to the 18-week period. It is just a target.
I have absolutely no plans to extend legal guarantees.
Thank you. I have a further question about this area. I presume that you accept that you are putting health boards under some significant ministerial pressure in relation to meeting the statutory targets. You said that clearly to the convener and the committee this morning. Does that have consequences for how boards deal with all the other responsibilities that they have to deal with, not least the financial ones?
I am keen to ensure two things. The first is that we plan appropriately for the national health service. We are working on the 2020 strategy. We have the vision and the route map, and we are working on the detailed plan for how we will realise the vision for 2020. We carry out fairly regular reviews of the health improvement, efficiency and governance, access and treatment targets and standards—indeed, we are about to start one—and I am anxious to ensure that we meet the targets. We have to achieve the treatment time guarantee target, but I want to do it in such a way that we do not misallocate resource or prioritise areas that should not be prioritised vis-à-vis other areas that should be prioritised. Indeed, that is built in to the legislation at an individual level.
That is fair. I asked you a general question and you gave me a general answer.
First, before we set the targets, we obviously take into consideration the need to ensure that we are not cutting across what should be the right clinical judgment. That is why we consult widely before we establish a target or a standard.
I have one final question on information relating to the monitoring of performance. The matter was raised by the Audit Scotland report. It is about ISD publishing detailed data back to October 2012 to address trend analysis for the period in relation to the Patient Rights (Scotland) Act 2011. Is that what is going to happen?
I am not charge of when official statistics come out. There is now the UK Statistics Authority and the UK statistics code. ISD, I and all my officials are governed by the codes. We provide ISD with all the relevant support, co-operation and information that we can, but it has to follow the code and all the instructions from the UK Statistics Authority.
I understand that. The committee is being told that all NHS boards will be providing detailed waiting time data to ISD by April this year, which is two months later than was reported to Audit Scotland, and that data will not be published until the end of August 2014. Is that your understanding of the position?
Yes. That is because, once we supply the information, my understanding is that it then has to go through the validation procedure that is laid down by the UK Statistics Authority.
So it will be published in the summer, by August 2014.
Yes.
Cabinet secretary, in your opening remarks you talked about the financial performance of NHS boards and you said that all boards met their targets. We know that the NHS in Scotland is an £11-billion-a-year service and that, overall, the service reported surpluses and actually made some savings. However, one of the recommendations in the Auditor General’s report was to look at the flexibility in setting the financial annual resource limits. Is it in the Scottish Government’s current thinking to allow the boards a bit more flexibility from one year to the next to plan their work?
Absolutely. At present, it is like trying to land a helicopter on the eye of a needle at the end of every financial year in every board area. Within our powers, we have as much flexibility as is required among the boards. We have 22 boards plus the central agencies and the Mental Welfare Commission for Scotland. From time to time, particularly towards the year end, it is necessary to reallocate funds, vire funds or brokerage funds internally, and we do that.
I have a couple of points. We have flexibility at the moment, although we welcome the Auditor General’s comments. We focus on long-term financial planning, but the artificiality of having to deliver something by 31 March each year can run counter to that. We agree three to five-year financial plans with boards and look at their financial planning assumptions.
Overall, on a year-by-year basis, the boards still have to broadly stay within their allocations. If all the boards reported an overspend next year, the alarm bells might ring in this committee. In the context of the flexibility that you are talking about, how would we get the sense that that was not an issue and that the measures had been approved and agreed? If something like that happened, how would we get the sense that an alarm bell should not ring?
We monitor the situation throughout the year, and John Matheson and his team are in regular touch with the finance people in each of the health boards. We look not only at the money that is already committed but at the balance that is available for the rest of the year, to ensure that they stay within budget.
Turning to waiting times, there has been discussion around the table about the 98 per cent compliance with the guarantee. I only ever achieved a 98 per cent exam mark in my first year at university and I was absolutely delighted with that, but I have never achieved such a mark since then. That is a fantastic performance, but some of today’s discussion seems to suggest that it is a problem. I do not think that it is a problem, if health boards are genuinely pursuing the 100 per cent target, as they are legally required to do. The 98 per cent compliance rate that has been achieved is a fantastic performance by the NHS.
For individuals, the result has been enhanced health outcomes. One thing for which we do not have a specific target, but where we are keen to make progress, is reducing the amount of time that people need to spend in hospital for any procedure. The longer someone spends in hospital, the worse their health outcomes will be compared with what could be expected if they spent less time in hospital. That seems ironic, but that is the truth of the matter, not just in Scotland but internationally.
You said that there are clinical reasons behind the 12-week target. I do not understand why it is 12 rather than 10, 11 or 13. I previously asked how quickly we pick up people after 12 weeks if they have not been seen within that period. Sometimes when we set a target, we forget to collect information at the tail end.
I can give you that statistic. I am looking for it now, but I am sure that John Connaghan will have it. What is the percentage of people who are treated within 15 weeks?
The answer was in Mr Gray’s letter. I think that it was over 99 per cent.
So nearly all the people were seen within 15 weeks.
Absolutely.
One of the hidden benefits of having a relatively tight performance regime on waiting times is encapsulated in the reference to transforming the patient pathway in the document “18 weeks: The Referral to Treatment Standard”. One benefit has been a transformation in the amount of day-case surgery, which has benefited patients and is making the NHS a little more efficient and productive. There are hidden benefits from transforming the system, making the entire journey a little slicker and pushing the boundaries of clinical practice.
Professor Leitch has not had a chance to speak. He can say a word or two about the health benefits of the targets.
Apart from the benefits that have been mentioned, we know for sure that healthy life expectancy is increasing and that in-patient hospital mortality is reducing. That is partly the result of the increased work on healthcare-associated infections, the Scottish patient safety programme and other things that we have done in the healthcare system, but it is also partly the result of treating people earlier.
I am hearing that the health service is performing well and is delivering positive health outcomes for the population. How far can we push that? Should we worry about the health of a person whose treatment has not met the 12-week target? How far can we push the improvement in performance? I know that budgets are not infinite and that some degree of sense must be applied. One day in the future, could we bring down the 12-week limit?
The profile is one of rising demand and increasing complexity. The ageing population has two consequences for health policy. The first is a significant increase in comorbidity, because people are living long enough to develop more ailments. The second is an increase in long-term conditions.
I would like to see that graph at some stage.
We are happy to provide this information to the committee and let members see how well we are doing.
I have a final question. To return to the 12-week waiting time guarantee, when we achieve that target in 100 per cent of cases Public Audit Committee members will inevitably ask whether we can get any better and where the scope is to improve the guarantee. For example, if a medical intervention is needed, should we ask you to reduce the guarantee to 11 or 10 weeks? What happens after we reach the guarantee in 100 per cent of cases? How do we improve the situation?
I would rephrase your question to ask how, at a strategic level, we improve further the health outcomes of the Scottish population, rather than to ask for a discussion on the targets. At the end of the day, the strategic objective is to improve the health outcomes of the Scottish population. We are doing loads of things in that regard. The whole patient flow is changing right across the system and turnaround times are improving dramatically in A and E and elsewhere. We could give you a list—it would be endless—of all the initiatives that we are taking, including improvements to the use of theatres, providing a 24/7 service in many areas and so on and so forth.
A number of members want to come in, so if Professor Leitch wishes to send us a note on the issue, that would be fine.
Okay.
I echo the convener’s comments and thank you for being here, which is helpful to this committee in the Scottish Parliament—not the United Kingdom Parliament—in looking at value for money and scrutinising. I have certainly found it helpful so far.
First, as you probably saw in the statement that we put out last week, Grampian is getting an increase of 4 per cent next year compared with a Scottish average for territorial boards of 2.9 per cent. We have a long-term plan up to 2016-17 and we are determined that, by the end of that period, no health board will be more than 1 per cent outwith NRAC. In other words, within the next two years every board will be within 1 per cent of their NRAC allocation. I think that that is substantial progress from where we started a number of years ago. The announcement last week that Grampian will get a 4 per cent rise compared with an average rise of 2.9 per cent shows our commitment in that respect.
I am sure that £54 million a year would help a wee bit towards addressing the problems.
In terms of solving the problems, Lothian of course got a very substantial increase over a period. In terms of implementing NRAC, one of the reasons why we have been able to make so much progress in the past two years and why we will be able to make so much progress in the next two years is that we can bring the likes of Grampian and Lothian up to their NRAC allocation without penalising the other boards. People would argue that, by definition, Glasgow has more than its fair share at the current time. However, given the deprivation and poverty profile of the area that is covered by NHS Greater Glasgow and Clyde, which includes the convener’s constituency, I think that the convener would be down my throat if I did not give that health board a real-terms increase in its budget over that period.
I know that time is moving on, so I want to be brief.
I wouldnae blame you for anything, Mary.
I am sure.
I will say a couple of things and then I will get John to explain the patient flow, in terms of the targets.
But the 12, the 12 and the 18—
We will get into that.
Thank you.
—and we will come back to you with terminology that is easier for me to understand as well as for MSPs and the public to understand. We would be happy to take any input from the committee with regard to suggestions in that regard.
It is important that the public understand what is being talked about.
I cannot add much to that explanation. The cabinet secretary is absolutely right. HEAT targets have been with us for 10 years and, before that, we had waiting time targets, so quite a legacy has built up over the years. We have tried to make the best sense that we could of that, in terms of engagement with the service, but I fully recognise that things can be difficult for the man in the street to understand.
And the woman in the street.
Sorry, it is difficult for the man or the woman in the street to understand all of this.
You have not addressed one of my points. The two periods of 12 weeks come to 24 weeks, but there is an 18-week treatment time guarantee.
I am happy to explain that. I could describe it as an overlapping target. Even though we expect that for 90 per cent of patients it will take 18 weeks from first referral to treatment—in other words, there is a 10 per cent tolerance attached to that—the in-patient and out-patient elements sit within that. In essence, you are absolutely right. If a patient is not seen until week 12, there will be rather less time for the treatment element.
So if a patient is seen in week 12, they should be guaranteed treatment within six weeks.
They cannot be guaranteed their treatment within six weeks because a 10 per cent tolerance is attached to it. Boards will bend their best efforts towards ensuring that they are seen as quickly as possible within that 18 weeks, but not all patients will be seen within that remaining time.
But we are talking about 90 per cent.
Yes.
In April 2011, the 12-week wait for new out-patient appointments became a standard rather than a target. The Audit Scotland report makes it clear that although all out-patients should be seen within 12 weeks, that situation has been deteriorating. In September 2012, 5,993 people were waiting more than 12 weeks for an out-patient appointment but, a year later, the figure was 11,544. In other words, the percentage went up from 2.7 to 4.6 per cent. The Auditor General’s significant point is that the out-patient target is being missed and the situation has been deteriorating. Has that got anything to do with the fact that it is no longer a target but a standard? Does moving from a target to a standard mean that things can slip, which is what has happened here?
I will deal with the final point and John Connaghan can go into the detail on it.
We recognise those figures. We fully understand that there is a risk if we continue to drift from performance and we are continuing to work with boards on the matter.
My final question has already been touched on by Colin Beattie and Tavish Scott. In response to Mr Beattie, who is always very good at asking for robust information, you mentioned that you have very cleverly managed to come up with hospital cleaning costs per square metre, which is something that I welcome.
I will let John Connaghan explain the history.
When the treatment time guarantee was planned for, the information that was available nationally was deemed to be acceptable. In fact, Audit Scotland, in its 2010 report on the new ways system, commended the NHS for having done well to implement it. We are all aware that, subsequent to the NHS Lothian audits, there is a requirement on NHS boards to provide much more detailed information, principally on the reasons for unavailability. Prior to that, the information was supplied on an aggregate basis. Over the past year or so, boards have been making big changes to their systems so that they can get that level of detail reported nationally and have it statistically validated. That is the new information that will come on stream from boards from 1 April, after the system changes are implemented.
On the methodology, under the old system, information was collected on a census basis at the end of each month, whereas now the process is far more robust, in that we measure what happens to every patient. The new approach is not to have a census at the end of the month; instead, every single patient is included in the measurement of the guarantee. Although the new approach has taken more time than was anticipated to set up, the statistics on the treatment time guarantee will be far more robust than those under the previous system.
It has taken two years. Obviously, good data is critical for Audit Scotland and the committee to do their job.
I will just say that, from April onwards, all that information will be available. As John Connaghan said, the NHS Lothian case threw up the fact that the systems were not as robust as they needed to be. Obviously, the Auditor General has done a lot of work on the issue—as have we, in implementing fully her recommendations.
I welcome the cabinet secretary, as it is important that he and the other witnesses are here to take questions from members. I do not really want a response on this, but I wonder whether the cabinet secretary agrees that it would be a better use of our time and the witnesses’ time if, when one committee member has 27 very detailed questions on one issue that could not possibly be answered here, the witnesses had prior notice of those questions. The cabinet secretary should be asked questions and he should not know what we are going to ask him, but when the questions are so detailed, I suggest that they would be much better dealt with by correspondence.
I do not think that that is for the cabinet secretary.
I completely agree and—
Mr Dornan, it is a matter for committee members to determine what questions they wish to ask and for me to determine their relevance. The cabinet secretary is here to answer the questions. He is not here to determine how the committee operates.
I am glad that you have put that on the record, convener.
Absolutely. We published a detailed report on the matter last week, which will obviously be available to the committee. Some 60 per cent of the high-risk maintenance backlog has now been cleared and we expect to clear the other 40 per cent over the next two years or so.
The figures show how much of the backlog is high risk and how much is significant risk. If we use that building as an example, would maintenance on a building that is going to become surplus to requirements be included even though you know that it is going to be—
No, that would not be included in the high-risk category. I will give a further example. Some asbestos was discovered in one part of Monklands hospital in my constituency, and that was classified as high risk. It needed to be sorted, and it has been and is being sorted.
Okay, and you are confident that the high-risk and significant-risk items will be dealt with by 2016.
Absolutely. We are determined to do that. In looking at the profile of the estate, we should consider not just hospital provision but the number of clinics. In North Lanarkshire alone, we are building two new clinics, at Kilsyth and East Kilbride, and a couple of years ago we opened the new Airdrie health centre. There is a lot of investment in new property and new estate right across the country.
I can assure you that the Victoria will not be on the market for long.
I would not have thought so.
It is going to be flats. Thank you.
I have a couple of final questions. The first is for Mr Gray, whose letter to the committee about the guarantee states:
Mr Connaghan has been in touch with the boards about that.
We need to give the boards a little bit of time to implement that as it requires additional administrative resources. My plan is that we will implement it from the end of June 2014 onwards, which gives boards about four months to prepare for it.
When will that information be available for Audit Scotland to include in its next report?
We would probably want to make that information available quarterly, so the first information would be for the quarter up to the end of September, but Audit Scotland can begin to look at the information as soon as we have it. If we have data for the first month—July—we will be quite happy to send it to Audit Scotland.
Okay, thank you.
The figures obviously vary between medical disciplines but it is true that the general principle is that throughput is very important to maintaining skills and upskilling consultants. For example, up here we can only really afford one centre for paediatric cardiology for reasons of clinical safety. We do not have the throughput in terms of the number of children who require paediatric cardiology provision to justify more than one centre in Scotland. It would not be safe to have more than one centre because there would not be enough throughput to ensure that the consultants had the skills.
Mr Neil is correct. It varies by specialty and by procedure within the specialty. In my specialty, we only have two cleft lip and palate centres in Scotland because it makes perfect sense to have only two such centres, but you can have your wisdom teeth taken out in every health board area in Scotland because there are perfectly competent people to do that in every health board in Scotland.
Okay—thank you for that.
Thank you. It has been very helpful from our point of view and, as I say, we aim to please at all times.
Is that your target?
It is a standard.
We will take a break for a few minutes to allow for a changeover.
“Reshaping care for older people”
Agenda item 3 is to take evidence on the section 23 report, “Reshaping care for older people”. Committee members have the report, and the Auditor General is here with her colleagues Fraser McKinlay, Claire Sweeney and Rebecca Smallwood. I invite the Auditor General to brief the committee on the report.
Thank you, convener.
Thank you, Auditor General.
The Government’s own evidence suggests that, in its current form, the system is not sustainable, which is why the reshaping care for older people programme was put in place in 2010. As you have suggested, the population is ageing very fast, and that is much more apparent in some parts of Scotland than it is in others.
But if, as the Government has accepted, the current system is not sustainable and if, as you have outlined and again the Government has accepted, services need to be reshaped but, as you have indicated, the pace of progress needs to be stepped up, because we are clearly not meeting the requirements or matching demand, what will the consequences be if services are not reshaped in time and the current system proves not to be sustainable?
The short-term consequence is likely to be the increasing pressure on acute hospitals that we have set out in a number of reports and which committee members will be aware of with regard to A and E waiting times, increasing emergency admissions to hospital and difficulties in discharging people to their own homes or better environments after their treatment. When reshaping care for older people was launched in 2010, the Government’s own estimate was that, without change, the amount of money spent on older people’s services was likely to rise from £4.5 billion a year to around £8 billion a year, which is a huge increase at what will be for the foreseeable future a time of very tight resources for public services.
In preparing the report, you have obviously spoken to different departments or sections of the Scottish Government and certain key officials, and I presume that you have also looked at what councils are doing at a local level. My understanding is that, under the legislation, anyone with a community care need should be offered a community care plan, the identification of which helps the local authority in aggregate to determine what resources are required, what gaps there might be and how services might be reshaped. Do you have any evidence that local authorities are preparing community care plans for those who require them?
I will ask Claire Sweeney to pick up the specific point about community care plans but, in response to your question, I think that any approach needs to happen at two levels. First of all, there needs to be planning for individual people’s needs, not only through the community care plan but as a result of older people contacting their GP for all sorts of reasons, which should indicate that they might need more support to stay at home more safely for longer.
We did not look in great detail at what is happening in each local authority area as part of the work for the report, but we are carrying out work to look at self-directed support and the raft of changes that that will bring for social work services in the next short while. In the report, we highlighted in case study 3 gaps in understanding about people’s needs locally. The position was difficult to determine from the national information that is available.
One of the problems that we have is that older people’s care is like a jigsaw—every piece fits with another piece and is integral to getting the bigger picture. Our local authorities are struggling to cope with demand and are stretched. Many skilled and experienced people have left under voluntary redundancy schemes because councils have struggled to stay within their budgets. Councils now have no flexibility to raise local funding, so many have had to resort to looking at increased charges and reduced service levels. That must be part of the bigger picture.
You are absolutely right that the issue needs to be looked at across the system. It cannot be considered in relation to just social work services or just acute services. As Claire Sweeney said, the work that we are doing on self-directed support is looking—from the individual up—at what is happening to assess each individual’s needs and to have a proper discussion, with the individual in the driving seat, about how they would like those needs to be met, against a backdrop of tight resources in social work services and the NHS.
Exhibit 11 on page 28 provides quite a good summary of the progress that has been made on reshaping care for older people. As an ex-teacher, I looked at the marks, which show improvement in three out of eight commitments—the commitments on third sector capacity, respite care and reducing emergency admissions.
That is one of our findings in the report. There are eight commitments under the reshaping care for older people policy, which we have set out in our report. On three of them, things are moving in the right direction, but on another three there is simply not enough information to know what is happening—
I am sorry to interrupt, but there is not even a definition.
A definition of the way in which the commitment will be measured?
That is right.
You are absolutely right. A lot of work has been going on in Government, particularly with the joint improvement team, to come up with measures that would allow all those commitments to be monitored and progressed, and we have recommended that it needs to pick up steam. I ask Claire Sweeney to talk you through the progress that is being made of which we are aware, and where that should leave us in the future.
We note specifically that on commitments 7 and 8 there is just no information to enable us to form a judgment. The same is true of commitment 5. Although it is fairly clear, there is no definition of what is meant by “waste” and “unnecessary variation”.
How can you measure the information if there is no definition? You do not know what you are measuring.
The terms need to be defined before we can start to measure the information and reach a judgment on how the Government is performing.
If we come back to the commitments in a year’s time, will we have a definition for commitment 5? Will the NHS know where patients are being discharged to under commitment 7? Is the information being gathered on commitment 8? Is a commitment not set in the knowledge that there is a way and a means to measure progress and decide whether the commitment is being met?
We certainly think that it should be; that is one of the report’s main messages. The reshaping care programme is good and detailed but where there are clear commitments the Government should be setting out how it will monitor and report on progress against them.
You say that the Government should be doing that, and that there should be a means of measurement, but we are saying that there are no means of measurement in the report.
We say at paragraph 51 that NHS Health Scotland is currently developing a series of outcomes to measure progress on reshaping care for older people, and that is due to be available in spring of this year. We will be keeping that area under review and will report back. The committee may wish to explore that area with the Government to see what progress is being made in that regard.
Forgive me, but we are constantly being told that more robust information will be coming forward on that. I appreciate that your problem is the same as mine.
I will ask Claire Sweeney and Rebecca Smallwood to comment on how up-to-date the data is. On the broader point about the trend in local authority spending, that goes back to the convener’s earlier point about the pressures on council budgets in particular.
A falling budget and a 20 per cent projected increase in demand have to be a significant concern.
That is at the nub of why we think that progress in this particular policy area needs to pick up. We are all getting older by the day and we know that the challenges are there. The money needs to shift to ensure that the services are in place. Fraser McKinlay might want to pick up the point on council budgets in general.
As Mary Scanlon has set out, the pressure that exists with declining budgets and increasing demand makes the agenda in using the full resource that is available to the public sector partners in an area very important. Community planning must be a key part of that. Specifically, as Caroline Gardner mentioned, it will have to be an enormously important part of the agenda for the new integrated health and adult social care bodies that will come into being next year.
I think that Rebecca Smallwood can answer the question on how up-to-date the data is.
Exhibit 6 is based on published information that uses the local financial returns. At the time of the report’s publication, the 2011-12 data was the most recent that we could get, as the data for 2012-13 was not yet available.
Do you have any information to suggest that the downward trend is continuing?
We will not have anything on 2012-13 until the data is published.
Nothing at all. Okay.
Before I bring in James Dornan, I would like the witnesses to clarify something. Commitment 7 states:
That commitment is about preventing older people from going directly into care homes when they are discharged from hospital if there are alternatives that better meet their needs. For example, someone could receive rehabilitation services or additional support at home to try to enable them to live independently in their home. The aim is to prevent the situation in which people are automatically referred to a care home or institution, even though alternative services could be put in place.
Because no national data is available, you just do not know where they are going.
Yes.
I seek clarification on commitment 5. We are looking for definitions. Are the discussions that are taking place on, say, bed blocking and trying to get people back into their homes happening only between the Scottish Government and the health boards or are other partners involved?
Our understanding is that a lot of that discussion is going on through the joint improvement team, with all the partners that are involved. One of the strengths of the change fund is that it has brought those partners together. That is important, because the problems are not ones that a health board, a council or a voluntary organisation can solve alone.
The issue is that many of the partners define things such as waste slightly differently, and you are trying to get a definitive description.
As we show earlier in the report in an example on NHS Lothian, the challenge is that, not just across Scotland but even within health board areas, there can be real variations in the types of services that are provided. Some of that variation might be proper and might reflect the fact that people are sicker, poorer or older in a particular area, but the challenge is that we do not know how much of the variation reflects people’s needs and how much of it reflects issues such as there simply being no other services that could support people or there being a GP practice that is not good at thinking about alternatives to referring people to hospital when a crisis occurs. The challenge is to understand what necessary variation is and what “unnecessary variation” and “waste” are and then to drill into that and tackle it.
Do you have any idea of the timetable for the partners coming to some sort of conclusion?
That is a good question. Rightly, the programme is a 10-year one, and the change fund is a four-year fund that we are two years through. One reason why we think that the monitoring information is important is that it is important to be able to track what is happening across those 10 years rather than wait until the end and look at the difference that the programme has made. So the answer is that it is a 10-year programme but we cannot leave it until 2020 to see what is different.
I commend the Auditor General and her team for pulling together information on what is a hugely complex and changing landscape. I have a couple of brief points to make before I go on to my substantive question.
Claire Sweeney and Rebecca Smallwood will keep me right on this. I think that you are broadly right, but in the “Other” line we are seeing a much smaller focus on things such as day centres and other more traditional types of care that are perhaps less valued by older people and are of less help in enabling them to stay healthy and independent at home for longer. Claire Sweeney will amplify that for me.
In paragraph 32, we describe in a little more detail what is in exhibit 6 and we highlight what is included in “Other”, which I think is helpful.
That fleshes out what exhibit 6 is saying.
That is a reasonable thing to say. In case study 4, on page 42, we talk about what NHS Lothian and the Lothians councils are doing. We think that they have started doing good work using data to explore what is happening in quite small parts of the health board area—down to the level of individual people—in terms of emergency admissions, use of social care services and so on. As you suggest, that information can be used to find out whether anything is missing in Edinburgh, East Lothian or wherever that would help to avoid emergency admissions, or to keep people safer at home for longer. We have identified two areas where that is happening well: the Lothians and the Perth and Kinross Council area, with NHS Tayside. We did not find evidence that it is happening as well as that consistently across Scotland. We think that that needs to happen.
That is a much more nuanced view.
You are exactly right: the change fund’s purpose is not short-term funding; rather, it is to leverage the £4.5 billion that is spent on the services across Scotland. Fraser McKinlay will pick up your questions.
I will make a very similar point. The clue is in the name: the change fund is designed to change how services are delivered. Inevitably, you want to start small and test out and pilot things. As Mr Doris says, given that we are two years through a four-year programme, our concern would be the extent to which the bodies are able over the next couple of years to “embed”—to use Mr Doris’s word—the changes and make them a core part of their work, so that that just becomes how business is done and how the service is run.
That is helpful.
Some of the things that we were looking for are directly related to that. In looking at what the change fund was being used for, rather than just look at small-scale projects and where new things were being tried out, we tried to see a connection between how much a service cost and its impact on people and the rest of the system.
I do not mean to cut across Bob Doris, but a number of members have pointed out to me that Parliament convenes at half past one today. I have at least four members who wish to ask questions, so I ask Bob Doris to make a very short contribution, after which I will move on.
In that case, I may just have to make a comment, so that I can put the matter on the record, rather than have an exchange with the witnesses. My final question was about how the issue fits with the Public Bodies (Joint Working) (Scotland) Bill. I have in front of me the stage 1 report that went to Parliament. It mentions COSLA’s desire to top slice some of the acute hospitals’ budget for reform of health and social care at local level through health and social care integration.
The spirit of the Public Bodies (Joint Working) (Scotland) Bill, and of the policy, is about being more transparent about how money is spent; you can see that in the examples that we have used from Perth and Kinross and from Lothian. What is working there is the health board, the council, the third sector and private sector providers sitting down and asking what is happening to older people, where there is room to improve care, what is likely to improve the situation and how they can try that and track what happens. That is the way forward. There is a need for monitoring at national level as well, and if we can join that up through all the policy initiatives it should be possible to make a step change in the quality of services for older people and their ability to stay at home for longer.
Point 4 of exhibit 11 on page 28 states:
No. I think that that money is specifically for carers. Claire Sweeney will talk you through that.
There is a little more detail in paragraph 61 on page 34 about the focus of the change fund resource on carers. The report highlights the fact that there was a lot of attention on that because it was seen as being one of the potential solutions for supporting people for longer in their own homes.
Am I right that the change fund was worth £70 million in 2011-12, and £300 million over the four-year period, of which £35 million per annum is being spent—or has been spent in the first couple of years—in that area? I am trying to understand the split and how the money is being spent.
Paragraph 61 sets out that at least 20 per cent of the overall change fund was to be spent on supporting carers, with £50 million being allocated for that purpose between 2012 and 2015. However, in reviewing the change fund plans, the joint improvement team has identified that in some areas more than that was being spent on carers, so it has been identified as a particular priority for the change fund plan. More attention has been paid to how that money is being used than is being paid to some other areas of the change fund plan, because it was seen as such a significant issue.
You also say, in paragraph 54, that 30 per cent of the fund is underspent. There are a lot of different things going on.
That is right.
Is Fraser McKinlay’s point that some initiatives are going on, but that it is difficult to quantify them? I cannot find any assessment in the report of how much is being spent on local initiatives; I take the point that they have got to be local to drive the process. We know that £35 million is already being spent on respite care, which is entirely fair and as it should be, but what is the rest being spent on?
Paragraphs 54 and 55 summarise what we know from the joint improvement team’s evaluation of the change fund. The short answer is that there is not a complete picture. We say that the returns that come back to the joint improvement team do not account for the whole allocation in 2011-12 and, as you said, there was in the first year an underspend, which partnerships were allowed to carry forward into the following year.
If I understood Bob Doris’s point, the fund is to ensure that £4.5 billion is being spent in the right way, and you have only two years of the change fund left to achieve that. It sounds as though we are not very far down that road.
We think that there is not enough clarity about how the change fund is being used, although we say that it has done some good things. It has genuinely improved partnership working, in particular by involving the voluntary and private sectors more in the discussion, and there are some good examples of local projects. What we have not seen is the information that would let people spot those good projects and think about how to spread them.
That seems to be very fair.
In a sense, that goes back to the convener’s opening questions about the scale of the challenge. In exhibit 3, we track the policies in this area back to 2000. In truth, such policies did not start in 2000; there has actually been a formal policy in place for as long as the Parliament has existed. What is different now is not only the speed at which the size of the ageing population is increasing, but the fact that after 10 years of growing resources we are now in a period of tight resources. That means that the problem of sustainability is much tighter, and that the need to focus on what is working and to ensure that we are learning from that right across Scotland has never been more important.
Thank you.
Given the time, I will restrict myself to one question of clarification. In paragraph 23 on page 16 of the report, you carefully state that the “figures are ... real terms”. Is the fairly dramatic move from £4.5 billion to £8 billion that is outlined in paragraph 22 also in real terms?
I am pretty sure that it is, but Rebecca Smallwood will keep me straight on this. The £4.5 billion to £8 billion increase is the Scottish Government’s estimate, and I would have expected the figures to be bigger if they had to account for inflation.
I think that we will need to come back to you on that.
We will double check and come back to you, but I think that those are real-terms figures.
The point is important, given the dramatic nature of the increase. We need to know the basis of it.
It is. It has been the case over quite a long period that eligibility criteria have been increased to focus on those with the most intense needs instead of giving people one, two or three hours of home care across the week. There is a debate over whether that is the right approach and whether there is value in providing lower levels of care that can help to keep people more independent. Of course that debate will become all the more intense when, as the report in general shows, resources are tighter.
The same paragraph says:
You are absolutely right, and I ask Claire Sweeney to pick up the issue.
You have drawn out one of our biggest challenges in this report, which was to use information that gave us an in to the issue of need and the appropriateness of treatment and care. There is actually not much information that tells us very much beyond counting units of provision for social care services. The issue is, I think, nicely highlighted in the report with the comment that it is not really possible to tell whether people use more than one kind of service, whether levels of service provision are low or high or, indeed, whether that is a good or bad thing. Throughout the report, we were trying to pinpoint what a good service might look like in the reshaped model of older people’s services, and we found it quite difficult to pin that down because the information at national level is either not joined up or not collected in a way that would help us to do that. There is definitely an issue about not having good enough information about appropriateness of treatment and levels of need, and that is reflected in that particular paragraph.
Clearly, the information will lie at council level, but it is not gathered at the national level at all.
In case study 3, we talk about the index of relative need, which is a tool that is used to measure dependency. Most councils in Scotland use it when they assess an older person’s needs and the services that they require, but in 2012 only 8 per cent of the records that came back from councils to the Scottish Government included that information. That is an example of the data that we think could be useful both in helping to plan the way in which services are developed in future and in thinking about the sustainability of the model of care that we have and how to make best use of the money that is spent.
Convener, in view of the time, I will leave my questions there.
Thank you. I call Ken Macintosh, to be followed by Willie Coffey.
I want to return to a subject that everyone has pursued. You state that
In overall terms, it is clear that money is not transferring. The figures in the report demonstrate that things are pretty steady, and actually the overall level of local authority spend fell between 2011-12 and 2012-13. That is not to say that it is not shifting in some localities and some council and health board areas, but across the country the Government’s commitment to shifting that relative spend is going in the wrong direction rather than the right one. That is happening for reasons that we all completely understand to do with the difficulty of making the shift at a time when finances are reducing, the number of older people is increasing and we need to keep on running the acute hospital service. However, the shift is not happening just now.
You have summed up the dilemma. You point to weak leadership, but could a different conclusion be drawn? I can see how we could put more resources into community-based care and expand that sector, but I cannot quite see how we could ever decrease investment in acute care. That is a different conclusion altogether, is it not? Do you tend to the view that, no matter how hard we try to shift resources away from acute care, that will not happen, and all that we can ever do is to maintain the level there while we increase preventative care?
It is certainly very challenging to make the shift, but I am not sure that anybody has the evidence to say that it is impossible. There are different drivers. As you heard this morning, we have seen a dramatic reduction in average lengths of stay, which is due to people being treated as day cases or outside hospital. There are technological advances that mean that people who would have been treated in hospital can now be treated at home with drugs. Some of the challenges go the other way, because we can do new things that cost more, so an awful lot is changing.
In paragraphs 62 and 63, you mention the role of the third sector, particularly in care, and the difficulties that you have in that area. Can you make any assessment of the role or value of the third sector in promoting community-based care? Many of us as MSPs see things such as lunch clubs, befriending, volunteer drivers and so on as both cost effective and important because they provide a culture and a supportive community that increase older people’s independence, but you do not seem to be able to make any assessment of such work in an auditable way.
I think that the consensus is that, as you say, those voluntary services can be both effective and highly valued by older people. However, it is also true that we do not have evidence of that at present. The stitch in time project, which we mention in paragraph 63, is intended to gather that evidence in order to strengthen the voluntary sector’s hand in discussions about where money should be spent in future. To a great extent, having the evidence makes it much easier to make the case for the shift.
Will that be published in time to influence the Public Bodies (Joint Working) (Scotland) Bill? The bill is about integrating health and social care, but it does not really involve the third sector in any meaningful way.
That is part of the agenda of reshaping care for older people and the changes around the integration of health and social care services. In some areas across Scotland, that relationship has been gained in part through the support of the change fund by bringing together partners to start to think about the way in which resources are used in totality for that local area. That relationship is new; it has not really been done before. We are starting to see a greater focus on that in local areas, which directly involves the third and private sectors in most discussions about provision in the local area.
Thank you. I think that I interrupted Fraser McKinlay earlier.
Claire Sweeney covered it.
Auditor General, I want to pick up on the issue of delayed discharge. The figure that is mentioned in the report is something like 305,000 days all in. From your comments in paragraph 67, it appears that the problem is half the size that it used to be, but it is still quite extensive. You also comment that 837 hospital beds or equivalent are being occupied for a year by patients who are otherwise ready to leave hospital. There must be quite a considerable cost attached to that. Do you know what that cost is?
It is possible to put a cost on it by basing it on the average cost of a hospital bed day. The question is how much that really tells us. As Mr Macintosh said, the problem is that, because of the pressure that we all put on acute hospital beds, if there is not an older person in that bed, it will be filled very quickly by someone else, so that sort of average cost is not particularly useful. That shows why stepping back and looking at the whole system is the only way to tackle the problem.
You hint at the issues in paragraph 66, but why are people being brought into hospital? Is there no discharge plan ready? Should people be admitted to hospital when there is no discharge plan for them? What are the main reasons for that?
You are right to say that there is no specific recommendation about that. That is partly because the ways in which it can be tackled just by focusing on delayed discharge have already been done. That “easy work”—if I can put that phrase in inverted commas—has already been done, which is why the figures have fallen so significantly during the past few years.
I will leave it at that, convener. Thank you.
Thank you. I thank the Auditor General and her colleagues for their evidence to the committee. With that, we move into private session.