Section 23 Report
“Overview of the NHS in Scotland’s performance 2010/11”
For item 3, I invite the Auditor General for Scotland to brief the committee.
Mr Robert Black (Auditor General for Scotland)
Good morning, convener. As I am sure committee members are aware, I bring a report on the national health service’s finances to the Parliament through the committee every year. Every second year, we take a wider look at performance in the round, as well as finances. I am pleased to say that this is one of those years in which we have a more wide-ranging report.
It is a pleasure to report that, for the financial year 2010-11, we can present a generally good picture of performance by the health service in Scotland nationally. In the past financial year, all the boards met their financial targets. We continue to see good progress against the big three diseases of coronary heart disease, stroke and cancer.
That said, pressures on the health service continue to grow. There are increased costs from a variety of sources and rising expectations, needs and demands as a result of public health problems in our society and demographic changes such as the ageing population.
The first part of the report comments on pressures that the national health service faces. Part 2 sets out the financial performance in 2010-11 and looks at efficiency and productivity. Part 3 looks at the health service’s performance in improving Scotland’s health.
It goes without saying that we all recognise that changes to the Scottish population in coming decades will increase the demand for public sector services and for the health service and social care services in particular. That will result from there being more older people and from the challenges in the public health agenda. Such pressures will continue to intensify in coming decades, but it is important to realise that they are already having an effect. The changes are so significant that we suggested in the report that current ways of delivering services in all respects might not be sustainable.
It is not possible for the health service to plan for and respond to such changes on its own, so our report emphasises the need for strong shared leadership and better partnership working, whereby councils and health boards work together to deliver more services and more effective services. One encouraging development has been the Scottish Government’s recent announcement about plans to integrate further health and social care services. I remind members that that was one theme that came through our report on community health partnerships, which the committee considered recently. I am sure that that development will feature in Audit Scotland’s work in the next few years.
The report confirms that the number of staff whom the NHS employs fell by about 2 per cent between September 2009 and March 2011. Exhibit 6 on page 10 shows that NHS bodies plan further reductions in 2011-12. There is perhaps understandably quite a lot of media and public interest in this issue. Therefore, it is probably worth noting that half the decrease was a result of reductions in nursing and midwifery staff, but the biggest percentage reduction was actually in administration and support services. Some challenging targets are set by the Scottish Government for a reduction in senior management staffing in the health service.
When any organisation is cutting its staff numbers—the health service is no exception—it is important to balance the risk of losing knowledge and experience during the period of change with the potential benefits of opening up opportunities for existing staff and employing new people who can bring new perspectives and carry it into the future.
Still in the first part of the report, under the heading, “Pressures facing the NHS”, we say that there continue to be some real challenges in developing and maintaining the physical estate—principally hospitals and health centres. The capital budget for the NHS reduced by 13 per cent to £474 million between 2010-11 and 2011-12 and it will fall again in real terms to £215 million by 2014-15.
I have commented previously on the high cost of addressing the backlog of maintenance and repair across the NHS estate. With the financial pressures that lie ahead, it might be even more difficult to maintain the existing NHS estate in a good condition.
In exhibit 8 on page 13, we set out details of 10 NHS capital schemes valued at more than £50 million that are currently under development. The Scottish Government is continuing to look at alternative ways of financing capital schemes and five of those projects will be funded through the non-profit-distributing methods.
The Scottish Futures Trust has an important role in facilitating the use of revenue finance for NHS investment; its role is outlined in exhibit 7 on page 12.
I turn to part 2 of the report, which summarises the financial performance of the health service. I am pleased to say that the overall financial performance of the NHS in 2010-11 was good, with all bodies meeting their financial targets.
Funding for the NHS continues to increase in cash terms, but in 2010-11 it reduced in real terms by 1 per cent from the previous year. The financial picture for territorial boards and special boards differs, with the Scottish Government allocating real-terms increases for territorial boards but real-terms reductions for the special boards in 2011-12. On pages 21 to 23 of the report you will see details of the variation in financial performance by health bodies.
In 2008, the Scottish Government introduced the NHS Scotland efficiency and productivity programme. NHS bodies clearly need to deliver efficiency savings in order to break even. In 2010-11, the NHS reported efficiency savings of £292 million. Those developments are encouraging, but as I have highlighted in several Audit Scotland reports in recent years it continues to be pretty difficult for the NHS to quantify productivity due to weaknesses in the underlying data and difficulties in linking costs, activity and quality. We have reported in the past on the challenges that we face in providing an independent assurance on the efficiency savings for reasons of information that is not quite up to the standard that we require.
The third part of the report provides a summary of progress in tackling health inequalities in Scotland and an outline of how the NHS performed against targets in 2010-11. There were some positive indicators. Personally, I am delighted to say that life expectancy in Scotland is increasing and death rates from the three main causes of premature death in Scotland—coronary heart disease, cancer and stroke—continue to fall.
As I am sure members know, there are many schemes in place to address some of those health inequalities—we summarise some of the main ones on pages 27 and 28 of the report. As I think we all recognise, there are still very significant differences in life expectancy between people living in the most deprived areas and those living in the least deprived areas of Scotland.
The NHS cannot tackle those challenges alone, which brings us back to partnership working. In that really important area, health bodies must work with their partners, especially the councils, to plan and deliver services that address inequality. Given the clear importance of those issues, Audit Scotland will carry out an audit of health inequalities in 2012.
In May 2010, the Scottish Government introduced the healthcare quality strategy for the NHS in Scotland, which was designed to help NHS boards to improve service quality. A great deal of work has been carried out to reduce healthcare associated infections, and the Scottish patient safety programme has contributed to reductions of 37 per cent and 71 per cent in MRSA and Clostridium difficile infection rates respectively.
Finally, I am pleased to say that the NHS met three quarters of the NHS performance targets for health improvement, efficiency, access and treatment—which are known as HEAT targets—that were due for delivery in the 2010-11 financial year. However, I should also mention that performance varies at local level. Only four of the 28 targets due for delivery in 2010-11 were not met at a Scotland-wide level, but in those four areas—breastfeeding newborn children, booking general practitioner appointments 48 hours in advance, electronic out-patient referrals and reducing the frequency of HAIs—there was still improvement against performance in previous years. The NHS is also making good progress towards achieving an 18-week referral-to-treatment target by the end of this December.
As ever, my colleagues and I will do our best to answer members’ questions.
Thank you very much for that very full briefing.
I have a couple of questions. Exhibit 6 on page 10, which sets out projected workforce changes, shows an increase of 421 for NHS Education for Scotland, which the footnote says is due largely to
“GP trainees being employed by NHS Education for Scotland rather than individual practices.”
Under which headings would those people have previously been counted? After all, GPs are generally self-employed rather than employed by the NHS. Who previously received the budget for those staff and has it been transferred from wherever it was before to NHS Education for Scotland?
Claire Sweeney (Audit Scotland)
Those GP numbers would not previously have been counted in these statistics.
They might not have been included here, but where would they have been included?
They would have been included in the numbers for GP practices and so would not have been reported in these statistics.
Are you saying, Claire, that, as a result, they were not included in the aggregate workforce numbers?
Yes.
So will the figures show a reduction in the number of GPs?
Not necessarily. I am not familiar with how those figures are reported and I am not sure whether a separate set of figures would have been produced.
Was the budget transferred?
I assume that it would have been moved over, but I am not certain about that.
If it had not been transferred, there would have been significant financial consequences. It might be worth seeking some clarification on that.
You have indicated that, although NHS funding continues to increase in cash terms, overall funding is decreasing in real terms. From what you have seen, do you think that it is possible for services to be maintained with a real-terms reduction?
The short answer is no—we are not in a position to look at that issue in this overview. As I mentioned in my opening remarks, we refer to reported efficiency savings of £292 million. We do not know how that figure is made up across all health boards, but in the report—I forget which page—we indicate some areas where efficiency savings have been achieved and suggest that more efficient use of theatres, techniques such as early discharge and so on will generate true efficiency savings because they free up capacity.
10:45
When you said “no”, did you mean that services would not be maintained or that you are not in a position to comment?
I beg your pardon for not being clear—I meant that we are not in a position to comment.
Okay. Fourteen territorial boards reported an underlying recurring deficit. You explained that, from what you have seen over the past year, there is good management and there is a positive picture. In a number of reports that we have looked at over the years, the underlying recurring deficits have been a source of troubles. Are there grounds for concern about the cumulative impact of the underlying recurring deficits in any of the territorial boards?
I would hesitate to say formally on the record that we have concerns about any boards, but the challenges in some boards are possibly greater than they are in others. The island boards continue to have the highest recurring deficits as a percentage of funding, although the absolute numbers are small, and it is clear that there are some challenges in one or two mainland boards but, from what we understand, they are being addressed.
Perhaps I should say to the committee, particularly for the benefit of members who have not been on the committee for a long time, that a number of years ago the problem of recurring deficits was quite significant. Boards were reliant, in my opinion rather excessively so, on one-off funding sources to get them through the financial year. A great deal of progress has been made in that area and, in aggregate terms, the level of recurring deficits is now relatively small.
Thank you for, as always, a very comprehensive briefing.
I am heartened by some of the developments that you touch on in the report. The overall financial performance seems to be good and we can all agree that the increase in life expectancy is a good thing. It is also heartening that mortality rates from the big three diseases are going down. However, you touch on the nub of the matter, which is that over the next 25 years there will be huge demand and huge pressure, because of what has been termed the demographic time bomb. From your experience, study and research, do you think that health boards are equipping themselves to face that challenge? Where should this Government and future Governments put their money to try to handle that pressure?
There is a very sound awareness in health boards and partner organisations of the challenges that are faced. As we say in the report, the response will have to include elements of service redesign. I guess that that is one of the principal reasons why the Government is making a new push to strengthen partnership working between social care and primary healthcare to facilitate service redesign and to push more services out into the community, with the change fund being used as a catalyst to help that happen. That is certainly the direction in which we have to move.
You say that the Government is trying to encourage more partnership working by health boards. What about local authorities? I know that this is a difficult question to answer, but have local authorities throughout the country taken the message on board, understood the demands and responded to them?
I refer you to the community health planning partnerships report, which we produced a little while ago. A theme in that report—I am sure that Claire Sweeney will recall the detail—is that there needs to be strong shared leadership between councils and the NHS to identify a common approach to problems and there is a need for much-improved information to help them understand the needs in the local area, the services that are being delivered and the pressures that will arise in future.
The overall message from that report is the need for clear leadership and for commitment to working together to join up resources and ensure that they are used effectively between councils and NHS boards. The report highlighted examples of where that has started to happen. Good underpinning information on local needs is required to inform plans of where resources should be targeted and of how they will be used.
Earlier, I talked about whether we could sustain current levels of service delivery. In paragraph 11 on page 8 of the overview report, we drop in a statistic:
“the ratio of pensioners to people of working age is expected to increase from ... 32 pensioners per 100 people of working age to 38”.
That is a significant increase. Real issues will arise, not only in meeting the needs of those people but in finding the workforce to provide services for them. That brings us back to thinking about new ways of supporting people.
And we should not consider it simply as an issue for the NHS. It is much wider.
Yes.
I have no doubt that other members will pick up on that point.
Pages 27 and 30 of the overview raise interesting points on the misuse of alcohol and drugs, which, according to the report, costs Scotland more than £7 billion. That is a huge cost; it is one fifth of the block grant. Parliamentarians, as well as people in the NHS and others, know the statistics, and the issue has to be a priority. What lies behind the increase? Figures from 1990 to the present show a stark increase in the numbers of people who are misusing alcohol and drugs. Are the methods that the health service is providing just not working? Are more people drinking? Is it a result of the economic times? I do not imagine that you can give a magic answer, but did your research indicate any reason why costs might be rising and not falling?
I strongly commend to committee members the annual report of the chief medical officer for Scotland, which, by coincidence, came out just a day or so before we published our report. It contains a full narrative on issues such as alcohol and drug problems in Scotland; it is an interesting document if you want to understand the challenges in the public health agenda and in health inequality. A lot of information is around, although I guess that it would be difficult to give a summary this morning.
Was there a lot of variation among health boards in the ways in which they tackled the problem? Were any health boards hitting the nail on the head, while others were not?
I refer you back to our report on drug and alcohol services, which I think was published in 2009. In that report, we considered in detail local arrangements for the delivery of services and the ways in which people’s needs were met. Again, an issue that arose was the need for partnership working among councils, NHS boards, the police and other partners, in order to address concerns about the levels of drug and alcohol misuse in Scotland.
I will be sure to have a look.
We can certainly provide the committee with a summary of the key messages in that report, if you would find it useful.
That would be incredibly useful. Thank you.
You referred to the 2009 report. At that time, you spoke about the importance of early intervention and prevention but you mentioned a lack of investment in such services. Have you seen improvements since then?
I think that it was the first time that anybody had tried to put any figures on how much was spent on prevention. We have not gone back to that piece of work, done the calculations again or asked agencies for information with which to update the data. The current overview of the NHS shows the need to focus on prevention at a time when demands on services continue to increase.
I would like to ask two questions. The first concerns data. I gathered from Mr Black’s slight sense of exasperation that the data that underpin the figures on efficiency savings might not be all that they should be. Has that kind of thing been an on-going problem from the minute that a Government—by which I mean any previous Government as well as the current Government—starts to talk about efficiency savings? If so, how can we resolve the problem?
My second question relates to the very interesting perspective that you have brought to the current debate on bringing together social work and healthcare. How is governance going to work in that situation?
On your first question, a recurring theme in our reports for many years now has been that the quality of information in the health service is not as good as it needs to be to manage the service, to demonstrate value for money and to drive the efficiency agenda. I might say, in a slightly sweeping generalisation, that the aggregate numbers are probably pretty accurate—in other words, they identify the amount of money that has been taken out or freed up in the health service through what is called the efficiency programme. However, when we go down a level or two into what is actually happening in the system, it is very difficult to get data that link activity, cost and the quality of the impact. That can be seen across much of the health service.
One can understand a fair bit of what lies behind that—for example, clinicians spend their time in various care settings. I would not want for a moment to suggest that the health service needs to load itself with a new bureaucracy in order to capture data and to chase a mirage of the perfect data set. However, we need to recognise that it is an on-going problem; we think that, across the piece, the NHS could continue to do more to rise to the challenge. A little while ago, we produced a report on orthopaedic services—Claire Sweeney was project manager on that, as well. Even in what seemed like a reasonably self-contained and defined health business area, in which we felt there might be really quite good data, we found it remarkably difficult to form any conclusions on cost, activity and quality.
On your second question, the governance of partnership working presents a real challenge. That very point came through in our recent report on CHPs and our report on community planning partnerships. After reading the Government’s recent high-level announcement on the matter, we felt that it might have been partly a response to the challenge that we highlighted of strengthening governance in the health service. However, a number of important questions will remain unanswered until we see the detail. We understand, for example, that the Convention of Scottish Local Authorities is still at a fairly early stage of negotiation with the Scottish Government over how the new partnership arrangements will operate and move on from the CHP model.
Indeed. I guess that the issue will be subject to some debate.
Again, I do not want to criticise the health service—I absolutely take your point that the last thing we need is more bean counters counting lots of beans. However, am I to take from your response to my first question that a degree of inaccuracy is built in to the figures for efficiency savings that are produced by the Government—by which I mean the Government over a period of time, not just the current Government—and that we simply have to accept that because of the difficulties that you have observed?
We would accept that. We have to recognise that the numbers are not in every case precise or scientifically built up from good local data.
This might be an oxymoron, but it is possible to be accurate about the inaccuracy of the figures?
I wish that it were; it would give me, as the Auditor General, comfort to be able to say how inaccurate the data are.
We covered a lot of these really important issues in the reports that we produced a couple of years ago on the efficiency programme. Barbara Hurst can perhaps recall some of the messages that came from the reports about quality of data and the sort of assurances that we were, or were not, able to give.
11:00
Barbara Hurst (Audit Scotland)
Yes. The key difficulties were about whether something was actually an efficiency saving or a cut, and whether quality had been retained as costs had been reduced. A more general difficulty was that, because the numbers were so big, some of the work had to be based on assumptions and there was an issue about the validity of those underpinning assumptions. We could have gone in and pored over all the figures, but we felt in some ways that there was no point in doing so. After all, given what our big message was, what was the point of spending a lot of resources doing more work just to prove it? It is a very difficult area and in some of our other reports we have moved away from it to say, “You need to start setting priorities”. The language of efficiencies is still important, but it is only part of the whole picture.
Paragraph 28 on page 14 shows the increase from £170 million to £197 million in the costs associated with private finance initiative projects, which is a little bit horrifying, but not unexpected. However, although the report comments that the costs will rise “in line with inflation”, surely that increase is more than an inflation rise. Are we to assume that the increase covers PFI contracts that have already been signed up to and which are coming on-stream and require repayment? Do we have projections for the couple of years beyond 2011-12? After all, those years are going to be critical and that particular cost seems to be a little bit uncontrolled. I realise that pages 14 and 15 refer to a number of uncontrolled costs, including the cost of medicines, but surely on this issue you should at least have some sort of guesstimate about what is coming up.
My second question follows on a little bit from Tavish Scott’s comments. Reading the report, I get the impression that, although Government indicators are broadly being achieved and although there are figures for those, the underlying statistics that might support an awful lot of the decisions that are made in the NHS are not as obvious as they might be. A theme that has been emerging from a number of reports that I have read is that there are difficulties in bringing together the figures to support some of the assertions that are being made in audit reports. Would there be any merit in following that up in a separate piece of work? I realise that I am groping a little bit here, but one theme seems to be that public bodies are not getting the kind of statistics that they need to fully manage their business.
I am sure that the team will correct me if I get this wrong, but in our overview report on Scotland’s public finances we said that the total annual costs of PFI will peak at about £1.1 billion in the early years of the 2020s and beyond. That is the magnitude of the costs to come. Of course, because a PFI is a contract, those costs are unavoidable.
Perhaps the team can help me out on the question of the recent increase.
Ally Taylor (Audit Scotland)
In addition to the inflation rise, the main increase in 2010-11 was due to the opening of the Forth Valley royal hospital in Larbert, which was a PFI scheme.
As for your second question, I find interesting your suggestion that, as a project, we should revisit the fitness for purpose of data. Of course, that would not be easy because the system is so large and complex. However, we could go back and have a look at it. I believe that a little while ago we carried out a piece of work on information in the health service. To be frank, I cannot remember what we said in it. Perhaps Claire Sweeney can help.
We have summarised for the committee the messages about information in the health service in all our recent reports. As Mr Beattie said, we picked up some common themes about particular gaps in that information.
I should also mention that in all the performance audits that we produce on particular health areas we will look at and comment on quality of data; I am sure that we do the same in our reports about the public sector. Because that work forms part of all the performance audit that we carry out, we were able to scoop up some of the messages and themes from the NHS reports in particular, and to summarise them in a list of generic issues.
This does not come out in the report, but is it correct that in large part the difficulty relates to not having information technology that can readily acquire the figures?
I would hesitate to give a simple answer to that question. My view is that, during the years when resources were more readily available, there was not necessarily the drive to understand and minimise costs that we now need. If that is true, there will be issues to do with the fitness for purpose of the IT systems that bodies are using. The starting point must be a business strategy that is focused on driving costs down and quality up. The IT needs will flow from that.
Especially in the acute sector, the health service probably has more data on its activity than any other part of the public sector. The activity in the community is less good, which matches what is going on around community care in councils. The point that we are trying to make is that people can have all the data they want—they can have loads of data—but they need to turn it into information on which they can make good judgments. The real gap is in cost information that can be linked with that. I do not want members of the committee to go away thinking that there is not much clinical data available on the health service; there is, which is why we can get such rich information over time about coronary heart disease and stroke outcomes, for example.
I come back to paragraph 28 of the report, to which Colin Beattie referred, and the cost of PFI projects. Have you considered and reported on some of the other issues? I had discussions with local councillors about PFI or public-private partnership school projects in my area. My understanding was that the cleaning, maintenance and running costs were included in the PFI, which took pressure off revenue budgets elsewhere, and that periodic refurbishments were also to be carried out as part of the contracts. I presume that the same would apply to most such projects. Towards the end of the 25 or 30 years of the contract, people would therefore be left with an asset that would be viable for another 15 to 20 years, and there would be a potential capital saving at that point. Are such issues factored into your calculations in your reports?
They are not factored into the report that we are discussing, which is simply a presentation of the NHS’s financial performance as we see it. The team may have something to add to what I will say.
Quite a number of years ago, we looked at the capital programme in education and what was happening in the schools sector. At that time, one of the findings that we put to Parliament was that the whole-life maintenance and repair costs were included up front in PFI-type contracts, but the major cyclical repairs and on-going maintenance and repairs of established capital assets were still not always properly costed. In other words, people—especially in local government—were not looking adequately at maintenance and repair costs. Over the years, that has contributed to some of the quite challenging numbers that we have produced on backlogs in maintenance and repair in the existing capital stock. It is important to acknowledge that, sometimes, we are not comparing like with like until we build that factor in.
No. Exactly.
I have two questions, the first of which is on staff. In your opening statement you said that between September 2009 and March 2011 staff numbers reduced by 2,500. A paper to the Health and Sport Committee in October showed that, in the 21 months up to that point, the NHS lost 3,910 staff. It seems that the pace at which staff are being lost in the NHS has increased. Do you have any information on that?
Unfortunately, we have no information to add to what is in the report.
The difference is quite significant.
My second question is on targets, which you raised at the beginning of the meeting. Two targets that are mentioned in the report—one on sickness absence, and one on mental health—were Government targets, neither of which was met, and both were subsequently abandoned. When we are talking about targets that have not been met, we are not measuring the ones that have been abandoned.
Paragraph 21 on page 11 of the report mentions a
“target of four per cent for sickness absence”.
No health board in Scotland met that target two or three years ago; I think that only NHS Education for Scotland met the target. The target has since been abandoned.
The paragraph continues:
“Six NHS bodies continue to report sickness absence rates higher than five per cent; the remaining NHS bodies report sickness absence rates of between four and five per cent.”
In the private sector, I understand that the sickness absence rate is between 2 and 3 per cent. Why is sickness absence so high in the NHS, and what should be done—
That question would best be answered by NHS managers. I do not think that we are close enough to what is happening in the health service to allow us to answer that.
As, I am sure, Mrs Scanlon has picked up, the direction of travel in sickness absence in the health service has been good. The health service has been addressing the issue, and we know from local audit reports that health boards have been taking the issue seriously. It is one of those turnaround issues that cannot be fixed immediately, but health boards have made some progress.
There would be a huge variation between a reasonable sickness absence target in a high-pressure public service such as the health service, and a reasonable sickness absence target in other types of business in the private sector. I am sorry, but I am not sure that we are expert enough to offer Mrs Scanlon further advice on that.
Perhaps you can offer advice on another target that was missed and then abandoned. Paragraph 93 of your report mentions mental health; from memory, the target was a zero per cent increase in prescribing of antidepressants.
Yes.
In fact, the increase last year was 8 per cent. Not only that, there has been a 60 per cent increase in defined daily doses over the past 10 years.
I really just wanted to highlight the fact that several targets have not been met and have therefore been abandoned. Are you aware of other targets—apart from the two that I have mentioned—that have been abandoned because they were not met?
In preparing the report, we thought a lot about how best to present data on performance, and we have tried something different this time in some of the exhibits. We considered how we might comment on issues such as the one that Mrs Scanlon has raised. Two slightly different issues arise. The first concerns the level of detail that we can present in an overview report, and the second concerns where we should pick up on particular specialties or issues.
11:15
The committee might remember that we produced a report, “Overview of mental health services” a few years ago, in which we got into quite a lot of detail—even in an overview of services—and said that we would go back and look at other issues to do with mental health services. The committee spent some time looking at issues to do with antidepressant prescribing and started to get into much more detail.
The issue is not one that we are unaware of or have forgotten about; it is just that we did not go into a huge amount of detail about it in the report that we are considering. We have made general comments about performance reporting and where things need to be strengthened, and we have talked about some of the issues in that regard, but there could be something there about other targets. If targets are no longer HEAT targets, there will still be some monitoring information, which we will have looked at as part of producing the overview report. There is other information in that regard, but perhaps the decision was taken not to go into too much detail on mental health, for example, because of the number of issues that we were able to fit into the space that we had.
Given that the target was a zero per cent increase, an 8 per cent increase in only one year is significant.
I understand; it is entirely appropriate that Audit Scotland did not have the opportunity to go into such detail in the report. However, Mary Scanlon has made a significant point. When you undertake analysis or research, will you continue to comment on whether targets that the Government set were met, even when the targets have been abandoned? If you do not do that work, no one will ever know whether there has been failure and whether political expediency led to the abandonment of targets.
In previous overview reports we have been quite firm about asking why targets have been dropped, because of the loss of trend data—bearing in mind that we cannot keep adding in the targets.
Mental health is on our radar; we want to do more work on it, and we have to identify which part of the mental health system to look at. To date, we have thought to look at dementia, but there are concerns about the rise in use of basic drugs in a much wider population group, which we might need to look at.
It is fair to say that we would not necessarily track every target that had been dropped, which would potentially be a big job. However, we have been robust with Government civil servants in asking them to be clear to the public about why targets are being dropped, if that is happening. The committee might also want to ask about that.
It might be worth the committee’s while to look at the general issue. By setting a new target that is nothing like the original target, the Government might be able to meet the new target and claim success, but that would hide an underlying failure. The Government made a commitment on teacher numbers but, with local councils, set a target that was lower than the previous target. Lo and behold! The new target has been met, but it is not the target that was originally set.
If Audit Scotland, through its objective analysis, cannot look at claims on targets, there will be no way that the Parliament can track failure, manoeuvring, obfuscation or anything else that is going on. It is about transparency, so it is important to have a mechanism whereby we can track commitments that have been made and find out the reasons for their being abandoned or not met. The committee might well want to come back to the issue, but it would also be useful if Audit Scotland kept an eye on the matter, because there are significant financial implications.
We note your concern, convener. We will take the matter on board for the future.
One of our debates in the chamber this week will be on the Welfare Reform Bill. Some 43.7 per cent of people on benefits have a mental health problem. I feel passionately about the issue. There was an 8 per cent increase in the prescribing of antidepressants last year, and the doses are up. When people are called in for a work capability assessment, they will say, “Well, I’ve been on antidepressants for 10 years.” I would have liked to see the target on antidepressants being met, because there is a lot of pressure on people with mental health problems and that ties in with the Welfare Reform Bill.
That is clearly and understandably an issue of great concern to members of the Parliament. Thinking in real time, I would say that the scoping of our work on health inequalities should take that into account. We cannot look at health inequalities in a narrow box; we have to look at them in context, as we do with everything to do with the public health agenda.
I will return to targets, but before I do so, I will go back to your initial discussion with the convener on the overall budgets. Clearly, there are some political issues, in that the Government’s commitment to maintain the budget has been met by putting money into the territorial boards but removing it from the special boards. Is there any evidence either that the special boards are doing less as a result or that functions are formally or informally being transferred from the special boards to the territorial boards to take up the slack of the things that the special boards no longer do?
No.
No.
Do you envisage going back to special boards?
I am sorry; I did not catch that.
I appreciate that the Public Audit Committee is always asking you to do other pieces of work, but do you envisage taking another look at the special boards?
We would need to have a clear understanding of the purpose of that work. The special boards have been set some pretty challenging financial targets—the percentage reductions for some are significant. We know that there are pressures, but we are not in a position to comment on how well the special boards are managing the financial pressures that they face. If there are areas of particular concern to the committee, we could always look at them and feed them into the annual audit work that is undertaken, as part of which we audit all the special boards.
Okay. I return to the indicators, targets and data. I appreciate that exhibit 22 on page 37 just contains examples, but two things concern me, and I want to ask you how concerned the committee should be. Mary Scanlon talked about targets being abandoned and we are told that no national data exists on the national target to reduce the proportion of pregnant women who smoke to 20 per cent by 2010. What is the point of having that national target if we are not measuring progress against it? Will you comment on the extent to which that happens?
Also, can you give us any assurance on single outcome agreements? You simply say that, because variation exists, you cannot comment on whether the targets are being met. Exhibit 22 gives some examples, but is there a widespread problem in the interaction between the health service and local government on single outcome agreements?
I will talk in broad terms about performance measures and use the exhibit as an example of our trying to do something more interesting to show what the information looks like and means. In quite a few Audit Scotland reports, we have commented on the problem of having different performance measures, on the need for clarity about what we are trying to achieve, on what different agencies contribute and what the measures are, and on the need to make the process transparent to the public and everybody else.
In looking at performance, we looked at all the published information and did some more digging on what information exists in order to build a picture of how well things are monitored. Exhibit 22 is new for us, and in it we try to bring together a range of different measures to explore in more detail what a problem looks like when it is broken down into the performance measures that are in place.
There are issues with single outcome agreements in relation to attempts to benchmark performance between different bodies, and there is a lack of consistency in some areas in how things are measured. Work is under way to develop national outcomes that everyone will apply, and more consistency is underpinning that work, but we do not believe that there is enough consistency at present. There is a problem with how the outcomes are aligned because they are measuring different things, and there is a problem with how transparent some of the information is. If it is hard for us to get, how easy is it for the public to find out the message on a particular target or area?
I am sure that we do not want to give the impression that there are difficulties and failures in the NHS, despite some of the previous comments about staff numbers, the failure to meet certain targets and the dropping of targets. The Auditor General’s report is clear that some great progress has been made in tackling heart disease, stroke and cancer, and it builds on the progress that has been made over a number of years, to give credit to previous Administrations. The health boards are meeting their financial targets, 75 per cent of HEAT targets are being met and, as the Auditor General said, we are close to meeting the 18-week target for referral to treatment.
The difficulty with picking out statistics is that the reports give snapshots of the NHS. We can pull out a figure and say that, for example, staff numbers are down by 2,000 or 3,000, but the report is clear that 20,000 more people are working in the NHS than in 2002. That has a certain value in the political argument among members around the table, but the statistics have to be balanced.
I would like the Auditor General’s staff to comment briefly on and clarify exhibit 16 on page 28. I look at it with some concern. It seems to suggest that the life expectancy for males in Scotland is 60 years. I am sure that that causes some concern to members round the table. Is there a difference between healthy life expectancy as opposed to life expectancy? Either the scale of the chart is wrong or we are talking about different statistics.
There is a difference between life expectancy and healthy life expectancy, which is how long someone can expect to live in good health. Someone might well live for another 10 years in not so good health. That is the difference.
I do not know whether to be comforted or alarmed by that.
You should probably not be that comforted.
I would also like to talk about an issue that the Auditor General raised earlier that was of interest to the previous Public Audit Committee. The information in exhibit 13 on page 22 relates to the problems that the committee identified with the deficits that the health boards were carrying from year to year and the significant progress that has been made in addressing that. I would love to be able to say that that progress was a result of the Auditor General’s report and the attention that the committee gave it.
The health boards are making some great progress in reducing those deficits. Convener, you will remember that the committee visited NHS Western Isles—it has made some fantastic progress on reducing its deficit over a number of years. That is reflected on page 22 of the report. However, can the Auditor General’s team explain the seemingly spectacular performance by NHS Dumfries and Galloway, which does not appear to have a recurring deficit? In fact, it has a recurring surplus, if I am reading exhibit 13 correctly.
We will have to come back to the committee with more detail on that.
It is a surprise to me, convener. I would appreciate it if the Auditor General could follow that up.
Are you particularly interested in NHS Dumfries and Galloway, Mr Coffey?
Yes. It looks like a really good story and it is worthy of further explanation.
I am sure that you appreciate that the report is an overview and that it would run to volumes if we attempted to analyse all the health boards and the business and financial strategies that got them to this point. However, we can certainly help you with details on NHS Dumfries and Galloway if that would be useful to you.
I would appreciate that. Thank you.
In one way, it is not a positive story that NHS Dumfries and Galloway has shown a surplus. We should also look at the significant turnaround that NHS Greater Glasgow and Clyde made in that one year. Those of us who represent communities in that health board’s area can probably refer to specific service delivery issues. However, we should acknowledge the efforts that are being made.
11:30
We receive a good report from you on the board’s financial progress, Mr Black, but MSPs such as George Adam and me know the local concern and furore that have been caused by, for example, the potential closure of the children’s ward at the Royal Alexandra hospital, which comes down to financial pressures. Although it is commendable that we see progress, we know the local consequences of the lack of money. We always have to balance cold, hard, objective financial comment against the human consequences of what happens locally.
As there are no further questions, I thank the Auditor General and his staff for a full contribution and an interesting report.