Winter Bed Planning
I thank the minister for providing us with a helpful report on winter bed planning, "Lessons From Winter 1999-2000". As a result of the issues that cropped up last winter—and have a horrible habit of cropping up every winter—the committee decided that it wanted to keep an eye on planning for winter. That covers not only winter performance, which the report deals with, but flu vaccinations. The Executive has a copy of our report on flu vaccinations; it has until the beginning of December to give us its response. Minister, most of the questions that you will be asked will deal with the wider issues of winter performance rather than our report, but we might stray into that area.
Throughout what is termed the Scottish summer, the NHS in Scotland has experienced difficulties caused by the continued pressure on beds, which has meant that, occasionally, elective procedures have had to be cancelled. The winter performance group identified areas in which we might be able to alleviate the pressure during the winter months. How can we be assured that best practice, which the report identifies in various areas, will underpin the planning process for this winter? Given that no specific direction has been given nationally, how will the performance of health boards and trusts be measured?
I can assure the committee that more work has been done than ever before to ensure that best practice is followed throughout the country. For the first time, we have captured what best practice ought to look like. That is a significant step forward.
I will not go into the detail of the winter performance group report, as members have copies of it, but it is worth saying something about the background. The report was published in August, after several months of work involving a range of professional groups and perspectives in the NHS. The experience of last winter was carefully considered in an attempt to identify what worked and what did not work. It is important to note that, although emphasis is placed on what does not work in winter, many parts of the NHS have developed effective mechanisms for coping. Margaret Jamieson rightly refers to best practice; the report captures best practice so that each part of the system has the tools and the knowledge to work effectively. Similarly, reports such as the chief medical officer's report on intensive care provide guidance to local NHS organisations to help them better to prepare for winter.
Margaret Jamieson also asked how performance can be managed. I assure the committee that a number of changes have been made to monitor and performance manage the service better. I stress that it has to be down to local NHS organisations to take the operational and planning decisions to ensure that services run effectively over winter, but obviously I want to be assured that the health department is monitoring the service across the country as effectively as possible. The report made some recommendations applying to the department, and they are being taken forward. In addition, as part of the overall departmental review and reorganisation over the summer, a number of changes have been made to the department's structure and performance management processes. Gerry Marr is the director of that operation and he would be happy to comment further.
In allocating additional investment to the service this year, we have not only identified planning for winter and other peak pressures as one of the priorities, but required each health board to set out how it plans to target investment to change. As I indicated, the emphasis has been not just on how health boards spend the money, but on what they achieve through spending the additional resources. A key element that we have assessed in looking at their plans for winter is how effectively they have worked in partnership with other organisations, because, as the report highlights, one of the keys to having effective service delivery in winter, as at other times of the year, is to have the whole system working together effectively. All too often, it is where that does not happen that patients are let down.
On performance management, in some areas—you will forgive me if I use Ayrshire and Arran as an example—good work was undertaken with rapid response teams, but those teams have not been stood down; they have continued throughout the year. However, on occasion, elective procedures have been cancelled because of the pressure on beds. That situation is replicated throughout Scotland. To say that a board has done badly because of that pressure is not performance management. We have not identified the fundamental difficulty. Perhaps Gerry Marr has some idea up his sleeve that he has not shared with the service.
It is time to pull out that rabbit, Gerry.
He is good at that.
Gerry Marr (Scottish Executive Health Department):
We have taken the report of the winter performance group and created a template that will, in effect, be an action plan that each health board must submit to us. We are asking specific questions about what the boards are doing at each level of the service—for example, in primary care and rapid response teams. What are they doing about the capacity of their intensive treatment units? What are the intended increases in the number of staff and bed capacity over the winter months? What is the planned elective reduction? In the past, there have been debates over the fact that the reduction has been unplanned. Health boards have been asked, "We accept that, at some times of the year, pressure will mean that elective admissions have to be stood down, but what will the reductions be?" More important, how are the health boards conversing with patients? Our expectation is that, within 28 days of a cancelled admission, patients will be given a guarantee of admission. Those are only some aspects, but the report is specific.
I have convened a winter planning panel, which, in the past fortnight, has assessed the action plans. We are writing to boards to ask them for more information, and in particular for quantifiable data with which we can measure their performance. In the department, we have put in place an escalating monitoring process, so that we receive information when something is going wrong. Everyone will be on weekly reporting from the beginning of December. However, if we begin to see evidence of an increase in bedblocking, failure to access intensive care units or failure to manage transfers between intensive care and other units, we will escalate the monitoring within the department. If necessary, at any point during the winter, members of the winter panel will go to local health board areas to scrutinise and try to understand better precisely what is going on.
By the end of the winter, we will want to understand what, given the pressures, is a good NHS performance in the winter for the people of Scotland and how we achieve that. By next year, we will have learned the lessons of this year, if there is anything to be learned. That will further improve the process.
Some of my questions about monitoring have already been answered. Witnesses talked about the winter pressures sub-group. Is the minister aware of pressures on beds, which have started somewhat early? Health board responses show that they are already experiencing pressures. Does the minister or the winter pressures group have any plans that will start to deal with those pressures now?
I am bound to say, almost as a common-sense statement, that pressures on the NHS in Scotland arise throughout the year. The winter performance group identified that fact. Many things happen in the winter that are not functions of winter. Margaret Jamieson's question alluded to the many special actions and efforts that are taken over the winter but are applicable 52 weeks of the year. There are always pressures and demands to be managed in a big and complex system such as the NHS. Patterns of illness and infection will impact on the system at different times of the year. That was shown particularly profoundly during last winter.
We have provided increased investment that is targeted towards meeting local needs and there is increased drive, energy and effort to put in place the policy framework to enable people to plan effectively. The winter planning report to which I referred is part of that, and monitoring processes will enable us to assess that work more effectively.
Our discussion about winter often focuses on beds—even the heading for the committee's agenda item reflects that concern. As the winter performance group's report identifies, the only way in which we can understand the effect of winter and improve services is by examining all the steps in the patient pathway. On page 9 of its report, the winter performance group identifies six steps: the prevention of illness, avoidable admission, primary care, emergency admission, critical care and discharge. In the past year, each of those steps has been the subject of considerable effort, discussion, joint working, identification of best practice and targeted investment. I am pleased that those processes have involved a range of professionals and parts of the service in a way they have not been before.
I therefore believe that there has been better planning and preparation than before. There has been significant additional targeted investment and it is now for all parts of the NHS and its partners in local authorities, the voluntary sector and elsewhere to ensure that that investment is put to good use and that policy is translated into practice to respond to the pressures effectively. Local management must do that, and do it responsively. We can provide the investment and the policy framework, but services must be responsive locally to deal with the peaks that Ben Wallace described.
I recognise that point, but given some of the good work or proposed work of the winter sub-group, including how it will be able to step in, monitor or assist, do you have centrally held funds that may be drawn on as back-up in an emergency? If so, are we allowed to know the amount of those funds and the criteria that will be applied in awarding them?
Investment in winter services requires to be made before winter, not in winter. That is the basis on which we have released resources to the health service during the financial year. First, £60 million was allocated to health boards in July, and two key priorities in the allocation of that resource were preparation for winter and the reduction of delayed discharge, which is an important part of providing winter services.
Secondly, £10 million was released to local authorities to tackle the continuing problem of delayed discharge, and a comparable planning process has been put in place by local authorities. They have planned ahead and set out how they will channel that investment to tackle delayed discharge. Thirdly, more than £10 million has been spent on the overall flu immunisation programme, covering both the vaccine, the administration of the vaccination programme—through GPs in the communities—and a national awareness campaign.
Investment has been made throughout the year, to enable planning and preparation to be carried out. Such planning and preparation cannot be undertaken during the winter: it has to be done in advance.
Last month, Grampian Health Board tried to use its winter pressure funds early, from the money that was granted in July. It needed to access those funds due to an increase in bed pressure in October. As that health board was seeking to use some of that extra money early, it could find itself with a shortfall at the end of the winter period. How do you define the winter period, at which the money for the management of beds is specifically targeted? Where does it begin and end? Why do some health boards view it as beginning in the middle of November and ending at the end of February?
I invite Gerry Marr to address that specific point.
I am surprised by Ben Wallace's comment and I would be happy to clarify Grampian Health Board's situation on his behalf.
The £60 million allocation, which included money to ease winter pressures, was made in July. Once that money was released, it was up to local health boards to determine when and how they wanted to spend it. I reassure Ben Wallace that we have not put an arbitrary date on the beginning of the winter period.
That would be a dangerous thing to do in Scotland.
Absolutely. I would be happy to clarify Grampian Health Board's situation outwith this committee.
I was happy to hear Gerry Marr say earlier that there will be weekly monitoring from the beginning of December. First, can he or the minister confirm that bed managers—winter pressure managers, or whatever they are called in different parts of the country—are now in place in all NHS trusts?
Secondly, are you aware that there is concern in some accident and emergency wards in Scotland—especially in ward 29 of Glasgow royal infirmary—about pressure to send patients to other types of ward, which the staff think are unsuitable for those patients, because of the expected winter problems?
Thirdly, as Richard Simpson's report points out, there is an extremely low service uptake among the high-risk group of under-65s who are vulnerable because they are bronchial or heart cases. Anecdotally, Richard said that that uptake might be as low as 20 per cent. Can you please give me your thoughts on that?
I shall address Dorothy Grace-Elder's point on the flu immunisation programme and Gerry can comment on the accident and emergency issues that she raised.
I have read Richard Simpson's report carefully, and officials are examining it at the moment. It will help to inform our work in this area. As the report recognises, we have put in place a range of measures to maximise take-up of the vaccine from those considered to be at greatest risk. As Dorothy-Grace Elder said, people under 65 but with chronic conditions are a key group. That is why the immunisation programme is carried out at local level, through GPs. Particularly with the group to which I have referred, GPs are best placed to identify which individuals would benefit and to decide whether it is clinically appropriate for them to get the vaccine.
This year we have put in place a new incentive payment arrangement for GPs, not least because of the decision to lower the age limit, which generates considerable additional pressures on them. We hope that that will generate wider benefits and increase take-up. We have agreed with representatives of the British Medical Association that we are aiming for a 60 per cent take-up. That is the target that people are working towards. National awareness raising is part of that, and so is local awareness raising. Efforts at local GP practice level to write to specific individuals with these conditions are a part of it.
The new arrangement for carrying out the immunisation programme will also deliver better monitoring and better data for the future. One of the things that became clear when we delved into this issue this year—again, this is in Richard Simpson's report—is that the data that we have for the past are quite limited. We are on a cycle of continuous improvement. I hope that after this winter, as well as having increased take-up, we will have better data to tell us what the level of take-up has been.
Have bed managers now been appointed in all NHS trusts?
I do not have the precise information to hand, but I can confirm that the plans that health boards have to submit must indicate precisely how they intend to undertake bed management. I have read most of the reports and many boards have confirmed that they have dedicated bed managers. If they do not, they must have something that we are satisfied will result in effective bed management.
Boards also have to confirm their plans for the management of accident and emergency. Glasgow royal infirmary, which I have visited in the past, has been mentioned. Our objective is that there should be dedicated teams on emergency call, that geriatricians should join acute receiving ward rounds, that those ward rounds should take place in the evening as well as in the morning and that early decisions should be made about triaging and treating patients in appropriate wards. Glasgow royal infirmary's scheme, which has now been in operation for a couple of years, is an example of the best practice that we are encouraging in other accident and emergency departments. That does not mean that there are not pressures on any part of the system.
I should declare an interest in this area—I am still a director of a nursing home company, albeit in England. This winter, will we use all the resources that are available to us? There are serious concerns about delayed discharges. I know that £10 million has been released to deal with delayed discharges and that that is one of the priorities in the use of the £60 million that was mentioned, but because we have had quite a bad summer, there is an impression that delayed discharges are still a big issue. Are you putting in place plans to use nursing home capacity effectively, where it exists—I know that in Lothian there is none—while you are improving the joint arrangements? Will we release those beds before we start to run into problems in the winter?
I am bound to say that that matter would be addressed at a local level. We have sought to make resources available to the local health and social care systems so that they can use investment in the most effective way.
Is there a monitoring system? We know that, inevitably, capacity in the system is limited and cannot be changed overnight. Given that fact, will we use the total capacity? As part of the monitoring system, if the bed occupancy in the nursing home sector or the residential care sector is 83 or 84 per cent, will we say that that could be pushed to 90 or 95 per cent? Will we require health boards to tell homes to use all their capacity?
The first national census on bedblocking, which I understand will be published next month, is set to show that in some areas 10 per cent of hospital beds are occupied by patients who have nowhere else to go. Local authorities are saying that the resources the Executive is allocating to them will address only about 25 per cent of the waiting list for nursing home care beds. Where do people go when they are not admitted to hospital because they are regarded as inappropriate admissions or when they are discharged although no care home place is available for them and their care needs are such that they cannot stay at home?
It is important to address the many dimensions of the complex issue of delayed discharge, which has blighted the health and social care system for many years. The Executive has targeted not just investment at this area, but significant effort to get behind the issue and identify the causes of delayed discharge. Investment and funding is only one part of the picture. Some cases are delayed while the local authority identifies the funds that are required. Some are delayed because the patient's house needs to be adapted to meet their changing needs. That is why the additional £5 million that I announced before the recess for aids and adaptations is important. Other cases occur because the patient needs to move to a ground-floor property, patient transport is an issue, or the patient and the family disagree about whether the patient should be discharged and where they should go.
Shona Robison referred to the census. The package of work that we have been doing on delayed discharge has been designed not just to quantify the scale of the problem more accurately but to identify possible solutions to the problem. We have identified 42 causes of delayed discharge. I stress that we want not just to count the causes, but to cure the problem. There is a complex tapestry of things that need to be done to achieve that. We have made an investment but we have made it clear to the health and social care systems that for that investment to be effective they have to work together and provide services that are focused on patients' needs.
The work that has been done by the joint futures group and the joint meetings that we have held with local leaders and managers of the NHS and local authorities are all a part of that. Effective planning, discharge management and communication between different parts of the system are just as important as investment. I take Shona Robison's point about the significance of delayed discharge. It is a profound problem, not just for the system, but crucially for the individuals who suffer as a consequence of it. In addition to extra investment in the system, we need step changes in ways of working to resolve this issue. This is a 25-year-old issue; we reckon that the solution will take between two and five years. We have embarked on that course and will continue to tackle the issue.
I will take one final question on this section, but I am aware that there are several members who have a series of questions for which we have not had time today. Is it acceptable that we send you those questions in writing for—hopefully—a speedy response before the winter sets in?
Certainly.
Are you satisfied that there are adequate supplies of the flu vaccine for everyone in the recommended category and all those who request it?
I am satisfied that the total number of vaccine doses that have been ordered and made available for Scotland is more than sufficient to meet total need and am concerned that there have been suggestions to the contrary in the press. That said, I should stress that, in a very large and complex immunisation programme, there will always be logistical issues at a local level. For example, supplies might not reach GP practices precisely when they were expecting them and we are very actively monitoring such distribution and supply arrangements.
However, our confidence that sufficient overall supplies of vaccine are available has been reinforced by representatives of the pharmaceutical profession. We continue to monitor the situation closely.
If members have any questions on this matter that they have not been able to ask, they can e-mail them to the clerks for tomorrow so that they can be sent to the minister's office as quickly as possible.
Minister, I am aware that I did not allow you to have an opening statement on that section. That was an oversight; however, I think that we managed to cover many areas of continuing concern. In light of Dr Richard Simpson's work and the winter planning that has already been undertaken, the committee will also acknowledge that, although this is a very big issue, the Executive has started to find ways through it. The issue is complex and involves a range of people across the health and social services sectors, from community pharmacists to people on the wards. I am quite keen for staff to be immunised and hope that the minister, as a key front-line worker, will do the same.