Official Report 247KB pdf
Good afternoon. We will continue to look at the national review of resource allocation. With us we have representatives from the Royal College of Nursing: Margaret Pullin, Sheena Cochrane and Sian Kiely.
Thank you for inviting us to give evidence. The RCN has extensive expertise in its membership so I have brought with me Sheena Cochrane, who until last month was a community manager in Renfrewshire and Inverclyde and has now been appointed manager of the local health care co-operative in Inverclyde. She has extensive experience in rural and remote areas. Sian Kiely is our research and information officer and is brilliant with figures. If you need information that we do not have here, she will be able to get you the answers by the end of the day.
Your points that 80 per cent of care is being delivered by nurses and that often they, and others, think of themselves as being invisible were well made. I hope that the Health and Community Care Committee will never think of Scotland's nurses as being invisible. We should always ensure that we recognise the great work that you all do.
The obvious person to answer that question is Sheena.
Nurses who work in remote areas must possess numerous skills: they must be midwives, district nurses and health visitors. As you rightly said, often they must deal with certain types of emergency treatments—not medical treatments, but nursing treatments. Many of those nurses have extensive skills that they require to undertake their duties. To acquire those skills, they require extra training, which can be costly. In remote areas, they are often the first or only point of contact and they work in a triage manner to ensure that patients receive the most appropriate type of treatment.
The problem is in the depths of my bag.
Sorry. Kay has a portable personal appliance in her bag. Please continue, Sheena.
To recap, if I am a nurse in Glasgow who needs to undertake training in Edinburgh, I may need to take a day off work to receive that training. However, if I live in a remote area or on an island, the costs are very different. First, there are travelling costs: it may take a day to travel, it may then take a day to undertake the training, and there are accommodation costs. There are also extra allowances to pay to individual nurses who are away from their homes for a certain length of time, and there are replacement costs for those nurses while they are receiving the training. In an urban area there are normally colleagues who possess the skills to cover for them while they are away; in remote areas an experienced nurse may have to be brought in to deputise for that individual, which again implies a great cost. If we want such nurses to be skilled, we must ensure that they have training to underpin all that.
Do you feel that the report has taken into account all those extra needs in rural areas? Has it considered them differently from the way in which they were considered in the past, through SHARE, recognising that it is not just a question of the distance from a GP's practice, but that there is much more to it?
Absolutely. It is nothing to do with distance; it is about travel and the time that it takes. The other thing to remember is that not all nurses are GP-attached; they do all work in GP surgeries or practices. In rural areas they generally work in a geographical location that may cover three, four or five GP practices. The time that it takes to cover those distances is a real issue.
I ask for clarification. Your response says:
I am not sure how that can be done unless something were to be put in the formula that would ensure that. I gather from the report that the allowances are given to the health board, which, in turn, distributes them.
There is no mechanism of which you are aware?
I am not sure. There is a possibility of ring-fencing. That is not always a terribly good thing, and can be counterproductive. I would hesitate to say that the allowance should be ring-fenced, and I would expect the health boards to receive sufficient guidance to recognise the risk.
My second question relates to that. I was taken with your suggestion, in paragraph 6.3 of your response, concerning the local health care co-operatives. As you say there, the Arbuthnott report was not considering the stage after the allocation of moneys; the spending priorities must be set. That is something that this committee can take on as a recommendation, and I think that we should examine that.
In the information that is available there is some very good evidence from nursing, in particular from district nursing and health visiting. The data have been collected on the number of home visits and the number of people that each health visitor and district nurse visits in a year, for example.
It is worth noting that education departments recognise the importance of such assessments and are undertaking to provide special courses on them for nurses. Many nurses who trained a number of years ago might not have those skills. Most universities are now providing such courses for nurses and especially for nurses such as health visitors, district nurses, school nurses and practice nurses.
You indicated that you would expect guidelines to be issued to health boards on allocation of nurse education. Are guidelines sufficient? We know that some health boards are better than others at allocating resources to individual trusts for provision of nurse education. I cite specifically the provision of conversion courses for enrolled nurses, for which some health boards have allocated nothing. I am concerned that you have said that guidelines would be enough, given that doctors in post-graduate education have a well-defined role and that the same is not true of nurse education.
As I have said, I would be very wary of saying to health boards that they must ring-fence funding for that.
I am not suggesting that.
Perhaps I was being diplomatic in using the word guidelines. I agree that we need something stronger than guidelines.
Are you happy that we should tell health boards that they have an obligation to ensure that they provide the facility to do that, as each nurse has an obligation to ensure that her practice is up to date?
I see nothing wrong with that.
I am delighted that in your paper you mentioned the nurse-led service that is based in Nairn. I would like to commend that service and to say that Dr Alistair Noble is absolutely first class.
Nurses have been doing that for a long time in their own ways. There is an example of that in Inverclyde, where I work. I am sure that all members of the committee are aware of the problems in that area, one of which is the serious problem of mothers who have dependency problems and who have children under five. The health visitors in the area have started to set up groups to tackle that problem. Nurses are already doing the work to which you referred.
The work of nurses in health promotion and health education can involve examining the multiple circumstances associated with deprivation—diet, drug issues, alcohol—and the housing and social circumstances of patients. They can provide that link in health promotion and health education activities.
Do you think that there would have to be a fairly hefty shift from secondary to primary care to achieve the benefits that you mentioned?
I would love to see some sort of shift. It does not matter where one works in the health service, one feels that one does not have enough. Everyone would agree that there has been a great shift from secondary to primary care over the past few years, as a result of early discharge, day surgery and so on. Much more work is being carried out in primary care services, not only by community nurses but by GPs and others. I welcome any shift in that direction.
Do you think that more needs to be done?
I would like to see more being done, as we are looking at ways to prevent disease. Disease prevention is the way forward; primary care will facilitate that.
Thank you.
One of the problems with the lack of data from the community services and so on is that the review has almost stopped, rather than taking us in the direction of greater use of primary care and care in the community. Those are areas in which nursing is at the forefront, whereas, to a large extent, most of the data that are already there are from the acute services. That issue has been brought up in many of the submissions that we have received so far. Community services can be developed in future if we have that extra data.
I would like you to consider the model that was developed for the maternity services programme of care. I draw your attention to the fact that the model appears to reveal two significant life circumstance variables: the percentage of people in non-self-contained housing and the percentage of children in lone-parent households. I invite you to consider whether, based on your experience, there might be other useful indicators in determining the relative need for maternity services.
I agree. One of the most obvious indicators is substance abuse, while the age of the mother is also relevant. I am sure that employment has a significant impact.
That would increase the work load and the need for services in a particular area.
Absolutely. Social isolation and family support all come into it.
Is there any evidence that the distribution of funds within a health board reflects those inequalities? When the trusts and the board are drawing up their budgets and deciding how to spend money on allocating staff and so on, is there a transparent mechanism in respect of the inequalities that the report is so intent on dealing with?
The Accounts Commission for Scotland published a report this month on acute mental health services for adults. In that report, evidence is brought together that looks at whether the current provision highlights inequalities, as you suggest. What the report has found regarding mental health services is that the distribution of resources in health board areas often follows the historical pattern of service provision. Mental health services have continued to be provided on the hospital model, while acute services have been provided differently. In that instance, it is highlighted that distribution has not been based on unequal need or on inequalities, but rather on historical perspective.
Is it your estimation that that is true of other community services—that they are based on a historical perspective of the way in which primary care and community service have grown up, rather than actually identifying inequalities and the needs associated with them?
Reflecting on other areas of health care, particularly in the community, it may be that that is being replicated for certain areas of health care. Again, that could be dependent on previous decisions on the provision of funds. There is now more recognition of issues of deprivation and social inclusion and of the way in which many health professionals can intervene positively on lifestyle issues and in clients' and patients' lives. We suggest that the new awareness of social inclusion and deprivation makes this a good time to reassess the current distribution of care, as the report suggests.
I have one further question, which is on the formula for determining nurses' work load. Has there been any attempt to include some of the social, economic and deprivation factors that were identified by the Arbuthnott report in generating a work-load estimate?
At present, most trusts are using historical work-load patterns or data, which are outdated. There has been some innovative work. There is a Glasgow model from a few years ago that people have been using, but they recognise that it needs updating. The Arbuthnott report is being examined in terms of new work-load models for nursing. I think that the Lanarkshire Health Board was involved in something, but I am not sure of the model.
Would it be true to say that, in general, you are fairly happy with the redistribution that has been recommended and that your main concern is that the money should be spent appropriately, in line with the new priorities? Reading between the lines, that is what you seem to be saying. I welcome your suggestion that members of the Scottish Parliament should be involved in holding health boards to account. Perhaps we should try that on the minister tomorrow. [Laughter.] I also welcome your suggestion for more of a role for district nurses and for community psychiatric nurses.
Local health care co-operatives are an ideal opportunity to involve everyone working on health needs in an area. For example, in the LHCC with which I am involved, there are representatives from GPs, community nurses, pharmacists, the social work department, housing, partnership agencies, the local health council and others—it is not only purely health individuals who are involved. One of the things that our co-op is doing—I am sure that other co-ops are of a similar mind—is looking at health needs by getting views from local communities. At present, that is being done via partnership and focus groups.
Thanks. I am sure that we will follow that up, either now or in our future work. However, I want to return to my original point. In general, would it be true to say that you do not have any substantial concerns about the methodology and conclusions of the Arbuthnott report?
With any report, there is room for criticism. However, we are reasonably comfortable with the general principle of what is being proposed.
You said in your submission that, ideally, LHCCs should be compatible with the geographical areas that are covered by local authorities. However, sometimes local authority areas straddle every social class. That can make things difficult, because if the majority of individuals in a local health care co-operative are from one part of the area, they may not have information about the whole area. How do you think that we should ensure that everybody's views and life circumstances are represented in LHCCs?
That is not an easy problem to deal with because, as you say, local authority areas are very diverse. I think that the solution is to get the right people on the LHCCs or, rather, the sub-groups of the LHCCs. We need to have patient representatives. It is difficult for professionals to include patients, but we are making progress on that. There are mechanisms to involve patients, such as audits and questionnaires, as well as one-to-one conversations. People also write in with complaints—we may not like that, but we can learn from it. Representation needs to be as wide as possible, and patients need to be more involved. This is not about what we as professionals believe is required, but about what the patient feels is important.
I am interested in the welfare of the nurses as a factor in the well-being of patients. Before I go on, could anyone update me on the current so-called wastage, both in training and in the early years of service, when many nurses drop out for various reasons? Apart from the old enemy—back problems—the reasons for that nowadays include violent patients and even problems that could be more easily tackled, such as needlestick injuries.
Margaret, I must stop you before you answer. Dorothy, are you deliberately trying me today?
No. Honestly, convener, I think that my question is relevant. If we are wasting time and money—
Dorothy, we could have Margaret and the other representatives of the RCN here all day to talk about all aspects of nursing, and that would be very interesting. However, our remit today is to talk to them about the Arbuthnott review. You have had an opportunity to ask your question, and at some later date Margaret may want to respond to you in writing. However, at this point we should stick to the Arbuthnott review.
It might, therefore, also be irrelevant to ask about the impact of agency nursing and whether that is the most efficient way of providing the service. However, I regard that as relevant to the Arbuthnott report and to health funding.
I will rule that as irrelevant and move on to Kay.
Margaret, I must apologise to you and your colleagues for having to leave in the middle of your presentation. As a Luddite by nature, I should never have allowed myself to be hooked up to new technology.
We had an interesting discussion about that. I think that Sian will be able to answer that question—she has a head for methodology.
In our response, we indicated that we did not want any area to be disadvantaged. We hope that, in the redistribution and allocation of resources, there will be differential growth between health boards to ensure that the percentage increases and decreases can be accommodated so that no health board or geographical area will have a real-terms loss in income.
Thank you for that answer. We have to accept that, if the cuts are spread over four years, they may be slightly less painful. However, if there is no new money, the same pot will be available and there will be losers as well as winners. I go along with your sentiments; we must start to address the link between poverty and ill health, and Arbuthnott is a small step in the right direction.
Your submission is very much about welcoming this and welcoming that—it is very complimentary. I would have liked a more rigorous analysis. In addressing deprivation and inequality, what is your wish list? What would you like nurses to do to address those issues? I know that similar questions have been asked, but I do not feel that we have got to the heart of your contribution to those areas.
Our organisation has 33,000 members in Scotland, who have great skills and expertise as well as the willingness and ability to address all the major concerns. Nurses want to do that, have the skills to do it and would like to be assisted in doing it.
How would you take the lead?
Perhaps I can give some examples. Nurses are working in many areas of the health service and there are specialist nurses with particular skills. For example, diabetes nurses undertake special health-needs assessments of patients and can advise on lifestyle and diet to help them with their condition. Incontinence nurses can help 70 per cent of patients with incontinence problems to live an active and enjoyable life by providing nursing care to limit their incontinence problems. In leg ulcer care, appropriate nursing care can reduce the pain and discomfort suffered by the patient. Specialist nursing is a cost-effective way of providing health care.
Health visitors would like to have a more important role in the future. Many local health care co-operatives have supported the health visiting aspect of community nursing, but it will require greater funding. Health visitors are very much to the fore in working with deprived communities. We need to identify the people who have the time—away from a case-load scenario—to undertake research into that type of work, forging the necessary links and developing the service. Health visitors dealing with public health issues could help with a lot of the problems that are related to deprivation.
In paragraph 4.4 of your submission to the committee, you make the point that the new formula does not take into account forms of nursing in rural areas other than the ones attached to a GP practice. What percentage of services does that account for in rural areas?
Nurses who are attached to GP practices might be practice nurses, district nurses and health visitors. Community nurses can also include community psychiatric nurses, community children's nurses and nurses working with clients with learning disabilities. The percentage that that would account for varies geographically and in relation to the population covered by the GP surgery. Rather than give you an isolated statistic, I would say that the proportion would vary on the basis of population and the provision of services that the primary health care trust and the surgery provide in that area.
The point is that if—as you have said—that is unsatisfactory at the moment, how would you correct the formula?
The current formula relates to the distance that a patient lives from the GP's surgery; to amend that formula we would need to consider the nursing services that are not tied to the GP surgery, but based in the community. We need to consider more than where the patient lives; we must take into account the overall provision of community services within a patient's local area.
Would you like to take some form of mean measurement of the extra mileage used by nurses outwith that sort of practice? It is all very well to say that there is a problem with the formula, but the difficulty in Arbuthnott is to reach some form of standardisation.
One issue that I would highlight is the time involved in visiting and caring for the patient and travelling between patients. It takes particular, professional skills to undertake such care.
Thank you.
I would like to thank the RCN for making an oral contribution, as well as for giving us a written report. No doubt its representatives will return to discuss the 80 per cent of care that is delivered by nurses.
Thank you very much indeed.
We will have a short break before we take evidence from the Scottish Association of Health Councils. The meeting will resume at 14:55.
Meeting suspended.
On resuming—
At the risk of starting a new trend, let us start on time. Next in the hot seat is Pat Dawson from the Scottish Association of Health Councils. I welcome her to the Health and Community Care Committee.
Thank you very much, convener and members of the committee. On behalf of the health councils in Scotland, I want to say how pleased we are to have been invited along today. I wish it had been to talk about something that was easier to digest and on which I could make more value judgments.
Hear, hear.
Perhaps some committee members share that view—who knows?
Thank you. It is excellent that you have come to give us the patient's point of view. We want to make use of the Arbuthnott review and all the evidence presented to the committee to improve patient care. That is at the centre of our work.
First, I would like to thank you for a radical and refreshing submission. You have made suggestions that other people have not—yours is the only body to have raised the fundamental and thought-provoking question of health boards.
In September, a motion on equity in health care provision came before our association's annual general meeting. An interesting debate followed, in which many people agreed that it is a fundamental principle and a desirable aim that we must all try to achieve. However, because of the wording of the resolution rather than because the issue is not important, some people said, "Wait a minute. Our health board is already delivering a range of patient-care services to a higher standard than is being delivered in other health board areas." When the issues were analysed further, people began to ask how we could get to a position in which equity is an issue that is rounded up for rather than rounded down for, and how we could ensure that patient care is not lost or lessened because of the issue of equity.
I would like to clarify what you are driving at. You suggested that perhaps the current boundaries or the current shape of the health service might not be the critical mass that we need for the future. Are you beginning to question whether health boards per se are the right type of organisation to distribute health funds and to be accountable for them, given your suggestions about partnership delivery of care programmes?
I thought that you were going to go on to ask another question.
Depending on your response to the first question, I may go on to ask another.
I am not sure that it is entirely related to Arbuthnott but, as you have raised the question, I must answer—
Allow me to explain why I think that it is relevant. One of the themes that we have heard consistently in our discussions concerns the difficulty of tackling inequalities of health provision. In your submission, you have touched on the complexity of the situation, and we cannot be unaware that a range of factors is involved in tackling health inequality. One thing that comes across very clearly is that, to tackle health inequality, we must consider poverty and the issues that surround it. Kay mentioned that earlier.
The conclusions from the acute services review on which I served were that there are large areas in which the acute care planning structures that we currently have need to be at higher levels than that of the health board. There are only a couple of health boards in Scotland that have the required critical mass in terms of the functionality of their hospitals, their range of specialties and all the rest of it. You could argue that, for acute hospital services in Scotland, the current number of health boards could be reduced.
You seem to be suggesting that there is potential for a certain part of the health budget to be allocated and managed at a higher level—either at Scottish or sub-Scottish level. At patient-care level, the service needs to be integrated with and more accountable to other services. Are you suggesting that if the health budget was split, with one central service responsible for some of the acute services, that the rest would be more easily integrated with local authority care services?
I think that that is entirely likely.
That resource allocation is perhaps something about which this committee needs to put down a marker. I do not think that we would have the time to tease that through to a conclusion.
The question, whether one formula fits all, was asked earlier. Can there be one formula that delivers for people in remote areas and for people in deprived areas? That can be turned on its head, and we can ask whether one formula for health care will ever deliver what we want, or whether we need greater integration so that the formula takes into account social work and care in the community and all the other things.
When you take evidence on community care, and when you look at areas where there is good practice—where seamless care is delivered and where there is integration of services—I suspect that one of the crucial findings will be the importance of joined-up budgets, where people with different hats work together in a common accountability framework to a common end, which is to meet patient-driven need.
I welcome this outbreak of radicalism that is sweeping the Health and Community Care Committee. Who will man the barricades?
I think that you heard some radicalism this morning when Professor Graham Watt talked about the end of the microscope that you were looking down. He suggested that the wrong question was being answered. My view is that the wrong question has been asked of Arbuthnott. I would have extended the scope of the review. I would have asked, "If we cannot come up with a resource allocation through care programmes, why are we not going back to the people who set the scope to tell them that within that scope we cannot answer the question?" I would have asked to have the scope extended.
The next part of your submission addresses the acute services review, which has already been referred to this morning. One of the terms of reference for that review was that it would not be constrained by the existing construct. Presumably, if there is to be a standing or an ad hoc body, that remit would be a more appropriate one for it?
The questions that we have asked about whether health board boundaries decrease or increase inequalities are fair ones.
You talked about reducing the number of health boards. What is your view on having trusts funded centrally? On the matter of integrated, seamless care, do you think that one budget is sufficient? If not, how would you see that care being achieved? You emphasised the issue of unmet need. Can you expand on that?
Before Pat expands on that, I should say that the first part of your comments strayed from our remit, but I will be kind. If Pat Dawson wants to answer, that is fine. The issue of unmet need is well within our remit.
Direct funding of trusts is an option if health boards are scrutinised. I am not suggesting that that would be the only way of providing funding, but it is one possibility. However, assumptions would have to be made about whether our current trust structure supports equitable health care with regard to geography and other factors. Because of the need for accountability, one issue cannot be addressed without addressing the other.
Your submission queries the idea that one solution fits all and makes some good points on that, particularly in relation to island communities, posing very relevant questions about transport and travelling costs. That is not just a problem for island communities. We spoke this morning about centres of excellence and how people have to travel to get good care. A lot of patient transport costs are absorbed by the voluntary sector. Is that something that you feel applies more widely, or just in island communities?
There is a patient travel scheme in the Highlands and Islands. People are paid travel costs for themselves and someone to accompany them if they travel more than 30 miles to a hospital. I do not know where that fits into Arbuthnott—the question needs to be asked. The scheme also applies in areas in Argyll and Clyde and to some, but not many, areas in Grampian.
There is a big issue there about hidden costs. I do not see it in the report and I know voluntary organisations in my area are bearing the burden. We do not have some services locally in Ayrshire, so patients travel to Glasgow, which is a 25 to 30 mile journey. Some voluntary organisations are being put out of business, which is having an effect on patient care and transport.
Far be it from me to suggest something to one of our sub-groups—I cannot remember who is on our sub-group on access to services, but would they like to consider the hidden costs of patient transport? They do not have to make any suggestions, but they could ascertain whether this is an issue that the committee should address. I think that Pat has raised some very important points.
I have a supplementary on this issue. One concern that I have, Pat—I am interested in whether you share it—is that the acute services review, with its apparent, quite rational, centralisation of some services, will affect the rurality element in this report and has not been taken into account. That is fair enough, because the review was based on current or historical need, but are you concerned that the formula is out of date before it is implemented, because of the acute services review?
You have picked a difficult example, because paediatric cardiac services are commissioned centrally, through the national services division. As I understand it, the costs are not borne by Lothian Health. Your question would have to apply to acute services where major rationalisation will take place as a result of the acute services review, and there are very few of those.
Before I ask Dorothy to speak, I would like to welcome the party of young people from Boroughmuir High School who are with us. I hope that you will find what we are talking about interesting. We are discussing how we can allocate resources to ensure that people have equal access to care.
Pat, I agree with you about the extraordinary complexity of this document. It is difficult for informed stakeholders on health councils to understand it—never mind patients. Busy hospitals are unlikely to have time to comprehend the document while they are trying to implement it.
Pat, the first question was about transparency and the complexity of the report.
No, convener, I was agreeing with her on that. The point was that the message was being delivered to politicians that patients did not want market-driven or two-tier services in the NHS.
Do you want to answer that, Pat?
It is safe to say that the idea of a market-driven service, involving consumerism, purchasing and fundholding, did not go down well with the Scottish public. Nor did they like the effects of that. They do not want people to get better services depending on where they live, the colour of their skin or any other determinant. Recently, we have heard how gender can affect access to coronary artery bypass grafting. We have to ensure that our service is equitable in terms of resource allocation and in the view of the Scottish public.
I think that, earlier, you asked, "What is this achieving?" in relation to the rather small sum of money that is merely being redistributed. Were you criticising the original remit of the report and, if so, what is wrong with it?
I would have liked to ask the Arbuthnott committee why it did not see fit to question people about the structures to which they were giving money, whether they were suitable and why they did not come back at any stage to the people who set the scope of the remit to challenge that remit and look instead at more innovative ways to deliver equitable health care and social inclusion strategies, joining up different strands of Government policy. None of those questions seems to have been asked. There seems to be an assumption that a medical, scientific and statistical model is driving the report.
Would you have liked them to ask why we could not recommend larger sums of money? [Laughter.] No, I mean it—would you?
That is a motherhood-and-apple-pie question—and it has already been asked three times. I think that we will have a final point from John.
This may be a difficult issue to consider, but your initial comments on the transparency of the formula suggested that you might have ways of identifying the steps that could be taken to reduce the extent to which people are disenfranchised by such a complex formula. Do you have any suggestions as to what steps could be taken?
Compared with the implementation of "Designed to Care: Renewing the National Health Service in Scotland", we have spent more time today debating health policy in Scotland than we have ever spent in the past. We have made a huge advance today by talking in public with school children, members of the public and the media present. We hope that the message is starting to go out.
Thank you, Pat. We all learned a great deal from that and we will raise some of those matters with the Minister for Health and Community Care tomorrow. I am sure that you will return to talk to us on many other issues.
Meeting suspended.
On resuming—
We move on to our penultimate contribution of the day. I welcome Pat Frost from the NHS Confederation to the Health and Community Care Committee. Pat, could you give us a general contribution to start with? We will follow that up with questions.
Thank you, convener.
Is there a general consensus among the bodies that you represent that there was a need for such a review to be undertaken?
Definitely.
Given that response, do those bodies accept that the methodology employed by Arbuthnott was rigorous and acceptable? Notwithstanding that there will be winners and losers, as Kay Ullrich said, is there a general acceptance of Arbuthnott's recommendations? We have heard from a number of witnesses today that this should be only the first step, but what is the view of your members about where we should go after this phase?
I will try to tackle all those questions, but perhaps you will come back to me if my answers do not capture them all.
There seems to be a recurring theme today: one size does not fit all. In your submission, you mentioned that there is
There are a couple of points. The effect of small numbers is important because of the disproportionate effect that population changes can have. When the members of the Shetland team give evidence, they will tell you that if a forces base moves from Shetland—200 people with young families—Shetland could, in theory, lose 1 per cent of the budget, although there are other layers to the formula that act as a safety net. In a small place, that is not realistic. The robustness of the formula for very small populations needs to be tested. That may reflect one of the issues that the Arbuthnott committee considered. The report says throughout that the formula was intended to work only at a macro-population level.
As for testing, would you want the committee to say that some of these allocations are wrong? To do that, we would have to go back to the methodology and we will not do that as a committee. I am curious as to what exactly you expect the committee to do about this, apart from just flag it up.
Flag it up, but in such a way that it shows that the effect on the ground is not feasible. It was not the Arbuthnott committee's intention that the proposals should be implemented without further detailed work, particularly on their impact. Is there enough cognisance of the problems in rural areas and do the proposals do enough for urban deprivation? There is anxiety that something will be implemented simply because it is in print, so I make a plea for further scrutiny of the proposals.
Do you have a view on what should happen about the long-term monitoring and review of the process? Some people have said that there should be a standing body looking at this, rather than an ad hoc review as and when people decide that they want one. If there were a standing group, new data could be looked at all the time.
The view of the membership of the Scotland confederation is that that is an absolute necessity. I made the point in my response that SHARE was initially seen as an absolute revolution. Now, 22 years later, it looks fossilised. We must keep abreast of two things. The first is whether the formula needs adjustment to deliver new objectives for the care services in Scotland. The second is whether the formula is delivering.
I was interested in what you said in your submission about long-stay services. You wrote:
I think that Lothian feels that it would be disadvantaged under the formula. Any study must use the data that are available, but it is clear that the way in which we measure community services produces less robust and less all-encompassing data than the way in which we measure institutional services does.
I have a couple of questions, the first of which is a general one. Is it the view of the confederation that the report is fair? The shift in resources is around 2 per cent. Under SHARE, which, as you said, everyone welcomed, people's health has become relatively worse and inequalities have increased, despite the redistribution effect. Do you think that the report is fair, and will it achieve anything?
It depends on what you are asking the report is fair about. Health boards that perceive a huge reduction in allocation feel that it is not fair, even though we are assured that the proposals amount not to an instant reduction but to a change in growth over time.
I acknowledge your caveat about size. I do not know whether you would agree with me but, when funding for health boards was cut, the calculations seemed to be based only on a capitation fee, with no baseline core funding. The same seems to apply in this review: there is a core element of health provision, which is much more expensive for smaller health boards. I am not sure that that has been allowed for in the formula.
I will provide a couple of examples. If you are staffing a service in an urban area, you can usually employ a large number of part-time staff. It may be difficult to achieve, but that can be done for primary care and hospital services. If you are trying to provide a GP service in a remote area—the most extreme example that I know of is on an island where the GP practice covers 125 people—you cannot roll up a part-time GP, a part-time nurse and so on: you must include an inducement payment.
We will take a couple of points from John and then finish, unless someone else has a burning question.
The first point is a small one. In your submission, you mentioned that one of the weaknesses that your membership identified was the use of one-year data. Is that because the wrong year was chosen, or is a larger data set required?
We need a larger data set. Everybody is anxious about changing health service funding for Scotland on the basis of one year's data. That is simply not robust enough.
So there is nothing peculiar about that year.
No, it is just that the sample is too small. People are made nervous by the fact that the sample is based on one year; they want it extended to cover another year. We are not saying that the findings are necessarily wrong, but we are dealing with a mighty service and huge sums of money. To make major changes on the basis of one year's data is not supportable.
My second point is slightly more complex. It concerns the assessment of the overall effect of the changes on a health board that is not a winner or a loser, but is surrounded by boards that are losers. How would you gauge the impact of such a situation on the access afforded to, for example, the residents of Fife, who might be using services outside the Fife administrative area?
It is important to realise that there are mechanisms in place across Scotland to allow the health boards and their trusts to work together—in large geographical chunks—to devise a joint planning approach that makes sense as regards changes to services. There is huge cross-boundary flow everywhere in Scotland, particularly in Fife, which is sandwiched between two tertiary centres. Those mechanisms are pretty robust. The principle from which people are working—it has been articulated in all the submissions that have been made to you—is that no health board is prepared to allow its community to get a worse deal than others are getting.
Thank you, Pat, for your contribution. We may hear from you again on a range of different issues, but it is nice to have had you here today. Thanks for answering all our questions.
Meeting suspended.
On resuming—
Good afternoon, gentlemen. We welcome John Telford, chairman of Shetland Health Board, and David Eva, its director of finance. We are also joined by Tavish Scott, MSP for Shetland. He is the first MSP other than those who are members of the committee to have attended it. Other MSPs cannot vote here but can sit in, ask questions or make contributions at my discretion, so he will obviously have to keep on the right side of me.
Thank you for inviting us. It is a privilege to be at the Parliament at such an early stage. I also thank the staff of the Arbuthnott group, who came to Shetland and spent time going through the report with us. I do not agree with the outcome but at least they tried to help us understand how they got to it.
It has been a recurring theme today that it is questionable whether there can be one formula that fits all. Do you feel that there cannot be one formula that suits everyone's needs? On the one hand, there is the situation in Shetland and in Argyll and Clyde—which, although regarded as a mainland board, contains about 23 islands—and, on the other hand, there is Greater Glasgow, which has atrocious levels of deprivation. We will hear from the Greater Glasgow Health Board tomorrow.
We certainly do not seem to have a formula that works—that is all that I can say. The old SHARE formula was supposed to be the answer, but ultimately it had to be changed for the islands because it did not work. We have been having discussions with our colleagues in the local authorities as to how the rate support grant formulas work and the differences between this area and that area. All the island boards have the formulas adjusted; it seems to be very difficult, if not impossible, to devise a formula that works across the board and takes into account the discrepancies between the islands and the mainland.
It is really quite a shock when one considers the losses—or the percentage changes, I should say—that Shetland will have to endure. I am surprised to hear you say that there will not be any cuts. You mention that, because of Shetland's small population, the application of this formula will lead to a high level of instability, which is obvious when the formula is spread over lower numbers. You also talk about reducing existing clinical services. The British Medical Association reckons that you will have 33 per cent fewer general practitioners. Is it simply a problem with the formula? What has gone so wrong that such a remote rural area has not benefited from the formula?
In trying to tackle deprivation mainly in the central belt, the formula is geared towards economic and deprivation statistics that do not seem to flow through to the island boards in the same way as they do on the mainland. It may be because numbers on the islands are so small.
Do you feel that all the unique factors relating to Shetland, such as patients having to go to Aberdeen for treatment, were taken into account? If not, which factors do you think should be taken into account to produce a more equitable distribution?
Perhaps the formula does not recognise that there is a base cost of providing a minimum level of services. For example, we run a maternity unit. It probably does not matter a great deal whether we have 50 births in a year or several hundred, we still have to have the service. We have to have two consultant surgeons, although it would be nice to have more, because we have to have a baseline service. The report seemed to accept that there was a linear progression on a graph that goes from somewhere up here above my head down to zero, in line with the formula. It cannot do that: it has to start with a reasonably acceptable level of service and then build on that.
You could not be expected to have economies of scale. I appreciate that you obviously have fixed costs that are greater than in other areas.
That is how we feel.
I am really struggling here. I feel very sympathetic towards you, because your figures look pretty awful. For example, there is a 31.6 per cent reduction in general medical services and the non-cash-limited GMS is going to be very hard to manage. However, of the island groups—with 21,000 people in Shetland, 17,000 in Orkney and 31,000 in the Western Isles—the Western Isles and Orkney seem to have gained substantially. Although it is perhaps unfair to ask you to comment on this point, how have they won while you have lost? As the formula does not work for Shetland, it should not work for the health boards on Orkney and the Western Isles either.
I want to ask a supplementary to that question. Do you think that Shetland has been in a better position historically than Orkney and the Western Isles, and that, as a result, you are now experiencing a levelling-down?
That may not be what the Arbuthnott report is about, but if we consider the present level of provision in the islands, perhaps Orkney has been badly treated by the SHARE formula and has needed an increase in funding. However, I think that the Western Isles already receives generous funding compared with Shetland. We have not been badly treated; we provide a reasonable service. However, it would not be unreasonable to be funded in line with the rest of the country and to receive our fair share of the growth for new developments.
I commend you for not attacking the other health boards. If I were in your position, I would be putting the boot in with all haste.
I do not know. However, we think that the end result is wrong in our case. There are two possible reasons for that. Either the methodology is wrong for the small number of people on the islands; or the whole methodology is wrong. With a small board such as ours, the beauty is that the numbers are quite small and what is happening can be seen quite clearly. That might be more difficult with the diffusion of a larger board. Perhaps that is a microcosm of the much bigger problems, but I do not know that. I can only speak about our own position.
Dorothy, you may ask a question as long as you do not ask Mr Telford whether he thinks that more money should be put into the health service in general.
Mr Telford would immediately reply that he thinks that more money should be put in.
We will take that as a given.
We have had disagreements about the remit of the committee. We do not, however, disagree about the immense amount of gobbledegook in the Arbuthnott report, which uses English as a third language and which is not understandable to most people.
Beta interferon is no different from any other newly developed treatment. If we do not get additional funding for anything additional or new that we provide, we must make cuts and savings elsewhere. Such decisions are becoming difficult for the board to make.
Is beta interferon being prescribed in Shetland?
It is not. Some patients in Shetland participated in clinical trials of the drug and we continue to supply it to them, but we are not prescribing it to any new patients. There are considerable doubts about its clinical effectiveness and its value, so perhaps it is not a terribly good example. It would be better to use as an example a treatment that is generally agreed as being clinically desirable.
I welcome your health board's submission because it puts the issue in perspective for me and, I am sure, for other members. We have talked about winners and losers, but the submission makes clear the effects on the so-called losing health boards.
From our point of view, I am not convinced. It is possible to examine the services provided by a small health board, and I am proud of the fact that we run a pretty tight ship—we do not waste much money on administration and we have done much to put resources into patient services. The resources that we have are about right for the service that we provide at the moment. If new money is provided to fund new developments and to tackle problems such as clinical governance and junior doctors' hours as they come along, we can continue to provide a service that has incremental growth.
Is that because of the effect on Shetland?
It is obviously a fairly selfish point of view, but that is the case.
One thing that we all accept is that the review examines the link between ill health and poverty and deprivation factors. Do you agree that there is poverty and deprivation in Shetland to some extent?
Absolutely. I have no objections to the overall objectives of the report, and we all recognise that in parts of the country there is massive deprivation. I wonder, however, whether some of the issues are connected more with economics than with health. I do not know how shifting funds around the health service will necessarily solve some of the problems quickly.
We have established that there will not be new money—we are talking about 1.5 per cent to 2 per cent of the debt being reshuffled.
I would like to go back to the economic issues. I am very aware that Shetland's economy is based on oil, farming and fishing and that those three sectors face problems.
That is correct—sorry, but I am not quite sure that I understand the question. Are you asking where would we make the savings?
Your submission states:
It would be invidious of me to sit here and say what we would cut, as we are talking about finding savings of £0.5 million. As a board, we will have to examine all our areas of activity to see where we could make cuts. As I said, we run a tight administration. We have kept our central administration costs frozen at the same cash level for the past three to four years and would have to consider making cuts in patient services.
You said that you have cut your management costs and so on and, from your submission—
I challenge anyone to examine our management costs and to show us where we could make significant savings.
Thank you.
As a supplementary point, you also said that £1.3 million was coincidentally the amount that you had put aside for development through the health improvement programme. What sort of work would you have undertaken had the anticipated growth continued?
One of our strategic objectives is to move services back to Shetland from Aberdeen, which is our main service-providing partner; over the years, we have been slowly pulling back services. As an example, we now have two consultant anaesthetists, which extends the work that we can do, and we are trying to encourage visiting consultants from Aberdeen to operate in Shetland. Two or three years ago, we got two new operating theatres so that the consultants could come to the patients, rather than the other way round.
At the end of the day, this is all about services for patients.
The most important people in the health service are the staff—doctors, nurses and so on. In Shetland and in rural medicine generally, recruitment is one of our biggest problems—getting good people into rural areas. If the board does not have development funds, we will not keep the good members of staff whom we have and we will not be able to recruit good people. We have recruited two bright, young consultant anaesthetists who are introducing pain clinics.
You indicated that £1.3 million was set aside for development and that you hoped to bring back services from the mainland to the islands. I take it that the guiding principle is that, in your view, that would improve patient care. That would have a knock-on effect on your recruitment and retention of quality staff who could provide a better quality of service to people in the area. Do you think that that is something for which you could make a special case, given the drive to ensure that patients are treated as near to their homes as possible? Is that a way in which you could argue against Arbuthnott's recommendations?
We have been making that case for many years and it has been the board's policy for quite some time. I was pleased when the remote and rural resource centre in Inverness came into being, but I would be sorry if it came up with lots of good ideas without the money being available to implement them. That would make it a bit of a nonsense as far as we are concerned.
Do you have evidence that you have looked at examples of best practice in other health board areas and that you have adapted and adopted them to ensure that your board gives best value?
I would like to quote some specific examples, but it might be difficult to do so during this formal evidence session. I like to think that we give best value as far as we can. In Shetland, everything has to come by plane or by boat, which puts up the cost of everything that we do. In some cases, we have to send patients to Aberdeen, which also has cost implications.
Will you bring them back?
I cannot express a view on whether that is desirable, but it means that there is no scope for savings there. The poorest employees of the board were paid even less, but it meant that the board could recruit two consultant physicians whom it did not have before. There were, therefore, medical benefits, but at a cost to some of the staff. As a board, we drive costs down pretty hard. Although we have not had the reorganisation of trusts that the rest of the country has had, we have organised our own management structure and had the sad task of making one of our managers redundant earlier this year. We keep squeezing administrative costs, to put money into patient care.
Some of us will have to undertake to study this, because it is complex and I have not really got my head round it. I have looked again at the table and it appears that, for remoteness, Shetland is getting much the same as Orkney and the Western Isles—23, 24 or 25 per cent above the national average—so that is not a significant variation. I thought that that was the main way in which islands would gain, so I cannot understand how that has happened.
We have the youngest age/sex structure in Scotland, but I do not know how much younger it is than in other board areas. The team that came up from the Scottish Executive confirmed that we lost out on economic factors and life circumstances compared with Orkney and the Western Isles. I still do not understand why the difference is so great, because the differences in the figures themselves do not seem particularly great. Perhaps the swing from the existing SHARE formula compared with Orkney has happened because we are doing better than Orkney at present.
I have been looking at the table. As well as figures for remoteness, there are figures for population structure and morbidity and life circumstances. The morbidity and life circumstances figure for Shetland is –8 per cent, whereas the figure for the Western Isles is +8 per cent. Many of those figures will have been calculated using the figures from the most recent census as a starting point and cranking them up. I assume that, at the time of the previous census, Shetland was doing pretty well for itself economically.
That is correct, but when it translates into the actual cost of providing the health service, the variations are not as great as the formula would suggest.
You can gather from the committee's questions and comments that aspects of the review are a mystery to us, even after a full day of informal briefing and after today, a full day of investigation. Having read every page of the report and every submission given to us, I do not necessarily see it as transparent, plausible or obviously equitable to people. The fact that we cannot come up with any reasons for the marked difference between Shetland and the other two island boards shows that—in that respect, if not in others—there is a problem with the review.
Malcolm asked the question that I was going to ask—it was the right one to pose. The committee has considered carefully what Shetland Health Board has had to say. I ask John Telford to illustrate the second point, on the second page of his document, about non-doctor islands. It brings home what the delivery of medical services in places such as Shetland is all about. It illustrates what it is like to be the male nurse on Fair isle, for example, what that means for patient care and how that nurse liaises with his colleagues in Lerwick, never mind Aberdeen.
One of the things that I like about the Arbuthnott report is that the map on the front has Shetland in the right place—that is fairly unusual. It is not a totally facile point, as I never cease to be astonished by how many people think that Shetland is in the Moray firth and that it is a half-hour ferry journey to Aberdeen. They do not realise that it takes 14 hours, which is a different ball game.
You were talking about people not knowing where Shetland is. As somebody who comes from the deepest, darkest central belt of Scotland, I assure you that I am aware of where it is, having landed at Sumburgh in a crosswind. Believe me, colleagues, it was not fun—I thought that my end had come. The aircraft simply drops through the wind on to the runway. It is an isolated place as far as transport is concerned—I can assure people that it is not easy getting in and out, even by air.
We are glad that you made it.
Of course you are.
I want to make a point about the small number issue, which you highlight in an impressive way in your submission. Looking at an indicator such as the standardised mortality ratio—which I believe the report uses for the combined experience of the islands as part of the calculation—would you be content to seek a combined index, based on the experience of the island boards?
We might be, but I am not sure about the other islands. To get back to my fundamental point, our present resources are not unreasonable, and as long as there is funding to support the current position and to support necessary developments, we do not want to throw the baby out with the bath water. We do not need a completely new formula.
We think that the decision in Arbuthnott to lump islands together or to split them up seems to be rather arbitrary. We want to know the basis of that decision. We cannot say whether it will produce a better result.
Is there anything else that you want to say to us?
I want to thank the committee and to say that if members ever want to come and see the health service in Shetland, they will be very welcome.
Having heard what Kay just said, I believe that the answer is probably no.
Shetland is a wonderful place to visit.
Thank you for the commercial.
I have heard from my colleague Tavish Scott that Shetland is a wonderful place. Thank you for the invitation; we will certainly consider a visit, because the committee intends to leave Edinburgh at some point in the session.
Meeting closed at 16:47.