“Cardiology services”
Our first substantive item is a section 23 report on cardiology services. Robert Black, who is the Auditor General for Scotland, Angela Canning and Jillian Matthew will present their report and answer the committee’s questions.
Thank you, convener. There are not many new things that happen to me in my professional life, but presenting a report on a leap year day is a first for Audit Scotland. We will be as professional as ever and not let the excitement go to our heads.
Our report on cardiology services was published on 23 February. It looks at how well the national health service in Scotland manages cardiology services, how much is spent on them, whether patients across Scotland have the same access to services and whether there is scope to improve their efficiency.
Thank you. The top line from the report seems to be positive. The fact that more patients are receiving more treatments earlier is paying off in terms of significant and on-going reductions in death rates. It is worth putting that on record because the tendency is to go straight to the “but” and look at more problematic areas. The one that jumped out at me from this report was the difference between survival rates in more deprived areas and in less deprived areas. While there might be reasons to expect higher rates of heart disease in more deprived areas, it is interesting that there was not just a difference in outcome; people in more deprived areas were also less likely to receive certain treatments or procedures. Is that a fair summary?
That is correct. We looked at two procedures in particular—angioplasty and coronary artery bypass graft surgery—which are covered in paragraph 55 onwards and in exhibit 8. Work done by the NHS highlighted the fact that people in more deprived areas of the community were getting fewer procedures than those in the least deprived areas. The report mentions a six-year study done in Glasgow, looking at over 5,000 patients. It found that a number of reasons are likely to contribute to those lower procedure rates, including: people living in more deprived areas being more likely to have a heart attack; being less likely to reach hospital alive; and being more likely to die during the heart attack. Jillian Matthew may wish to expand on that.
Everyone is aware of lower treatment and procedure rates for those in more deprived areas, but how to tackle the problem is less clear. The research points to some reasons, but the evidence is still anecdotal or uncertain. There are other reasons why people might not get to hospital: people in more deprived areas present later, and people who smoke—smoking is also linked to deprivation—are more likely to die from sudden death. There are therefore a lot of things preventing people from getting to hospital in the first place; that also includes people not being aware of the symptoms due to educational problems.
Paragraph 56, which points towards what might be some of the reasons for the difference in treatment rates, is quite speculative—you used the word anecdotal in your comments—although some research has been done in Glasgow. Is it fair to say that the possible explanations for the difference in accessing treatments are speculative, and that we do not really know why it is there?
I think so, yes. We have recommended that we need more research in that area, and more evaluation of the measures that the Government is employing to show whether they are working.
Exhibit 9, on page 25 of the report, which looks at non-invasive tests, identifies significant differences in the tests provided by local NHS boards for heart disease—some tests are offered only by a handful of or less than half the boards. Some of those non-invasive tests seem to be related to early diagnosis. Is there is a connection or are those two different issues?
The tests referred to in exhibit 9 are all, as you said, diagnostic and non-invasive—apart from the angiography, which we compared them against—so there is some relation in that respect. The sources that that data came from were not organised in a way that we could necessarily link to deprivation, although we did a comparison with boards in areas of higher deprivation.
Referral to another board is a possibility, but does that happen?
Yes. People are referred for a procedure, but they are less likely to be referred for a diagnostic.
To continue with the convener’s theme, the report’s message, as shown through the statistics that Audit Scotland presented, is generally very encouraging. The convener talked about exhibit 8. Does that show procedures rather than survival or death rates?
That is correct.
This question may not fall within your remit, but I will ask it anyway. In exhibit 5, on page 13, there is a chart that shows the 10-year downward trend in death rates. Is a similar chart available that shows death rates by community, health board or area covered by the Scottish index of multiple deprivation statistics? Is there perhaps a picture emerging that death rates in those communities are not as impressive as those in exhibit 5?
The statistics are available by health board and community health partnership area. Exhibit 5 relates to the overall population, but statistics are available for the 15 per cent most deprived areas of Scotland. They show the rate for the more deprived areas as a whole. As we say in the report, death rates are higher in more deprived areas. There are figures available from the past 10 years that show that death rates in those areas have gone up slightly.
That is obviously worrying. That particular issue is probably one for the Health and Sport Committee, but it is certainly of interest that the downward trend is not reflected in those communities that perhaps need the most intervention.
We do not know that about deprived areas, specifically. The rate of angiography has gone down slightly because other diagnostic tests that are less invasive are being done, as shown in exhibit 9. We did not have the figures by deprivation category.
As the convener has suggested, perhaps there is an opportunity for further work to be done to assist those communities so that earlier interventions can be carried out and the statistics will decrease rather than increase.
I have a question on deprivation, in addition to what my two colleagues have said. I was shocked that the number of did not attends in a deprived area is more than twice that in a less deprived area, as stated in paragraph 91. Seventeen per cent of patients failed to turn up for out-patient appointments and gave no explanation why. There is a problem not only before diagnosis or before a person reaches a hospital and not only about disparity in treatment, but in the fact that 17 per cent do not turn up. That is more than twice the national average—a shocking figure.
Greater Glasgow and Clyde and Lanarkshire have a higher proportion of deprived areas, so that pushes the figures up. We did not do a lot of detailed work in Tayside. We did further work with a small sample of boards, but Tayside was not one of them. Case study 3, on page 32, has a variety of examples from boards across Scotland on how they are trying to improve did not attend figures. Some of those apply to more deprived areas, where the problem is obviously more difficult.
The figure is quite shocking. Convener, I would like to move on to rural areas. Is that all right?
Mark Griffin wants to follow up on the original point, so I will come back to you after that.
Has any work been done on the reasons given for missed appointments, for example failures in patient transport?
We did not look at that issue specifically in the report, but we have done work on it previously. We published a report last year—“Transport for health and social care”—that picked up on some issues about delays, for instance in getting patient transport to patients. If patients missed their transport, they missed their appointment, or if it was late, they were late for their appointment.
As an MSP for the Highlands and Islands, I always look at how NHS care is provided in remote and rural areas compared with elsewhere. Paragraph 17 of the “Key messages” version of the report refers to
Not every board provides the same service because, as a new service, it had to be introduced gradually to make sure that it was done the right way. The service started in NHS Lothian and it has been rolled out across Scotland over the past five years. The six regional centres have come online gradually. Highland regional centre is the last one of the six to provide the service so it is at an earlier stage. It is not providing full cover yet because the service is not fully up and running yet, unlike in the other areas.
So, you are saying that NHS Highland does not provide any out-of-hours cover but it is developing an out-of-hours service at present. Where would people from north-west Sutherland, for example, be taken? Would Aberdeen be their nearest regional centre?
We try to show where people might go on the map on page 19—exhibit 7. I think that a lot of patients would go to Aberdeen but some who are further south might go to the Golden Jubilee national hospital. It depends on where they are and which is their closest centre.
If I was a patient with a heart condition in the Highlands and I read that, I would be pleased that the service is being developed. However, it is worrying when you say that treatment is most effective within 90 minutes. In Orkney and Shetland, which is Tavish Scott’s area, were there any problems in getting people not just to the airports in the northern isles but to Aberdeen, particularly given that NHS Grampian has only recently started an out-of-hours service? Would patients from Shetland have gone to Glasgow or Tayside? Those journeys would definitely take longer than 90 minutes.
Those patients would more likely get the clot-busting drugs, and possibly further treatment after that. We were told that there may be cases when someone in the islands would get to hospital quicker: with air transport, some might get to hospital within 90 minutes.
You said, in response to the convener’s question, that the Scottish Government was looking at various issues. Is it also looking at patients receiving the treatment within 90 minutes, in spite of where they live?
The Government has that issue under review. Part of that work involves looking at whether treatment within 90 minutes is the most effective treatment, and whether it can be extended to 120 minutes. The treatment is fairly new and further evidence is always emerging. In Europe, for example, some countries allow a longer time between the diagnosis and the treatment. The Government is also looking at the patient flow and whether the current set-up is appropriate. If the time was extended, potentially more patients would get the most effective treatment.
To return to exhibit 8, the table shows that more than one in five men and roughly one in five women from the two deciles with the highest areas of deprivation are, perhaps, not reaching the hospital and missing out on surgical procedures. Those figures are from 2008-09. However, the Government has started preventative work and all NHS boards have exceeded their targets for the number of cardiovascular health checks, and I hope that that would improve the situation. When do you expect the 2008 figures to be updated to reflect the increase in health checks?
I am not sure when the Government plans to update the figures, but it may look at that as part of its evaluation of health checks over the next few years.
Paragraph 39 of the report states that
That is not something that we looked at in detail—that information was drawn from the Health Improvement Scotland review of clinical standards for heart disease. It may be that some people are coping well and do not need rehabilitation, but I cannot comment further on that.
I return to the point about remote areas. I suggest gently that if, like me, you live in Bressay in Shetland, the time taken for the Scottish Ambulance Service to commission an aircraft to get to Shetland, and for you to have travelled by ferry and ambulance to Sumburgh—whether that takes 90 minutes, 120 minutes or 177 minutes—adds up to a lot of minutes. I can assure you of that.
That is an entirely understandable and reasonable question, but I am not sure that we, as auditors, are best placed to answer it. The report is a presentation of standards that are applied at the moment. I encourage you to take that question to the health directorates, if you are minded to do so. Ms Matthew may be able to say something about the clinical health risk associated with the regional model.
It is worth reiterating that people in those areas still get good treatment. Delivering the most effective treatment within 90 minutes of diagnosis is the gold standard for people who have severe heart attacks, but it is a new treatment that has been available only over the past five or 10 years and has been introduced gradually. It is not something that you would expect to see in every single health board, as we are talking about fairly small numbers of patients. Consultants and doctors need to deal with a certain number of patients to make the treatment safe. There needs to be a balance.
If you are auditing a service, there are some obvious areas—and you pointed to one that the convener asked about, on deprivation—where there are inherent difficulties. I guess that you audited those difficulties as part of the study, although I accept that this is a policy question. Have you come to the conclusion that the regional structure creates an inherent challenge to delivering the type of services detailed in your report, which could or should be available to everyone in Scotland, no matter where they live?
The geography of Scotland creates a difficulty, given that the most effective treatment has to be given within 90 minutes of diagnosis. The Government is reviewing how the services are being provided, and may extend that period. We expect to hear something on that over the next few months.
I will wait with bated breath.
It is something that the NHS is always working on, but you can see that we have had considerable problems in compiling the report. It is also a reflection of how complex cardiology services are, because a lot of cardiology patients are also treated in other wards—general medicine and geriatric medicine, for example—so figures are difficult to quantify. However, there were examples of boards not having separate cardiology costs, or including them in general medicine costs, so we could not identify what was spent on cardiology wards.
Would it be fair to say that Audit Scotland would have found it easier to make recommendations about potential efficiency savings of £4.4 million if the available data sets were rather more exacting, full and complete?
That is fair. We found particular problems with rates of day-case surgery. There is variation across boards that is more likely to be down to how the data has been recorded and collected, rather than there being a variation in the services provided, so there is more work to be done there.
Your point is that there is a lack of consistency across health board areas.
Yes.
To follow up on that, the point is that in looking at cardiology services, we are dealing with the second biggest killer in terms of disease in Scotland. I acknowledge that there have been significant improvements, but we still have the worst heart disease rates in western Europe. Our health service cannot tell us where the cardiology patients are or how many there are, or basic information about what happens in cardiology services. Is that not a cause for concern?
As I think the committee has noted before, one of the issues that we tend to raise in health and other performance audit reports is the desire for better information. That information is not needed just so that we can audit it and tick a box. It is information that managers and clinicians use to look at areas where efficiency savings can be made, and to benchmark clinical performance and so on. It is a very important issue. ISD Scotland has some great clinical data, and that should be recognised. What we find lacking is data on cost, activity and quality.
I have a couple of points, one of which follows on from Tavish Scott’s comments. I sat in on discussions on a number of reports and data collection was an on-going issue. There are two issues in that respect. First, there is the inconsistency in the collection of figures in the different NHS areas—I cannot see any real excuse for that. Secondly, realistically, the NHS is dealing with legacy systems, which were perhaps never intended to give the level of sophisticated reporting and statistics that we look for nowadays.
That is an entirely reasonable point and one that is well worth recording. We have had conversations with the NHS about the issue of data collection and information. The point that Mr Beattie makes is right—data that is collected must be fit for purpose. ISD Scotland, as Angela Canning mentioned, collects a wealth of information, but there is some way to go to ensure that the information that is collected is collected for clearly defined purposes, and is presented and used well.
I have a second question. One thing at paragraph 43 of the report jumped out at me in connection with specialist heart failure nurses. The report mentions that case loads vary from 50 patients per nurse in NHS Shetland to 140 patients in NHS Forth Valley. That is a huge variation. I do not know what the optimum case load for a nurse might be, but within that variation either NHS Shetland is getting a very good deal or NHS Forth Valley is getting a very bad deal. Where does the balance lie in that regard?
We brought in some of those figures from another report. That report related more to community services, which we did not look at in detail in this report, which focuses on hospital services. We know from our discussions that there is a lot of pressure on resources for heart failure nurses in the community. The other report, which will be due out soon, has been examining overall services for heart failure in more detail.
I will build on that, if I may. As I am sure that members of the committee will have registered, the service is a good—and an important—example of preventative spend. As you can see, we are talking about a relatively small number of specialist staff.
Am I correct in saying that another report will be published that might give a little more information and background on that?
Yes—voluntary organisations such as Chest, Heart and Stroke Scotland and the British Heart Foundation have been involved in it. That report is refreshed every year or every few years, so there will be a lot more information on the whole service and other things that are going on in the community.
Have you any idea of the timescale for that report?
I am not sure; I think that it is imminent, but we can find out whether there is a publication date.
My question relates to paragraph 40 on page 17, which relates to heart disease patients at risk of stroke who do not always get the appropriate drugs. Have you identified why that variation is occurring across the various boards? Can we identify the boards in which such a difference occurs?
Again, that was taken from Healthcare Improvement Scotland’s review of the clinical standards, because it was one of the standards that HIS was measuring. HIS might have further information on what the level was in each board, but that was not published as part of its overall report.
Do we know which areas come in for more criticism than others? Is there a breakdown of health boards in which there appear to be problems?
I am not sure that HIS reports published that detail, but we could check. HIS will have further information if it has not been published.
A number of my colleagues have made important and salient points. I wonder whether you will allow me to be a bit selfish and focus on my own mortality for a moment. I have read and have been brought up hearing the statistic that ethnic groups in particular have higher rates of coronary heart disease and other heart ailments, to the extent that they are eight times more likely to suffer from heart attacks. That is an important point, particularly for cities such as Glasgow and Edinburgh.
It is a similar situation to that in the whole of Scotland. We know that it is worse, but we are not entirely sure why. We know that high risk is linked to deprivation but that does not explain wholly why rates are so high in Scotland.
What about those health board areas that have a high concentration of people from an ethnic group? In some parts of Glasgow, such as Pollokshields and Govanhill, 10 to 12 per cent of the population is from an ethnic background. Do those health boards have strategies to get information out to those communities and then to provide the appropriate treatment, particularly on the preventative side? Did you come across any of that during your study?
We did not look at that because this work was focused on the hospital specialty side and cardiology. A lot of preventative work will be going on in the community, so we did not pick up on it as part of this study.
I have a brief general question. Over the past eight years, spending on cardiology services in hospitals has gone up from £80 million to £146 million and death rates have fallen by 40 per cent. Have death rates fallen because of the 50 per cent increase in spend or because people have improved their lifestyles?
It is probably a mix of both. As more treatments have become available and as treatment constantly improves, people are more able to survive heart attacks or other conditions and are living longer.
So it is a combination of the increase in spend and improved lifestyles.
That is right.
One of the bullet points in paragraph 42 of the report says:
The British Cardiovascular Intervention Society, which audits rates of different procedures across the United Kingdom, is aware of the issue but is not entirely sure about the reasons for it. It is quite well known that certain European countries are a bit more aggressive in their use of interventions than the UK; indeed, the rates for all procedures are generally a bit lower compared with some other countries.
Does the difference between the Scottish and English rates come down to a purely clinical decision?
Again, the reason is not entirely clear but it might well just be down to differences in the way treatments are provided.
Going back to opportunities for making efficiencies, I note that, according to exhibit 12, those who live in island communities can be in hospital twice or three times as long as those on the mainland who are getting the same procedure. My attention was drawn to that because at a previous committee meeting we heard a more colourful explanation about why people in the Western Isles stay in hospital: there is no bus to take them home. I hope that that is still not the case—I know that the data is perhaps two years old—but nevertheless the report recommends that health boards pay attention to the issue. In any case, it is interesting to find out that those in the islands could be in hospital three times as long as those on the mainland getting the same procedure. I have no idea whether that is down to transport issues, family issues or whatever but there is clearly an opportunity to improve that situation.
I, too, noticed that paragraph but bowed to Mr Coffey’s longer membership of the committee in raising the matter. Does the same thing emerge in Audit Scotland reports on different NHS areas of work or is it unique to cardiology? Mr Coffey’s comments imply that the issue comes up regularly. Is that true? Is it a theme? Is it always the same colourful places that keep people in hospital longer?
In this case, the length of stay includes all the transfers, including the transfer from the island board to the mainland board for treatment and the transfer back for recuperation. That might be what is underpinning that particular cardiology information.
But is there not an implication in the report that, even for the same procedure, for example implantation of a pacemaker, there is quite a big disparity—the island issue aside—in how long people find themselves in hospital? Is that true?
Yes.
Not just in cardiology.
It is not just the islands either. There is differentiation elsewhere, too.
I have a few brief questions. I return to exhibit 8. Are there any shining examples in deprived areas that outpace the Scotland-wide chart? Are there any areas where the situation is a bit different from that which is shown in the chart? Is any area better informed?
We have no information on that. In that example, the ISD has been able to link the number of procedures to deprivation, but much of the information does not have that level of detail attached to it, so we cannot consider that issue in detail.
My other question concerns a comment on page 17 about palliative care. The number of patients who are on a palliative care register is very low. Do you have any additional information on why very few people are registered?
When we looked at palliative care services three or four years ago, we found that most people who are on a palliative care register have cancer. That reflects the history of where palliative care services came from and when they have been funded. Most patients who are on palliative care registers have cancer. Fewer folk with heart disease or stroke are on such registers. That issue requires to be tackled.
Is that because for a long time the emphasis has been on cancer patients rather than on folk with other life-limiting illnesses?
I think that that is right. The situation reflects the history of palliative care services and what they were focused on.
As no one else has any follow-up questions, I thank Jillian Matthew, Angela Canning and the Auditor General for their forbearance. We will discuss later in private how we will take forward our consideration of the report.