Audit Committee, 02 Sep 2003

Meeting date: Tuesday, September 2, 2003

Official Report 198KB pdf

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“Outpatients count”

We move on to the next item on the agenda. I ask the Auditor General to outline the results of Audit Scotland's census on out-patient activity.

I will briefly introduce the report and then invite Barbara Hurst and the team to give the committee a bit more detail.

In September 2001, we prepared a baseline report—rather like the GP prescribing report that we have just considered—that drew attention to some significant gaps in management information for out-patient services and recommended a whole-system approach to ensure an efficient and effective assessment of service delivery. Since that time, Audit Scotland has worked with the NHS and has provided all trusts with a self-assessment handbook—drawing on accepted best practice—on managing out-patient clinics. We felt that that was a way of supporting continuous improvement in an extremely important area.

The most recent report provides the results of a week-long census of out-patient clinics and shows that a range of health care professionals from consultants through to physiotherapists carry out an enormous amount of out-patient activity. We estimate that, in total, there are up to 10 million attendances a year. However, much of that activity is not recorded by national data collection schemes, which focus almost exclusively on consultant-led clinics.

With the introduction of new ways of working in the health service, patients no longer need to be admitted to hospital for a number of conditions and treatments; it is thought more appropriate that such patients should be seen by a health care professional who might not be a doctor. However, information systems have not kept up to speed with such developments; they are out of date and need to be overhauled to ensure that they inform and enlighten us about those new ways of working.

The committee might be interested in the finding that, overall, one in seven people did not turn up for their appointment. That rate is rather high and affects the time that other people have to wait for their appointments. As a result, non-attendance has a cost as far as the service that other people are denied is concerned. We suggest that trusts should examine their booking and communication systems to ensure that they are working properly and to minimise the rate of non-attendance. Trusts also need to consider introducing policies that deal with the small minority of patients who repeatedly fail to attend without giving reasonable notice.

Very few clinics are cancelled; indeed, cancelled clinics affect less than 1 per cent of patients. However, although some cancellations are clearly unavoidable, more could be done to monitor the reasons for cancellations.

Finally, we found that very few clinics are held outside what we would call the traditional office working hours of 9 to 5, Monday to Friday, and that most take place in traditional health settings. We suggest that there is scope for the health service to consider the potential for meeting patients' needs in different ways, such as exploiting telemedicine and developing more outreach clinics.

We intend to produce a follow-up report on out-patient services. The census is just another snapshot of what is happening in the system. However, I welcome the fact that a great deal of work is going on within the health service on improving out-patient services. I suggest to the committee that my colleagues in Audit Scotland should have the opportunity to liaise with the Health Department about the most appropriate timing and approach for the follow-up work. The census report is a work in progress, in which we have highlighted a number of significant issues that we intend to revisit. I seek the committee's support for not suggesting an exact time scale for that follow-up work until we have had further communication with the Health Department on the subject. Perhaps Barbara Hurst would like to add a few comments.

As the Auditor General said, we have tried to support continuous improvement in out-patient services for the past couple of years. This year, the Health Department issued an out-patient action plan that picked up on many of the issues that we raised in the census report and in the self-assessment handbook that we provided to trusts. Those issues are specifically around managing the demand for out-patient services, the queueing systems and capacity. I think that capacity will be the most challenging problem for trusts to tackle. Most of the actions in the action plan are due to be implemented by next March or April, which is why the Auditor General suggests that we wait until after that time before going back to assess progress.

Given the work that the Health Department has undertaken, I agree that we need to revisit the whole out-patient issue. I think that the "did not attend" rates—DNAs—have a huge impact on waiting times and waiting lists. Do you envisage undertaking further work to get underneath the issue of DNAs to find out, in the first instance, why people do not attend and what impact that might have on referral protocols? Are those protocols as robust as they should be? When we consider service redesign in local areas, one issue that is flagged up time and again is the variation in GP referral of patients. Some practices have higher referral rates than others. Will further work be done on the timing of clinics as well as on where clinics are held?

Part of the reason for the census was that we had information about consultant clinics but no information about all the other clinics. In a sense, we wanted to get that baseline information so that we could decide what type of sample we would take of the clinics. We are particularly interested in the referral process—for example, how patients are kept informed of where they are in the system and whether they are contacted before their appointments. We are also interested in whether patients' test results are available when they turn up at a clinic. It would be a waste of patients' time if the results were not available, because patients would have to come back for them. We want to sample and consider such issues, but we also want to build in consideration of what the Health Department is doing to monitor the referral process. The sampling will be difficult because of the scale of the activity. However, I think that we should follow up on the areas to which I have referred.

You will be pleased to know that I have only three questions this time instead of five. My first question is specific. You recorded in the report that one in every 100 clinics was cancelled and that that affected less than 1 per cent of out-patients. Can you clarify that you are talking about the cancellation of total clinics as opposed to the cancellation of individual appointments? I think that the perception of many of us is that the cancellation of complete clinics might be relatively rare but that a substantial number of people are affected through their individual appointments being cancelled—sometimes repeatedly. I would be interested to know what the figure of 1 per cent represents in terms of the number of patients who are affected. I am sure that the figure is sizeable. Do you have any data on that?

No. The analysis of that area is incredibly complicated. I can confirm that the figure in the report refers to the cancellation of clinics that had patients scheduled into them. The figure does not include clinics that were cancelled because they had no scheduled patients.

Collecting the report's relatively basic information was a difficult process. We have no information on the number of times that individuals' clinics might have been cancelled. It would be nice—if we could do it—to sample individual patients at a clinic level to ascertain what is happening throughout their whole out-patient experience. That would be an ambitious project, but we have considered how we could do it through the follow-up work.

For the moment, rather than prolonging this line of questioning, I will simply make a comment. I echo what Margaret Jamieson said about the possibility of your doing a more in-depth piece of work on the level beneath the current analysis and on the management of appointment systems in general, which, of course, is linked to the earlier discussion about the use of information technology and so on. I acknowledge that it is the Auditor General's decision whether to do further work, but I believe that such work would be enormously valuable.

I have a further question. From your work in the area, can you indicate when we might expect data collection processes to be aligned with practice? You referred to that issue in the report and in your comments to us this morning. As politicians, we live in an almost dysfunctional world in that, when we debate issues, we have to use figures and reported data that lag substantially behind what might be happening in clinical practice, as you acknowledged. Can you give us a ballpark indication of when we might expect that alignment to happen nationally?

You might feel unable to comment on my final question, but I will ask it anyway. What do you think could or should be done to accelerate the pace of change in data collection at a local level? There has been much reference to work that the Health Department has done and is driving forward at that level, but some of the data that you identify in your report has traditionally not been collected at a local level. However, it would be reasonable to expect local management to take responsibility for collecting such data rather than being instructed to do so. If you feel able to comment on that, I would be grateful. If you do not feel able to do so, I would understand.

I will have a stab at giving an answer. On your point about national data, the health service's information and statistics division has a data development project to realign activity on the ground with national recording systems. I do not know that project's time scale, but I could find out and get back to you.

On accelerating the pace of change in data collection at a local level, two key issues would need to be addressed. First, clinicians would have to be involved, because we should not try to force doctors, nurses and physiotherapists to collect data that are not valuable. Secondly, we should identify someone to manage the process. At the moment, that management is disparate in a number of trusts in that no one person is responsible for managing the clinics. Part of the difficulty that we faced in collecting the data was that were was no oversight of out-patient services. That is another area in which there could be movement. I noticed in the out-patient action plan that trusts are being asked to identify someone at executive director level to take responsibility for oversight of those services.

I welcome the fact that patients' preferences are to be considered. I note from the report that there was a high number of repeat out-patient visits. Was that in comparison with initial out-patient visits?

Yes.

I thought that that was the case. Patient preferences are a big issue. In my experience, patient preferences are not taken into consideration when referrals are made for initial out-patient visits. People are given appointments almost out of the blue. However, when they attend clinics and make repeat visits, their preferences are taken into account because they make their appointments, subject to the constraints of when clinics are held. It is important that we consider not only extending clinics to non-traditional hours, but patient preferences—what patients are able to do and when they are able to access a car or get time off work.

I agree. We are interested in that matter. One difficulty is that patients do not tend to complain.

They complain to me.

Surveys of health services and social care services suggest that people are less willing to complain in those areas, because they are grateful for what they get. We must try to think of ways around that problem. However, patient preferences are a real issue.

I would like you to explain further your answer to one of Susan Deacon's questions. You said that we should not expect the Health Department to force GPs and clinicians to capture information. I assume that they do not regard collecting information as a worthwhile exercise, because they work in a demand-driven service and the information is irrelevant to the overall need, which is to meet demand. Is that correct?

I probably did not express myself very well. Clinicians must be involved with the development of a service, which takes place at every level—from demand and referral by GPs, through to planning of clinics and the exercise of patient preference. I was trying to make the point that we should not impose something on people, because that does not work.

Who is currently responsible for the clinics? Clearly, there is no managed service. Is the process driven by clinicians—consultants and practice nurses?

Clinicians hold individual clinics and make bookings through their secretaries. That is a very traditional way of running the service. A GP will refer patients to a consultant. If referrals were managed more appropriately and were not made to individual consultants, that might help to reduce waiting times.

I assume that you will be able to comment only very generally on the issue that I want to raise. Reference has been made to the number of people who fail to turn up for appointments and to the need for patients to be able to choose appointments outwith the normal hours of 9 to 5. Is there a perception that the increased costs of extending hours beyond 9 to 5—which would presumably involve time-and-a-half and double-time payment to staff—could be balanced with savings arising from the fact that people will be less likely to fail to turn up for an appointment that they find easier to keep? Is information too vague for that to be seen as a possibility at the moment?

At the moment we do not have enough information on that issue. In the negotiations on the new consultants contract, there has been discussion of working different hours, which would have cost implications. However, I cannot answer the question in any more detail.

Should we ensure that the issue is followed up and that attempts are made to work out roughly what percentage of patients would be more likely to keep an appointment if it were at a more suitable time, so that we maximise savings?

Trusts are being asked to consider the ways in which they provide services. In our report, we say that a balance must be struck between costs and, if you like, the increase in patient preference. That is a key point, because a consultant's time is very expensive. To send a consultant to see two people at an outreach clinic is not cost-effective. You have touched on several important issues.

That sounds like an opportunity for another pilot scheme. As there seem to be no further comments, we will bring discussion on that agenda item to an end.