“Overview of the National Health Service in Scotland 2002/03”
We move on to agenda item 4, which is consideration of a follow-up response from the Scottish Executive to the committee's eighth report in 2004, on the "Overview of the National Health Service in Scotland 2002/03". I invite committee members' comments on Ian Gordon's letter.
I find the content of the letter unhelpful. When we wrote again to Mr Gordon we gave him an opportunity to provide robust and detailed information, but, again, he has not done so. I have real concerns, given the issues that have been brought before the committee time and time again and given that we are considering the situation in NHS Argyll and Clyde later in the month. One must wonder why individuals such as Mr Gordon remain in post.
First, I will respond to the two suggestions in the letter, which are to have a briefing on pay modernisation and a briefing on the review of health and care statistics.
My view is that, subject to our finding time in our schedule, we should take up the offer of a briefing on pay modernisation, because that issue could usefully be explored through discussion with the relevant officials. I do not believe that we should take up the offer of a briefing on the review of statistics at this stage. However, we should return to the request, which I am sure we made before, for a clear and succinct written brief on what data are collected, through what means and with what frequency, and what the plans are for the piece of work that is under way. Presumably, draft proposals must exist for how the data collection systems will change. That information can best be conveyed with precision—and in a way that is time efficient for us all—in a written note from the Scottish Executive Health Department. I make that formal proposal.
I also wish to take this opportunity to comment on the review of health and care statistics. I am sure that I am not the only member of the committee who is finding the frequency with which we return to the issue wearisome. I ask colleagues to bear with me as I outline some of my concerns. We are told in the letter:
"NHS data collection has not kept pace with changes in service delivery. As you know, to address this deficiency a major review of health and care statistics has been launched. The review aims to identify gaps in current information and make recommendations by April 2005."
If recommendations are being made in 2005 I presume that thereafter there will be a consultation process to consider them. The department will not be in position to consider the implementation of revised data collection systems until 2006 at the absolute earliest. By definition, any change to the data collection system will require considerable changes within the health service, which has to provide the data. To be realistic, we will be the best part of a decade down from the creation of the Parliament before the Scottish Executive Health Department has effective data collection systems in an area that accounts for a third of the Executive's budget. That is fundamentally unacceptable and I have to say—I arguably have a vested interest in saying this—that I honestly do not believe that that is about a lack of political will. Ministers, even prior to devolution, have looked consistently for improvement in the area. I know for a fact that post devolution the instruction to change the systems has been given on a number of occasions.
I think there are serious double standards in operation. If a surgeon in the health service were to take a decade to adopt modern and effective clinical practice, he or she would be found negligent. Similarly, if a nurse or health service manager were to take that amount of time to adopt good practice in relation to hygiene and infection control, I am sure that the Health Department and relevant regulatory bodies would have something to say about it. We should have something to say about the fact that a major department of Government is failing to do its core job.
Managers past and present, particularly those who are responsible for the performance management function of the department, have failed to undertake a core part of their work. People may think that the issue is one for anoraks or is purely of concern to members of the committee, but it is worth reminding them of the impacts of the deficiency. First, it means that we cannot have effective accountability in the political system. For example, it is an absolute nonsense that ministers have to stand up every time waiting list data are released to explain all sorts of caveats and give clarifications about what the figures tell the country and how they reflect what is really going on in the health service. That is unacceptable.
The second impact is an issue that the committee has discussed previously. If the wrong data are collected, performance in the health service is driven in the wrong direction. Old practice is being measured and, de facto, being rewarded and recognised at every level of monitoring and accountability in the health service, which means that there are no drivers in the system to put in place effective, modern clinical practice and to incentivise meaningful service redesign. The issue is fundamental to the wider question that the committee and the Parliament have addressed several times—and, no doubt, will return to—about how to improve and modernise performance in the health service.
I return to my request for a written report on what is happening with data collection at present and what will be done in future. Can colleagues or the Auditor General advise me of any further work that can be done on the issue? I will duck the Latin, but a question that has gone through my mind several times as the committee has considered the issue is this: who guards the guards?
The Auditor General will comment once we have exhausted members' questions and observations.
I am amazed at the Health Department's response. In effect, the department admits that, although the present initiatives are changing fundamentally the way in which services are delivered in the health service—they are probably the biggest changes in the past 40 or 50 years—it has no idea of how to measure their impact or even of how to project the expected end results, such as the output from the system or what will be delivered for patients. I am utterly underwhelmed by the department's ability to manage what is, as Susan Deacon rightly said, one third of the Scottish budget, which will be £10 billion by 2007-08.
It would be useful to have the two written briefings that the department offers, but the committee must make a robust criticism of the department. The changes to junior doctors' hours and the pay modernisation systems are not new; they have been coming down the track for some time. It beggars belief that, despite repeated requests, the department cannot measure the costs or carry out any modelling to provide the committee with its views on the impact on the service. To be frank, the view that I have had since we started to investigate the matter, and which I still have, is that the department is flying blind.
I thoroughly agree with what members have said. We are dealing with an absolutely fundamental issue, but we do not have accurate statistics with which to look forward. Nor do we have performance information, such as information on how best value is used to measure success or failure. We have not had replies on either of those fundamental questions. We are probably dealing with a systemic fault. The committee would do a service to the whole community of Scotland if we pursued the issue further, investigated it and got to its root. We are asking people to improve their performance and to work out the correct way forward. The points that members have made so far are absolutely spot on. I hope that we will get accurate advice about how to progress for the benefit of all.
I agree with Susan Deacon on the need for that information to be made available, and I share her concern that it could take even longer until we have it. In the short time that I have been on this committee, we have looked at two areas within the Health Department—community care and NHS Argyll and Clyde—from which it is clear that information is not always available to enable us to see why certain decisions have been taken and how matters are progressing. Without that basic information, it is difficult to examine issues from the audit perspective and to say whether policies are effective. It is impossible to take a clear view of the way in which policies are being developed and whether they represent value for money or whether they are costing the country more than they should do and are not producing the results that people are looking for. I agree with Susan Deacon and share her frustration that we have not been able to get a better response.
Ian Gordon's response to the committee is unhelpful to say the least; it does not provide us with the information that we need, and it does not recognise why we need it. The question seems to be, "Why do you want this?", as if the information is unimportant; that gives further cause for concern. Any suggestions from the committee or the Auditor General on how we can address the lack of information would be useful.
One of the most powerful elements of Susan Deacon's argument was the possibility that large sections of the national health service could be being driven in the wrong direction as a result of lack of proper information and accountability. That rings a lot of bells for me. How do we get the Health Department to come up with a plan that will deliver within a time-limited framework of perhaps three or four years—or perhaps less—instead of a decade?
Members have made powerful contributions. The letter is deeply disappointing. If someone is driving a car and they cannot see where they are going, they are meant to slow down and stop. The health service, however, is trying to go faster without being able to see where it is going.
I invite the Auditor General to comment on the letter, and to help us with the context of where we might go with regard to his forthcoming report on the NHS overview. In determining how we should react, we might take into account any publications that the Auditor General has coming out, and our available meetings, so that we can take those publications into account. The offer of briefings is in the letter, but if further information is going to be available to us from the Auditor General, we need to be aware of it and to take it into account.
The next report that I shall lay in Parliament is the financial overview of the NHS for the past financial year 2003-04, which will complement the overview of the performance of the health service that we laid in the summer. The financial overview will be out within a few weeks, and it will be available to the committee early in the new year as a basis for further evidence taking from the accountable officer of the Health Department, if the committee so wishes.
The overview report will mention pay modernisation and the costs that are associated with it, which will provide the committee with the opportunity to ask questions of the department on the basis of my report. That might be an opportunity for the committee to take formal evidence from the accountable officer and possibly one or two others, such as Mike Palmer, and for the evidence to be recorded in the Official Report. That would be helpful as a future reference point. That opportunity will be available in the new year.
I welcome the project to develop better information on the health service. As members will recall from the performance report that we prepared in the summer, the biggest problem that we had was a lack of reliable data with which to measure performance in some key areas. We found occasionally that the reported information did not tie in well with the analysis of what was happening in the health service. We welcome the fact that the department is pushing ahead with that.
In a sense, the department is in a difficult place because it is arguable that the whole area should have been addressed much earlier than it has been; I think that that is the sense of Susan Deacon's comments. I am not really in a position to comment on policy matters relating to such issues. Barbara Hurst is generally aware of what is happening in the department and if it would help the committee, I am sure that she could give a general indication of her understanding of how that work is going.
Barbara Hurst (Audit Scotland):
The committee knows that a data deficit project has been going on for some time. In the main, the project has been examining data on out-patient work and the different health care professionals' activities in that field.
I am aware that the information and statistics division of the health service has been preparing a draft report on its work on identifying the current gaps and trying to put together proposals for filling those gaps. I think that that report is due to go to the Health Department shortly. If the committee wanted to pursue its understanding, it might want to take up Susan Deacon's idea of getting a summary of that work; I am not suggesting that the committee go for the whole report, because it is quite detailed. The report outlines what ISD is doing, where the gaps are and what it proposes to do. The ISD is pushing quite strongly for the Health Department and health boards to take ownership of that issue as well.
For clarification, can Barbara Hurst explain the respective roles and relationships between ISD and the Health Department with regard to this exercise? The performance management unit in the Health Department might be called something different now, but where do the responsibilities lie for analysing that work and driving it forward?
You would probably have to ask the Health Department for the definitive answer on that. As I understand it, ISD has been taking the lead on finding the gaps in the information, but it has also been working with the department's performance management people. However, ISD feels that there might be an issue about who is driving the project and who owns it.
I have another question, although I would accept it if you were to say that you cannot answer it yet because of the lack of information and the apparent confusion. If there were maximum investment and commitment, what would be a reasonable timescale to stipulate, within which the situation would have to be sorted out?
I feel that that question puts me on the spot.
That is why I apologised in advance.
There is a legitimate need to ensure that the work is done properly and that will take time. However, the frustration that has been felt by the committee and others is not really appreciated in terms of the proposed timescales; I suppose that I am wriggling out of answering the question directly, but I suspect that the eventual timescale will be shorter than the one that is currently proposed.
I think that we have gone as far as we can in burrowing into what is happening in the Health Department.
After the December 2003 report was published, we issued a report in which we asked many probing questions; we were not sure whether we were dealing with misinformation or whether the information just did not exist. That report contained a series of questions to the department. We now know fine that the information does not exist. The committee is deeply concerned about the Health Department's ability to manage the service with any strategic direction. The department does not even have in place the basic reporting systems to allow a strategic direction to be laid out.
The time has come for the committee to decide to issue a short report that is based on the August 2004 overview report and which lays out our concerns. Two new ministers are in place and I expect a new accountable officer to be put in place. I suggest that that will provide an excellent opportunity to push them in the right direction and to flag up the committee's genuine concerns about the Health Department's ability to manage the health service. It is clear to all of us that the department has been found wanting on several matters. It is time to put that on the record and to push it, in order to speed the process of overhauling the department and enabling its systems to support proper strategic management.
I was keen to have an idea of the context, because we have an inquiry in the next month on NHS Argyll and Clyde, which will take up some days of business. In December, Audit Scotland will publish the financial overview, which is a development from the previous overview. We also have an offer of briefings. We have deep concerns about gaps in information, to say the least, and we have a working knowledge of our likely commitments in January.
What is the committee's reaction to the idea of briefings? Given that other reports are to be published, should we ask for both written briefings? If members are unhappy with that, we can discuss it. We will consider later in private aspects of our agenda for our meeting on 11 January, which will be our first of the new year. If the financial overview report is published in December, we could put it on the agenda for our meeting on 21 December, but I would be concerned about rushing to consider the report and having to pick it up again after the break.
The document will be laid before Parliament before we break up, but the Auditor General could deliver evidence to us on 11 January, which would allow us to consider our reaction, taking account of George Lyon's proposal. We could pull in all the evidence—the financial overview and the written briefing that is being offered to us. After that, we could decide about writing a report, which might concentrate on matters such as statistics and information gathering. Is that a reasonable way forward? Do members have any concerns that we would not proceed fast enough if we did that? Further information will come on stream for us.
I am happy with that approach, provided that we have the aim of producing a report towards the end of January that sums up the committee's concerns. That is the objective. We will hear from NHS Argyll and Clyde and have the next overview report, plus an evidence session with whoever the new accountable officer is. Many strands need to be pulled together and we must aim to do that by the end of January.
A piece of work is needed that reflects the concerns that the committee expresses every time that we discuss the health service. Otherwise, we could continue to discuss those concerns week after week.
I agree entirely. We need to see where closure comes for us to say definitively what we feel. I will talk the committee through the likely progress that we will make.
We will take evidence from NHS Argyll and Clyde, and we will take evidence from the Executive in January. In reaction to our discussions, it strikes me that it would be possible to consider having an evidence session with the Executive on NHS Argyll and Clyde. We would then need to consider having a second part to that evidence session, on the financial overview. The only alternative would be having people back a fortnight later. We would have to take advice about that, but that approach would make sense if it is possible to do both things, perhaps with a break in between. I recognise the pressures that we would put on the clerks through having to write up and produce two reports. I suspect that we might see—I detect a feeling that we might want to see—a report by the committee on the Health Department coming out before the report on NHS Argyll and Clyde. Clearly, the question is how we can manage things. We must take that into account.
That said, although we can have all the evidence gathered in January, the report would be more likely to come out in February. If we are going to take evidence, I do not think that we can do things more quickly because of the break for Christmas and the new year.
I do not fundamentally disagree with what you say. I agree that, as a general rule, if one is going to do a report on anything, it is better to do it properly. I am happy to defer to the convener and the clerks, who can manage all the details of our schedule.
However, I have one comment to add. Is there anything that we can do now with a light touch to convey the point about urgency back to the department? One hopes that the department will pore over the Official Report of the meeting and take to heart the concerns that have been raised.
There is always a first time.
In case that does not happen, I wonder whether there is an appropriate mechanism that can be used to draw the department's attention to the discussion and specifically to the urgency. We are operating in real time. Big ticket announcements and debates about the shape of the health service will take place over the next few months. The fact that it is not possible to conduct those debates with an accurate and transparent picture of what is really going on in the health service in Scotland is a matter of concern. It would help if we could inject a note of urgency from the meeting.
Partly because we seem to be discussing the national health service constantly, I appreciate entirely why members think that we are not making progress. We have produced reports and will produce more, but there is a sense of urgency.
I could write on behalf of the committee to Ian Gordon and refer to the Official Report. I suggest that we take up the offer of briefings, but say that we would prefer them in written form. On the statistical briefing, we should take up Susan Deacon's point and ask the department to discuss progress and not simply to give an idea of what statistics are being gathered. I think that the committee is concerned about the lack of progress or its ability to see any progress in the department. We should also inform the department that, subject to the financial overview report by Audit Scotland, we are likely to return to take evidence on a number of issues in the coming months. I hope that that will convey the committee's sense of urgency. Are members content with that proposal?
Members indicated agreement.
Thank you. That discussion was helpful.