Audit Committee,

Meeting date: Tuesday, May 11, 2004

Official Report 151KB pdf

---

“Day surgery in Scotland – reviewing progress”

Item 3 is a discussion of the report by Audit Scotland on day surgery in Scotland. We shall be hearing from Barbara Hurst.

"Day surgery in Scotland—reviewing progress" is a report that we published in April. We have done a number of reviews of day surgery in the past, so the new report is, if you like, a follow-up of a follow-up. It was a desktop review and we extend many thanks to the information and statistics division of the health service for providing us with the central data that we analysed to examine performance across Scotland. We looked at 19 procedures that have been widely regarded as suitable for day surgery, because we wanted to ensure that we were comparing like with like.

The findings are fairly straightforward. The key finding is that the rate of day surgery continues to grow, but the pace has slowed significantly. There is still scope to improve the rate of day surgery in some places. We found wide variation between trusts, and even within trusts there is variation between specialties. In general, for the procedures that we compared with England, Scotland is doing less well, although there are a few procedures for which we are doing better.

There is an interesting finding that links with some of the evidence that the committee has taken on the report "Overview of the National Health Service in Scotland 2002/03". We were quite careful to consider whether some procedures were now more suitable to do as out-patient procedures, so we asked the ISD to do a check for us on a given number of the procedures, to ensure that the activity was not transferring into out-patients. We must remember that the data on out-patient procedures are not as good as they are for day-case or in-patient procedures. Even so, we found just one of the procedures—cystoscopy—that has now shifted and can be done in out-patients, and we are recommending that that procedure should come out of the targets for day cases, otherwise there will be a perverse incentive.

The key recommendations that we are making focus on the data. If the information is collected consistently across out-patient, day-case and in-patient procedures, we will have a better way of monitoring what is happening in real time, so we can track whether procedures are being done in the most appropriate places. We have also recommended to boards that they should take a more active interest in what is happening in their areas, both in relation to the rate of day surgery in general and in relation to specialties.

I am happy to take questions on the report.

Thank you. I remind members that we have a further item on the agenda to discuss how to approach the report. At this juncture, we have the opportunity to ask questions of the Audit Scotland representatives for the record.

I would like a further explanation of why the rate of increase has slowed considerably. Will Barbara Hurst give us a little more detail on that? The difference between the various trusts is extreme, as we can see from the performance of Argyll and Clyde Acute Hospitals NHS Trust compared with that of Fife Acute Hospitals NHS Trust and some of the other trusts. Have we any explanation of why that is? I see that rurality is hinted at as a possibility, but although Argyll and Clyde has a rural hinterland, it also has a huge urban mass. Perhaps she could also give an indication of the fundamental drivers behind the difference in performance between hospitals in England and Wales and hospitals in Scotland.

No difficulty there, then.

On the rate of increase, when we saw what was happening, we thought that perhaps we had reached an optimum, and we would expect the curve to flatten out to reflect that. For some areas, that is the case, but it is not the case across the piece, because of the wide variation. It is a Scotland-wide picture, and although we would expect the curve to flatten out a bit, we might not expect it to flatten quite so much.

You are quite right to comment on the difference between the areas covered. The first thing that we thought of was the fact that we have areas with huge rural coverage, which must have an impact, and I think that it probably does have a partial impact. When we start looking at some of the individual procedures, we find that a trust such as Argyll and Clyde Acute Hospitals NHS Trust covers a big rural area, but is the highest-performing trust for some procedures. Therefore, it is not just rurality that is at issue; something else is going on. The review was a desktop review, so we have not gone back into the detail to explain. However, previous work suggests that the way in which day surgery units are used affects performance, and that clinicians' preferences also come into play. That may explain some of the variation.

Will you explain that point a little further? What do you mean by clinicians' preferences? Are they saying that they will not perform procedures as day work?

The situation is quite complicated. Day surgery is certainly not appropriate for everybody, so we would expect even some of the procedures that we were considering in the review to be done on an in-patient basis if the cases were complex. Other research has found that some clinicians want to manage their surgery list so that they can mix big surgical procedures with smaller ones, with the smaller ones being performed on people who can be seen in day surgery. Clinicians might balance procedures in that way because of how they want to manage the list.

The point that I am trying to get at is whether such a decision could be overturned by management.

It is a clinical decision. That is how it is presented, but it is not a simple equation.

I would like to come at the issue of concern from a slightly different angle. We would expect the report to be considered by individual NHS bodies. We would expect clinical directors and the board to be aware of it and to ask reasonable questions of their clinicians about the level of day surgery performance achieved in individual trusts compared with performance in the rest of Scotland or in England and Wales. It would be inappropriate for us at the centre to try to drive the system out of audit or to suggest for a moment that individual clinicians were not acting appropriately. However, it seems entirely reasonable and appropriate that the information should be used at local level to ask informed questions about what is happening in local clinical practices.

It is an interesting question. I have had discussions with several medical directors who, although they may not agree completely with the report, think that there is enough in it to be able to take it back and consider performance in their own area. That reinforces what Robert Black has said.

On George Lyon's final point about differences compared with England and Wales, I suppose that any comments will be a bit speculative, because we have not considered why the picture is as it is in England. However, there are a few issues that we thought might affect performance in England, including more pressure on beds, which could be driving the move to day surgery, and possibly a stronger or more aggressive central drive to promote day surgery. However, that is speculative.

To return to clinical preferences, which I know is sensitive terrain for us—including me—to get into, I think that it is worth while to note, as your report does, that previous work by Audit Scotland identified as early as 1998

"considerable variation among consultants in the percentage of day surgery they carry out".

That was six years ago, but the variations appear to continue.

I recognise that there are all sorts of reasons for that, but I am aware that there is a dynamic in the system that militates against consultants who wish dramatically to change aspects of clinical practice; there can be a pull-back to previous practice. You talked about feeding back your observations and comments to clinical and medical directors, but have you done anything to discuss them with the medical royal colleges, which play a key role in driving clinical practice in such areas? I have a second question, but I will pause there.

The honest answer is no, but I think that it would be good to have that dialogue. The more that we can do to promote our findings and improve practice, the better, so I take your point.

Further to George Lyon's question about comparisons with England, and to address the factors that have apparently led to a slow-down, will you say some more about the bricks-and-mortar issues that are involved? In England, there has been a move towards the provision of walk-in treatment centres, and new physical models of care are being delivered. There were, and I believe that there still are, plans to make similar changes in Scotland and to develop what have been called ambulatory care and diagnostic centres—ACADs—although I prefer to call them day hospitals. However, such facilities have not been delivered in the timescales that were planned, not least because of local controversy, consultation and debate about the configuration of hospital services. Do those issues have a direct impact on the trends that you observe in your report?

I do not think that I can answer that question. We did not examine the matter, so it would be risky for me to give opinions on it. We are certainly aware that walk-in treatment centres appear to drive some quite different models of practice in places where they exist, but we have not examined that yet, so I do not think that I can go far in answering the question. I am sorry.

On the statistics in exhibit 5, it is important to note that the English performance is almost consistent across the board. There is slightly more day surgery in England in every category except bunions and sub-mucous resection. In the Scottish results, there is little difference between the median and the mean, which suggests that there is no long tailback caused by people staying for extended times. Of course, one cannot have a tailback at the other end, as day surgery is day surgery. Why do we not have the mean results for England? They would add to our interpretation of the figures and would give us a better steer on them.

We had a lot of debate about whether we should mix median and mean figures in the exhibit that you highlight. We worked closely with our sister organisation in England, the Audit Commission; it provided us with the English comparators but it could not give us the mean figures.

We would have run with the Scottish and English medians, but for the very point that you have highlighted: we wanted to show what was happening. As some Scottish trusts were so small in relation to the English trusts, we wanted to ensure that the comparison seemed sensible. I am sorry that I cannot give you more of a response on that matter, but we did try.

I understand perfectly.

As someone who has benefited from a quick in-and-out knee operation, I was very interested in this report. There seems to be a consensus that, although day surgery is not suitable in certain areas, it is beneficial in the main. However, we seem to have a logjam and we are not quite sure why such an approach is not being taken as far as it might be or as speedily as it could be. How can we break the logjam? We could write to the health boards for their views on the report, but it appears that you have already had some informal—if not more formal—discussions with them. Should we take a more outside-the-box view on this matter by, for example, wielding a stick or introducing incentives? After all, we are almost grinding into the sand and we need a solution.

Oh, what a question. I suppose that, if I could answer it, I would make a lot of money as a consultant. Can anyone else help me out here?

The health boards have a key role in this situation, particularly now that they are unified organisations and are responsible for setting the direction of health services and ensuring that the operating divisions can deliver them. As the Auditor General said, health boards need to sit down with the clinicians and the clinical director to come to a better understanding of what lies behind the figures and whether the rate of increase is being slowed down by the availability of day surgery units; the level of deprivation that makes it harder for more patients to go home the same evening; or the clinicians' preferences. Such a local understanding of the constraints that are operating in each situation, specialty by specialty, would allow people to move forward. I guess, in that respect, that the committee might be interested in finding out what the health board is doing to promote such dialogue and to take action on the back of it to break the logjam that the member described.

If consultants' preferences are a constraint on the situation, will the new consultant contract—which the Executive's Health Department would have us believe will lead to greater flexibility in managing consultants' time—help to tackle the problem? Clearly, we must get something back from the extra money that we are giving them.

The contract will certainly be one of the mechanisms that will be used. However, we have not yet seen any job plans, so we do not know how it will play out in practice. As the contract forms part of the whole pay modernisation agenda, we will examine how it changes service delivery.

As there are no further questions, I thank Barbara Hurst for her responses. I should point out that, later in the meeting, the committee will discuss how to take the matter forward.

We will now have a five-minute comfort break, after which we will resume in private session.

Meeting suspended until 11:08 and thereafter continued in private until 12:28.