“Managing long-term conditions”
Item 2 is the first of the reports that I mentioned. I invite the Auditor General to brief the committee on the report.
Mr Robert Black (Auditor General for Scotland):
With your agreement, Barbara Hurst, who is our director of public reporting, will lead on the report.
Barbara Hurst (Audit Scotland):
"Managing long-term conditions" is a joint report for the Auditor General and the Accounts Commission. The main focus of the work is on the way in which the national health service is developing community-based services for people with long-term or chronic conditions. We also considered the extent to which health and social care services for those people are joined up. To consider what is happening in more detail, we examined two tracer conditions: chronic obstructive pulmonary disease, or COPD as it is more commonly known, which includes chronic bronchitis, for example, and epilepsy. We chose those conditions because they are not widely researched, unlike diabetes or asthma, but information is available from the new general medical services contract for general practitioners. Where possible, however, we also took elements of good practice from other conditions and built those into the report.
We examined the management of long-term conditions because it is seen as the biggest health care challenge worldwide, so it is pretty significant. More than 1 million people in Scotland have at least one long-term condition and many have more than one. Not surprisingly, people with long-term conditions make the most use of hospital bed days—they account for about 60 per cent. The introduction of the policy to move services from acute to community settings and to provide integrated health and social care services gave us an opportunity to consider the incentives for that in the system, to examine what is happening on the ground, and to consider whether the policy is being rolled out throughout Scotland.
We found that better information is needed on the costs and effectiveness of services. Without that information, the sharing of good practice throughout Scotland will be limited. Specifically, we found that the Scottish Executive did not estimate the cost of implementing new models of care in its policy document "Delivering for Health". Locally, cost information is not collected consistently in different parts of the health service or between the health service and social care. The consistent collection of such information is important if we are to have more joined-up care.
We estimated the costs of health services for people with COPD to be just over £98.5 million. For epilepsy, we estimated the cost to be just under £38 million. Those are significant sums. However, we were unable to estimate the costs of social care in relation to those conditions.
As I said, we were concerned that very little work is done on the cost-effectiveness of services, which means that decisions on the use of resources are still being made with limited evidence about what works. The health service must improve on that. It must also get much better at sharing good practice and rolling it out more widely. We found a number of examples of good practice, such as epilepsy services in Forth valley and community rehabilitation services for people with COPD in Dundee and Glasgow. However, those were often down to the enthusiasm of local professionals rather than the result of a strategic approach.
We found that the move to provide more community-based care is mixed across the country. The picture looks quite good for people with diabetes and asthma, but it is far less well developed for other conditions. I will bring a number of key issues to the committee's attention. We found that community health partnerships were at different stages of development. Many were still addressing the key issues of governance and getting themselves going, so they were not yet key players in developing community services throughout the country. We found little, if any, real incentive to move resources from acute to community settings, with the exception of the quality and outcomes framework under the new general practitioner contract. We accept that it is not necessarily easy to move resources from hospitals into the community, but we expected to see more evidence of that happening.
The lack of access to comprehensive information on patients was seen by professionals as a barrier to joined-up care. There are some signs in the health services, such as the emergency care summary, that health professionals can now access information on patients, but it is not shared with social care professionals. That is a barrier to integrated health and social care.
Finally, and probably most important, we spoke to about 100 patients throughout Scotland. The message that came from them was clear. What they really want is better information, particularly at the time of diagnosis when they find it difficult to take in the full implications of their condition, and better support to enable them to be involved in managing their own care. It strikes us that it is not too difficult to fix that. We know that voluntary organisations produce a wealth of information, which could be made available to patients early on when they are diagnosed.
The study was quite a full one. We are happy to take any questions that the committee may have.
Thank you. I throw the discussion open to committee members to ask questions and make comments on the factual issues identified in the report. I remind members that we will discuss what the committee will do with the report under agenda item 7.
I understand that the quality of life of people with long-term conditions should be paramount, but let us talk figures. Was it possible to put a figure on the cost of treating someone in an emergency setting, when they have difficulties that require hospital or emergency out-of-hours treatment, as opposed to the cost of on-going community-based care, to see whether a saving could be made? If a saving was possible, who would make the decision? Barbara Hurst said that there was not much evidence of a transfer of resources from secondary to primary care. Who should lead on that work, analyse the various costs and decide whether such a transfer should take place?
Those issues also exercised us during the study, so we commissioned a health economist to carry out quite an extensive piece of work on the costs of different services in different settings. The health economist examined whether savings could be made by moving services into the community as opposed to retaining hospital-based services. As a result, the report contains a number of detailed exhibits—in particular, exhibits 13 to 15—that try to break down the costs of treating people in different settings. However, I should issue a health warning about the figures, as they are estimates and it was quite a difficult exercise.
An interesting point is made in exhibit 18, on page 16, which shows the health economist's conclusions about the various types of treatment for people with COPD. Not surprisingly, stopping people smoking is the biggest saver for the health service. Of course, that does not necessarily come under the health service's budget. In Scotland, we are in a good position because the smoking ban should save money in the longer term. Indeed, it has been reported this week that the smoking ban is reducing people's risk of heart attacks.
However, some clear issues arise. We are not saying that we do not expect people to be admitted to hospital—of course there will be stages when people need to go into hospital—but it certainly looks like some services could lead to money being saved, such as pulmonary rehabilitation in the community. There is a fantastic example of that in Glasgow that both increases people's quality of life and should save money. We have taken the issue as far as we can in our report, but we think that the health service has a responsibility to start doing those calculations.
On the second part of your question, which was about who should make the decisions, I think that it must be the health board, given that the health board controls both the acute and the community budgets. Presumably, many doctors—excluding the more forward-looking ones—do not want the money to shift from the hospitals budget into the community budget, but we feel that health boards need to take a far more strategic approach. Health boards need to work with social work to ensure that health is not considered separately from the social care that is provided.
I am sorry if that is a long-winded answer, but the issue is quite important.
You mentioned that the CHPs are at various stages of development, with some more developed than others. Is there evidence to suggest that resource transfers are more likely to be possible where CHPs are more established? Can we be optimistic about the role that CHPs will play in that?
We have to be optimistic that CHPs will play a key part. Places such as Tayside are getting on top of the issue by building in plans at CHP level that feed into the board's overall plan on the management of long-term conditions. We have some evidence of pretty good practice, but it has not yet been rolled out across the country.
If one fifth of the Scottish population are affected by a long-term condition, the report obviously highlights a massive problem. I note that the report states:
"However, decisions on the best use of resources are currently being made on limited evidence – there is little information … about the activity, cost and effectiveness of services for people with long-term conditions."
Why is that? How easy or difficult is it to obtain that information? In other words, who has the information and how do we get it if it is required for good decision making?
Because the health service is so massive, there is a real risk that the service will just carry on treating people in the same way. To change that, we need to use the evidence and the knowledge of the professionals. As they have the patient's interests at heart, they are the people who are most likely to come up with new ways of providing services.
In our report we suggest that, if a new way of providing a service is introduced, we must look not only at whether patients are satisfied with it but at whether it reduces hospital admissions and whether its costs are equivalent to or less than having to admit patients to hospital and other such outcomes. Although a lot of innovation is going on, evaluation at the latter end of the process is not so good, and it is up to health boards to ensure that their pilot projects are properly evaluated. Indeed, the Scottish Government must also ensure that any good practice that is identified is rolled out.
The report says:
"There is a need to … ensure that relevant staff have access to comprehensive information on people's health needs".
How can that happen if no accurate data exist?
That question links to on-going discussions around access to patients' single health records. Mr Welsh will recall that the previous Audit Committee, of which he was a member, discussed our report on information management and technology in the health service, which highlighted the fact that progress in that area is still slow. Since then, measures such as the emergency care summary have been rolled out, but we still need to ensure that any individual who treats a patient—particularly one with on-going health needs—has access to their entire medical record. We are highlighting that point again to give some impetus to improving the situation.
I have more questions, but I will let other folk in.
As Barbara Hurst has made clear, the roll-out of good practice has been poor, which clearly poses a major problem for services such as the chronic obstructive pulmonary disease community service in Dundee, which has been running for six years and which, as exhibit 17 shows, has reduced the level of hospital admissions and GP and out-patient appointments. On the face of it, the service appears highly cost-effective. Why are the current mechanisms in NHS Quality Improvement Scotland and the Government's innovation division so ineffective in rolling out the best practice represented by the Dundee COPD service, the Forth valley epilepsy service and, indeed, the many other services that treat chronic conditions?
Related to that is the fact that if outcomes were audited effectively, health boards would know whether their services were working properly. Did the health boards that Audit Scotland reviewed carry out good audits of COPD services?
On your first question, as NHS QIS evaluates against set standards, its role would have to be extended if it were charged with examining services and recommending the roll-out of best practice in other areas.
I know that the health directorates have a small team that helps boards to work on innovative practices, but given the current focus on waiting times, that team might not have the resources to take your proposal on board. That said, it is not beyond the wit of people in Scotland to find a more systematic way of rolling out some of that good practice and we hope that, by highlighting the issue in the report, boards will take it seriously. Indeed, the report contains a self-assessment tool that we expect all boards to check their own work against. That might help to get the discussion going.
As the study's project manager, Jillian Matthew has more detailed knowledge of what was going on in the boards, so I will ask her to answer your question about the COPD audits.
Jillian Matthew (Audit Scotland):
I assume that the question is about clinical audits. We did not really examine clinical audits of COPD, as the issue was slightly outwith our remit. Instead, we examined the overall management of COPD services. As members will see, the effects differed from area to area.
As Barbara Hurst mentioned earlier, progress depended on enthusiastic individuals within the board—either community nurses or a consultant—taking matters forward and considering different ways of providing the services. Although there were enthusiastic individuals in other areas, they were not getting the permission or the funding to go ahead with the initiatives that they wanted. Therefore, it also depended partly on the view of the board about how to take matters forward.
The issue is more the existence of the clinical audit than the quality of it. Does it exist in every health board for, say, COPD? I would like to know whether someone is actually doing it, because there is no outcome audit in many areas.
I will take the totally different example of benzodiazepines, which first came out in 1963. The first report on adverse reactions to them was published in 1964, but it was not until 1990 that the profession decided that prescribing benzodiazepines might not be a good idea and that treatment needed to be more focused. The average period for such responses is getting shorter, although it took 35 years for us to ban the use of amphetamines for weight loss and all sorts of other things. It takes an inordinate amount of time for good practice to be adopted, and we need to find a mechanism for its better adoption.
The other question that I want to ask—if I may, convener, and then I will shut up—is about the major problem of the lack of both vertical and horizontal integration. Despite all the changes that the previous Administration tried to introduce, we still have a hospital sector and a community sector, and the degree of integration on a patient-focused basis is minimal.
In the case of the COPD service, in which there were many specialist nurses, what degree of integration was there with general practice so that the general, day-to-day management of the 4,120 patients on whom you reported was supported by professionals with a particular interest in primary care? When such numbers and such common conditions are involved, unless there is a degree of vertical integration and the primary care side is properly engaged, day-to-day management of patients will be difficult. Primary care will still pick up acute exacerbations, if not acute admissions, rather than become involved in day-to-day management.
Did you find any evidence in the COPD service of a horizontal integration with social work, benefits and housing—in other words, the management of the disability that a person faced? For example, adaptations in a person's house can be as important as almost anything else. To what degree were services functioning on a whole-patient basis as opposed to being the classic fractured, siloed services that we generally have, which just do not work for patients—or clients or whatever we want to call them?
I will pick up on the last bit of your question and then hand over to Jillian Matthew to deal with vertical integration.
The honest answer is that we do not know whether the CHP can be a mechanism for horizontal integration. We could not get information from the social care end. Patients are not categorised in the same way for social care, so we could not track a patient through the system, although such tracking is crucial to joining up health services, social care, benefits and the community equipment that might be needed. In Scotland, we are at quite an early stage in the management of services for patients, because of the lack of shared ownership of the information that is held on individuals.
The Dundee community service seemed to be fully integrated as far as we could tell. The nurses who treated the patients with COPD went round all the practices in Dundee. If anyone was picked up as having COPD, they were referred to those nurses as well as being supported by their GP. It was not a separate service; the GPs still saw those people in their practices, but they were supported by other staff as necessary. The patients could also be referred directly to a dietician or a physiotherapist, if required. The system seemed to work very well and the nurses were well accepted by the other staff.
So at the moment, there is a good vertical model, but a poor horizontal one in terms of development.
It does not seem to have spread to the social work side.
I return to Andrew Welsh's point about access to comprehensive information on people's health needs. I accept the requirement—and the need—to have more joined-up working, but my concern is that if any of the information on a patient's health record is factually incorrect and more staff gain access to it their future treatment could be prejudiced.
It certainly would, if that happened. However, we cannot use bad cases to make judgments about how things should develop. If the patient has access to the record, there is no reason why they cannot try to ensure that their records are accurate. However, I take the point: accurate record keeping is crucial, particularly if the information is shared beyond the immediate, one-to-one relationship.
I asked the question because I know of an individual who, over quite some time, has had many problems with their health board to do with the number of people who have access to their health record, to the extent that their health has been adversely affected.
We have spent some time on the report, but I will let Andrew Welsh in if he puts his question briefly.
When it comes to the availability of comprehensive information, how long will it take to introduce in a systematic way the required level of such information?
Obviously, the area is complex. No health care system in the world has an all-singing, all-dancing patient information system. Certainly, we know of the serious difficulties that are being faced in England with the attempt to roll out such a system. In Scotland, a patient's heath record will not be presented as a single record, but as a set of linked records—a patient's test results will be linked up with their health record. That is the way in which the system would be built up.
Although I cannot give you a definite answer today, I can say that, on the back of our previous report on information management and technology, we are proposing to return to the subject to see what progress has been made.
Obviously, the feasibility of solutions is a crucial factor in all of this. I note from the paper that
"national and local assessment tools are being developed"
and that
"Intensive care management approaches are still being developed and piloted".
Clearly, something is going on. Do we have any indication of how long it will take for those tools and approaches to be effective? What will the financing and cost consequences be? In other words, are calculations being made of the consequential budgetary effects of those decisions?
I would like you to put that question to the Scottish Government health directorates. I am not in a position to know what they are doing to cost such models. However, in relation to such intensive care management, the aim is to ensure that resources are targeted at people who are most in need. Many people can manage their condition effectively themselves, with the aid of their general practitioner. The pilots are being undertaken to identify the small number of people who need much more complex care packages involving social care and health care. The number involved will be much smaller than 1 million, which is the number of people with a long-term condition.
Thank you.
I will offer some general comments on why we think that the study is significant, as I sense that members might be coming to the end of their questions.
First, as Barbara Hurst mentioned, the study is significant because there is a lack of specific investigations into chronic obstructive pulmonary disease and epilepsy. That is important. Secondly, the incidence of those diseases in the community is growing. Linked to that is the huge resource commitment that is going into them, which will grow enormously over the next few years.
My third comment is a thought that I want to share with the committee. The whole thrust of thinking in the health service, and in social care generally, is around moving resources from acute settings to primary and community settings. What really comes out of the study, in which we have focused on a couple of conditions, is how difficult it is proving to move significant resources from acute settings into community settings. The department expects health boards to take responsibility for that, but we have not seen information about activity levels being joined up, or indeed about the resources that are being committed. We do not have the basic information that would allow that to happen.
We also find in the report that significant resource transfer is not taking place. That is scarcely surprising if we do not understand the level of activities and the costings that are in place. The significant issue for the whole of public service is how we get out of this locked position. The study is pointing towards that—I would like to think persuasively—as one of the biggest challenges in the implementation of public policy over the next few years.
The most successful achievement has been in the area of mental health. We have largely closed the chronic mental health bins—the old asylums have all been closed. The problem for the first 20 years after the decision was made to make that shift was how to move people out of long-stay wards into the community when there were no community services. The only way in which that was achieved—as in the area of learning disability—was to get some of the community services up and running so that they were ready for the transfer. There have to be good innovative examples and then pump priming, so that people have a short period of transitional funding. That worked particularly well in learning disability—it has been hugely successful. The number of people with learning disability in long-stay wards is tiny. When I first started in the early 1970s, we had 1,800 beds in Forth valley; there are now 50. That is a staggering shift, but it was achieved by having services in the community, such as new housing.
You raise a particularly interesting example, which I can relate to my own experience. I found initial resistance among my then constituents—I was in local government at the time—because they regarded the old services that were being closed down as being of higher quality than those of the old-fashioned social work day care model. Other issues, to do with the consumers of the services, also have to be taken into account.
Absolutely.
We will have the opportunity for a broader discussion under item 7, which we will take in private.