“Overview of the performance of the NHS in Scotland 2004/05”
Item 3 is a briefing from the Auditor General for Scotland and Barbara Hurst on the "Overview of the performance of the NHS in Scotland 2004/05".
As the committee will recall, last year I produced a financial overview of the NHS and a separate review of health service performance. This year, I am laying before the Parliament my first integrated overview report on the NHS, which relates to 2004-05.
The report, which concentrates on the main areas in which the Scottish Executive is committed to improving performance, comprises six parts, each of which covers a different aspect of the NHS. Those aspects are: health improvement; clinical outcomes; waiting for care; workforce; financial performance; and keeping pace with change.
The Kerr report and the Scottish Executive's recent response to that report clearly highlight the changes and challenges that face the NHS over the coming years. In our report, we acknowledge that changing environment and indicate areas in which it is putting pressure on the future design and delivery of services.
I will briefly describe some of our main findings. Health care improvements are resulting in better clinical outcomes and contributing to increased life expectancy for people in Scotland. Part 2 of the report shows that death rates for cancer, coronary heart disease and stroke have improved significantly. For example, between 1995 and 2004, the death rate for coronary heart disease fell by about 44 per cent. Because of that success, the Scottish Executive has recently raised the bar for that target and now seeks to reduce the number of deaths from coronary heart disease by 60 per cent by 2010.
It is emerging that, although the people of Scotland are living longer, they are not necessarily in good health. Exhibit 1 on page 5 shows that, although life expectancy at birth for men and women has risen, people's healthy life expectancy has remained relatively constant.
The poor health of some people in Scotland, particularly those in deprived areas, continues to be a problem. Exhibit 4 on page 12 shows that people who live in the most deprived areas of the country have a higher incidence of, higher death rates for and lower survival rates for cancer than people who live in the most affluent areas. The committee will be pleased to note that the Executive has now set specific targets for improving health in Scotland's most deprived areas.
The Executive has made significant progress in reducing waiting times for in-patients, day cases and out-patients. The NHS in Scotland is on course to meet the six-month target for people with waiting time guarantees for in-patient and day case treatment. However, more needs to be done to meet the cancer waiting time target. I will produce a more detailed report on the management of waiting times next February or March.
Most patients who arrive at accident and emergency complete their treatment within the four-hour target. Most GP practices meet the 48-hour target of giving access to care. The number of patients who are delayed in hospital awaiting discharge has fallen significantly since 2000, with the discharge delay falling from a median of 80 days to 44 days between January 2001 and July 2005. New figures released since the publication of our report show that that median has risen slightly. There is some way to go to tackle the problem—a wait of 44 days or longer is a considerable period. The most recent information shows that just under 1,600 people are waiting to be discharged from hospital.
Waiting times continue to be a major challenge for NHS 24. The management of callback is its biggest problem, accounting for one third of all calls between December 2004 and August 2005.
Targets can help to focus attention on the Executive's priorities, but some of those need to be reviewed and developed. For example, the target for mental health care is a reduction in deaths by suicide. That is a relevant indicator, but it is at best partial, and inadequate for monitoring the improvement of mental health.
Part 4 of my report comments on the NHS workforce. The NHS in Scotland has set workforce recruitment targets, but progress has been mixed. The number of consultants has increased, but as exhibit 8 on page 23 shows, there are still significant problems with high vacancy rates in parts of Scotland. If the current trend continues, it is reasonable to suggest that it is unlikely that the recruitment target for consultants will be met. The number of nurses and midwives is increasing, but it is difficult to tell whether the recruitment target for those posts will be achieved. An indication of the pressures on this workforce is the increasing use of bank and agency nurses, on which we reported some years ago. The use of those nurses has gone up by 33 per cent since 2002, and the spend on them now stands at £87 million.
The implementation of the three major pay agreements has been very challenging for the health service. Further work is needed to ensure that those agreements deliver a more flexible workforce. Good information is needed to plan and manage the workforce effectively, but it is concerning to note that basic workforce information, such as sickness absence, is not routinely available in all health boards.
Most NHS bodies met their financial targets in 2004-05. However, four boards—Argyll and Clyde, Grampian, Lanarkshire and Western Isles—overspent their budgets in 2004-05. The combined cumulative deficit of those four boards has increased by nearly a half, from just under £62 million in 2003-04 to over £91 million in 2004-05. That is a very small proportion of total NHS expenditure, but the pressures are significant for the boards involved. There is evidence of wider pressure still in the system. Exhibit 11 on page 30 shows that at the beginning of the financial year boards projected funding gaps of around £183 million for 2005-06. There are plans to generate savings to address most of that gap, but a projected shortfall of around £28 million is likely. However, that projection is based on the estimates that we have been given.
The continuing financial pressures in the system are discussed at paragraphs 148 to 154. I have previously reported on the costs of implementing the new pay agreements and, in exhibit 13 on page 34, I have provided the committee with the Health Department's latest estimate of the additional cost for 2004-05 and 2005-06. Next year, I will bring a more detailed report on the consultant's contract to the committee.
The NHS in Scotland is expected to contribute to the Scottish Executive's efficient government initiative by making savings of £515 million by 2007-08. Audit Scotland has previously commented on the Executive's efficiency technical notes and has given evidence to the Finance Committee. I have asked the auditors of NHS bodies to report back to me on progress in that area.
The final part of the report looks at the issues that are involved in delivering change in the health service. The structure of the NHS in Scotland has changed significantly over the past few years, with the establishment of unified boards. The development of community health partnerships is seen as central to the future delivery of health services, but there have been delays in their implementation. We have provided an outline of the current position at paragraph 182. I have asked Audit Scotland to carry out a high-level review of governance arrangements in the community health partnerships, and I will report on that at a future date.
The committee has previously expressed concerns about shortcomings in performance information. There have been some improvements in the collection of activity data; for example, more information is available about nurse-led clinics. However, the NHS still has some way to go to provide a comprehensive picture of its activity, its costs and the quality of its treatment. For example, exhibit 14 on page 40 shows a continuing decrease in elective in-patient admissions and a levelling-off of day cases and emergency admissions since 2002-03. We do not have an explanation for that; we cannot say whether that trend is the result of quality improvements, a more complex mix of cases or whether there are growing problems of efficiency. We do not know whether those trends are explained by activity elsewhere in the system. For example, some patients are treated in out-patient situations. Therefore, the question of whether productivity as a whole is improving must remain unanswered. At the same time, we know that costs are increasing as a result of the new pay deals.
In conclusion, the NHS in Scotland is achieving significant improvements in health care, there are better clinical outcomes for major clinical diseases such as cancer and coronary heart disease, and it is significantly reducing waiting times. However, it faces major challenges in changing health services to meet the needs and expectations of the people of Scotland. It needs to improve its financial, workforce and performance management significantly.
Thank you very much; that was a full briefing on the report.
I would like a little more information about exhibit 11 on page 30, which lists the funding gaps of each of the health boards in 2004-05 and the potential for gaps in 2005-06. What is that exhibit based on? Are those figures the boards' wish lists? I am concerned that the health board for my area does not appear. I take it that it is wholly satisfied and that it is able to achieve its own wish list.
Exhibit 11 shows individual health boards' assessments of the gap between their projected income and the funding that they need to continue services at this year's level. It does not include extra, one-off money, or the results of savings plans. It is an indication of pressure in the system, but it is not a confident prediction of what will happen, because that gap is being managed this year. The purpose of exhibit 11 is to indicate that, while the majority of boards came into financial balance in the last financial year, there was a lot of pressure in the system. It is appropriate to highlight that risk to the committee.
The differences between 2004-05 and 2005-06 are quite significant in some health boards, such as Greater Glasgow and Lanarkshire—a reduction of £21 million is quite significant. I am interested in what is behind those figures. What assurance do you have that the boards were robust in reaching those conclusions and in developing those figures? As you say, only Argyll and Clyde, Grampian, Lanarkshire and Western Isles were overspent. It is when we look also at the outturns that I start to ask who is really telling the truth.
It is fair to say that there are significant pressures in the system. The auditors invited the boards to give us their best indication of the potential funding gaps. The figures are not scientific, but they provide a reasonable indication that a number of boards are looking for quite significant sums of money to bridge the gap. If they do not manage to achieve savings or additional income from different sources, there will be a problem at the financial year end.
Am I correct in assuming that, because NHS Ayrshire and Arran has not provided information about its funding gap, it is happy with its lot?
I will turn to Angela Cullen for help with that.
Angela Cullen (Audit Scotland):
The fact that Ayrshire and Arran is not listed suggests that it does not have a projected funding gap—on the basis that the other boards submitted the information. It is worth bearing in mind the fact that exhibit 11 lists projections at the beginning of the financial year, so the figures are the projected funding gaps at the beginning of 2004-05 and 2005-06. Ayrshire and Arran told us that it did not have a funding gap.
That information will be helpful to me at a later date.
Before I move on to other questions, I note that in exhibit 11 funding gaps for the vast majority of health boards are going down, with two exceptions—Western Isles, which one cannot compare because it does not have data for the previous financial year, and Forth Valley, whose position appears to worsen. Are we aware of why Forth Valley is bucking the trend?
I will give a general answer then invite colleagues from Audit Scotland to help with your detailed question. Where there are significant financial pressures and funding gaps, the Health Department is requiring the health boards to have in place plans to get back into balance. There is a lot of activity in the system, so it is natural to see the figures for 2005-06 coming in below those for 2004-05.
With regard to Forth Valley, and possibly Western Isles, I turn to colleagues in Audit Scotland for assistance.
I can only assume that the majority of funding gaps are coming down because the boards are reducing their operating cost base, so they are taking recurring costs out of the system. I cannot give you an answer on Forth Valley at this time, because I do not know the details behind its funding gaps, or whether it is just starting to identify cost pressures that are coming into the system.
I have a couple of workforce questions. An obvious one relates to the comment on page 21:
"Basic workforce information, such as sickness absence figures, is not available in all NHS bodies."
I find that surprising. They must have to pay out sick pay and bring in staff. Such concrete information should be get-at-able, or am I being naive?
I agree with you. Given that the NHS in Scotland employs 150,000 people and services are provided through staff, it is entirely reasonable to expect the NHS to provide sickness absence information. Another factor is that sickness absence is comparatively high in the NHS compared with other parts of the public sector and the economy more widely. Boards will only be able to achieve the target figure for sickness absence of around 4 per cent, and the efficiency savings that they anticipate, if they have good information.
In the table on consultant vacancies, Western Isles stands out. I also notice that you used Western Isles as a case study on governance arrangements on page 38. Are the two issues linked? At one level, I can understand that there might be difficulty in recruiting to more peripheral areas, but Orkney has no problem and Shetland has considerably less of a problem than Western Isles, which has a serious, embedded problem. You are also concerned about corporate governance in the Western Isles. Are the issues related, are they specific to Western Isles, and should we examine them?
We included the Western Isles case study on page 38 because, although it is a small board, it is clearly a vital organisation to the island community. For more than a year, auditors have reported concerns about the need for improvement in the governance of the board. We included in the case study examples of weaknesses, such as the absence of a full clinical governance framework, which we see in other boards. We could not make the leap and say that that is an explanatory factor for the comparatively high level of consultant vacancies in Western Isles, not least because Western Isles has had a problem in filling consultant vacancies for a number of years. Nevertheless, it is fair to conclude that a well-managed board would be more capable of tackling some of the challenges. There is a need for improvement in the Western Isles situation.
I will carry on that theme. Obviously, workforce costs are a significant part of a board's expenditure. We see that the numbers of consultants, nurses and midwives have increased but, as Eleanor Scott said, there are still vacancies. Are vacancies the result of shortages in certain specialties or are boards using vacancies to offset costs?
We do not have the level of detail to give you a full answer. I will offer a couple of comments, then invite Audit Scotland to come in and support with a fuller answer.
First, vacancies will never disappear, as we all recognise. There is natural turnover in the system. I am not qualified—neither is anyone here—to say what that level should reasonably be in the nursing workforce, let alone the NHS as a whole. Secondly, recruitment is taking place but, particularly in relation to the nursing statistics, we cannot talk significantly about the loss of nurses from the NHS. The NHS needs that total picture to manage its workforce well. I am sure that Audit Scotland can provide a fuller answer.
Barbara Hurst (Audit Scotland):
We have no evidence that boards are deliberately not filling vacancies, particularly consultant vacancies, to manage some of their financial pressures. However, it is fair to make the link between nurse vacancies and the spend on bank and agency nursing. Something obvious is going on there. Boards should be tackling some of the efficiencies in terms of nurse recruitment.
Were there any examples of nursing recruitment being tackled, or of boards using innovative schemes to reduce the use of agency nurses?
We are about to kick off a study that revisits nursing, so we will pick up the bank and agency aspect in that. There has been a reduction in the reliance on agency nursing, which is good, so most of the increase has been in the use of bank nurses, which is better in relative terms. However, we will consider this in more detail, particularly as we previously reported in 2002—as the Auditor General said—and that report does not seem to have had much impact.
I am delighted to hear that. I was going to ask whether you had any plans to review the matter following the work that was done in 2002. Some of the figures are worrying and some of us have concerns not only about the finances that are needed for bank and agency nurses, but about the quality and continuity of care. However, I will skip over that.
Your report says that the data on productivity and performance are not there at the moment. The Kerr report says that there should be even more of a shift from the acute sector into the community sector, but you are saying that we do not have much idea about what is currently happening in the community sector. Will the Executive's on-going work do enough to tackle the problems or will things potentially get worse?
A lot of work is going on in the health service to improve information systems and it hopes to make a significant improvement next year in how it captures information. There is no doubt that that work is urgently needed.
I return to exhibit 14, which shows trends in acute activity. Planned admissions—or "elective in-patients", to use the jargon—are steadily declining and the number of day cases and emergency in-patients are levelling off. When such trends emerge and extra resources are being made available through pay deals and so on to improve the flexibility and quality of care, it is entirely reasonable to ask the health service what is happening in the acute system.
One gap lies in the underdeveloped nature of information about out-patient activity. Endoscopy cases, for example, will possibly become out-patient cases rather than day cases, but we do not have the data to allow us to assess that. At board level, as well as nationally, the NHS still has a long way to go to capture the performance information that will be critical to running the service.
Is the NHS on the right track with the work that it is doing? The report states:
"A Strategic Review of Health and Care Statistics has been undertaken by the SEHD and ISD".
Publication of that review is imminent. Do you have any idea whether it will satisfy your concerns?
I ask my colleagues to comment on that. We would not want to second-guess what is happening, but my colleagues can give a general impression of how things seem to be moving along.
We understand that the review is considering filling in the data gaps on community activity and we want to find out the timescale within which that can be achieved. We need the information sooner rather than later and would want to consider such matters in a bit more detail.
NHS Quality Improvement Scotland collects information to satisfy itself that individual hospitals and health boards are meeting the stringent demands that are placed on endoscopy, for example. Is there a bit missing in the translation of that information to ISD Scotland?
To tell the truth, I do not know how the flows of data work between NHS QIS and ISD Scotland. NHS QIS's data will be more qualitative than ISD Scotland's data, which are more quantitatively based. However, there appears to be a slight missing link in the chain between the quality outcomes and the activity that is going on. We hope that the strategic review of data will also address that.
You said that the NHS in Scotland lacks information to monitor progress on improving mental health and well-being. I agree with what has been said about suicide rates. Obviously, a target to reduce suicides is relevant, but such a target cannot be the sole measure of improvements in mental health. What would meaningful targets be?
That puts us on the spot. Mental health obviously involves far more difficulties than cancer or coronary heart disease, for example, as there are obvious outcomes for cancer and coronary heart disease. However, I would have thought that there would be indicators for long-term mental health that relate to the ability to return to what most of us would see as a normal way of life—I am referring to things such as return to the workforce and community involvement. The service users would have to be involved in developing indicators on what makes a difference to their lives.
Involving them would be relevant.
As members have no more questions, I thank the Auditor General for Scotland, Barbara Hurst and Angela Cullen for helping us with the report.