“Overview of the National Health Service in Scotland 2002/03”
Under item 2, we will consider a response from the Scottish Executive to our eighth report in 2004, which was on the "Overview of the National Health Service in Scotland 2002/03". I will be inviting committee members and the Auditor General to comment, after which we can discuss what action to take. There has been a lot of activity with regard to the NHS—we have had inquiries, there have been reports, and there are further reports coming down the line. I therefore thought that it might be better to ask the Auditor General to give his response first, so that we can have some context. After that, members can come into the discussion. I see members nodding, so I think that they agree with my suggestion.
I welcome the Auditor General, Robert Black, and his team to the meeting and invite him to respond to the Executive's response to us.
Mr Robert Black (Auditor General for Scotland):
Thank you, convener, and I must say what a great pleasure it is to be in this building at last, in this magnificent committee chamber.
The response that the Scottish Executive Health Department has provided is very useful as an information base for the future. I am conscious that it has come as a result of the report that the committee produced in June; it is right to advise the committee that a further overview of the financial performance of the NHS will come out in December. The department's response contains new information that complements and responds to the committee's report.
This morning, the committee will consider my report "An overview of the performance of the NHS in Scotland", which also contains a lot of information on a similar theme, and the financial overview report will come out in December. Therefore, the committee may wish to consider how it will pull all that information together for the future. It may be appropriate for you to consider not taking any further evidence in relation to the information provided by the department until such time as we have more information on the financial performance of the health service as a whole.
There is much detailed information in the department's submission and, as might be expected, some of the numbers are different from numbers that we have seen previously and from some of the numbers in the performance overview report. That partly reflects the continuing dialogue with the department and the attempts to strengthen the information base; it also partly reflects the reality that we are dealing with a moving picture.
I hope that that context is helpful to the committee in deciding how it wishes to progress.
Thank you—that was very useful in giving us a base for our discussions on this agenda item and for other discussions with regard to the NHS.
I pick up on the Auditor General's last point. You spoke about numbers in the Health Department's response that are different from those in your report and you spoke about a moving picture. Will you give a more robust explanation of what you mean by that?
I will need to turn to my colleagues from Audit Scotland to expand on that. We have not analysed in detail the response to the committee's report. The picture continues to change because there is so much change going on in the health service with regard to the estimates of the costs of pay modernisation, the consultant contract, the general medical services contract and so forth.
Caroline Gardner (Audit Scotland):
We have been scrabbling through the pages of the department's response since George Lyon asked his question. As an example, in section 2 of the schedule that forms part of the response, there is a breakdown of additional funds that were provided to health boards in 2004-05 for the consultant contract and the GMS contract. On a first reading and with the analysis that we have been able to make so far, those figures look slightly different from the figures in the report. However, we need to go away and reconcile the two sets of figures to understand the basis for those differences.
As the Auditor General said, I suspect that the Health Department's estimates are becoming better refined as the contracts start to be implemented in individual health boards, and the figures are being clarified as they are based on real evidence rather than on assumptions. The two sets of figures will continue to converge over time as we get more clarity about what underpins them.
Forgive me if I have this wrong, but I remember that we asked previously for a costs projection to 2006. A number of the health boards that gave evidence to the committee gave us a tabular exposition of what they thought the costs were, but we got no answer back from the Health Department as to its view of the costs over the next two to three years. I note that the department's response covers only 2004-05 and that there is still nothing for 2005-06.
That is correct.
Is that because the department does not yet have that information?
You will have to ask the Health Department that question. However, I will jump ahead and refer to the Auditor General's report that is to be considered next on the committee's agenda. We have some estimates that we have agreed with the department for year-by-year costs through to 2005-06. The information is gradually becoming more available, but it is still moving.
Our report stated:
"the Committee concludes that the Department is not in a position to measure whether planned efficiencies will be delivered; whether the benefits of pay modernisation will be achieved; and whether the service to patients will improve as a result."
It seems that the Health Department has not addressed that question in its response. I was looking for mention of activity levels or the benefits that would flow from a more efficient way of working, but there is nothing. What is the Auditor General's view on that?
It is true that there is not much in the response, but the committee should pursue that with the Health Department if it wishes.
Convener, are we to confine our comments at this stage to questions to the Auditor General or are you looking for more general discussion?
Although we have had a dialogue about the general nature of the statistics, this is an opportunity to comment on the response without having to ask the Auditor General about it.
I am happy to take the opportunity to do that, although should the Auditor General wish to comment on any of my observations, I would be grateful for those insights.
I am struck by a number of points in the response. First, I echo what the Auditor General said in that the response provides a useful information base for the future. It provides us with a detailed account of a range of areas of activity in the department and a range of the department's expectations of what pay modernisation will achieve, for example. On one hand, that is welcome and it is good that we have the information, which was not shared with us in such detail before, because it shows that the process of scrutiny and committee examination works. On the other hand, I am bound to ask why it has taken so long to get some of that detail from the department. However, I will leave that sticking to the wall for now.
After reading the response in detail, although I am reassured about some of the work that is in place to measure and monitor—one of the main concerns of the committee and indeed of the Auditor General—I think that the answer to the question of how change will be achieved, driven and incentivised is still missing in the lengthy response. A great deal of process is identified in that regard, for example, and a great deal of emphasis is put on the work that is being undertaken by the centre for change and innovation, which I welcome. I note for the record that the centre was recognised as being necessary some time ago and not just in "Partnership For Care: Scotland's Health White Paper" and that a commitment was given in the Scottish health plan two years earlier, in 2000. I am pleased to see that centre motoring and developing its work. However, simply having a centre in place to develop such work will not deliver results. Something is still missing from the Health Department's response about how change and improvement will be achieved.
There are a lot of warm words in the covering letter from Ian Gordon of the Health Department. The letter says:
"Pay modernisation recognises the crucial importance of incentivising the staff of the NHS to deliver on the change agenda".
Those are laudable words and aspirations, but I am still left asking detailed questions about what those incentives are and, indeed, what the change agenda is in this context. Also, the second paragraph of that letter identifies a number of service improvements that are under way with which I agree, such as the development of one-stop clinics, allied health professionals working in the community and the development of managed clinical networks, but those measures are not new and neither is that direction of travel. I am conscious that I am speaking as the former minister in this portfolio, but I am not just pointing back to my time in that role, as I am also referring to the time before that and even to the period before the change of political leadership in 1997. What was not in place at that time was the investment to implement those changes, but the direction of travel and the desire to see service redesign and change in the health service has been with us at Government level for years, possibly even for decades.
The tone that runs through the response is that the department has suddenly discovered lots of things that need to be done and that it is now motoring on them. Nobody is happier than I am to see evidence of where change has taken place—as it has in many areas. However, I guess that my substantive point is that there is not enough in the response from the department to give me confidence that change is happening in the NHS in Scotland at the pace and scale necessary or that the mechanisms are in place to ensure that such change happens. That is not just the $64,000 question but the £X billion question in Scotland.
However, although there are still unanswered questions, the response provides welcome information and clarification on a number of points. I am at a loss to know where the committee goes from here other than to add our insight and analysis to what will continue to be one of the major debates in Scottish politics for a long time to come.
I am not terribly happy about the response to our 12th recommendation, which was made in paragraph 68 of our report, in which we asked boards to pay
"particular attention to removing the duplication of functions and reducing management overheads."
A general commitment to produce efficiencies seems to exist in almost every branch of the NHS, except management. The tone that the response takes is that problems arise because different boards have different structures, so an overall target cannot be set. I would welcome the Auditor General's comments on the response. Could targets for reducing administrative costs not be set for boards individually?
That would be a policy matter for the department. In theory, there is no reason why a target could not be set, but a much wider context of what the department is trying to achieve has been set out.
Could you remind us of or bring us up to date on work on the best-value framework in the health service? Where do we go from here on that?
The situation throughout the Scottish Executive is that securing best value was made a duty of accountable officers back in April 2003, I think. Draft guidance was issued in April this year and was made available to accountable officers, and it is closely related to the guidance to and requirements on local government under the Local Government in Scotland Act 2003. However, much variation remains in how best value is applied in practice throughout the public sector outside local government. In Audit Scotland, we are developing our thinking on how we might assess how well public bodies are responding to the new duty, but it is fair to say that the duty is less well defined outside local government than it is in that part of the public sector.
I presume that discussion continues about how best value should be delivered in sectors such as the health service.
Implementation of the duty to secure best value is a matter for the Scottish Executive, its departments and non-departmental public bodies. We have discussed with them the draft guidance and our view of what audit might add to that, but that is still work in progress.
I have said before and I will say again that I find it difficult to apply conventional best-value measures to the information that we receive—I am trying to get a handle on that. There seem to be many ways of measuring what goes on in the health service. Should doing that eventually become more simple and straightforward, or is that a vain hope?
I am not sure whether best value is the answer to that problem. Best value involves a much wider set of questions about what the health service is trying to achieve, how it is organised to do that and how it monitors and reports on its performance. Agreement to priorities locally and to systems to show how well those priorities are being achieved will be a step forward, but the underlying problem of difficulty in obtaining information will remain.
We need to pursue two or three questions, but I guess that we will discuss some of those issues when we debate "An overview of the performance of the NHS in Scotland". Item 1 is that the Health Department has failed completely to address the fundamental questions that we have all been asking, which are how the success of pay modernisation is measured, what the objectives are and what information will be gathered to measure whether the objectives are reached. Those are simple questions. More than £2 billion extra has been put into the NHS and a measure of whether the system improves must be in place.
Activity levels are fundamental—we will discuss them in relation to the overview report—because the ordinary taxpayer out there thinks that they will have more activity from the service and shorter waiting times. That is not mentioned in the department's response.
I would be interested in having clarity about the increase in hours contracted to the service, which the response says is from 21 to 30 hours, and in finding out the number of consultants who work the bare 21 hours. Consultants have told me that the deal will reduce rather than increase the number of hours that they work, because the consultant contract was predicated on the experience south of the border, where private consultancy work was a much greater issue. I would like clarity on the number of consultants who currently work the minimum 21 hours and on the number who already work 30 hours a week, because in some ways they will receive the salary increase for working their current number of hours.
The response says that a major review of NHS statistics is being undertaken and I would like clarity on that. Will the Auditor General comment on that claim? I take it that the review's purpose is to answer some of the questions that we keep asking.
The response says that consultants could be paid twice under the old system. I would like clarity on what that was about. How big an issue was that under the old consultant contract?
The department also states that it is about to develop a new vision for the NHS. Some would say that that is a little late, but it would be interesting to see a bit more detail about what on earth that new vision will be about.
I would also like to know how many one-stop clinics have been established, because the department claims that that is a beneficial new development in the system.
I am unsure whether the best route to take is to put that ball back in Audit Scotland's court.
If Audit Scotland could provide the information, that would be helpful.
I will be happy to hear from Caroline Gardner in a second, but the scope of George Lyon's questions and members' comments is such that we are concluding that we will have to write a letter to ask questions for the Executive to answer directly. That is because questions have been asked about statistics and pay modernisation—Susan Deacon asked about that and George Lyon touched on it.
I invite Susan Deacon to speak before Caroline Gardner, so that we may be able to wrap up our discussion.
In my earlier stream-of-consciousness comment, I forgot to mention an issue on which I would very much welcome the response of the Auditor General or his team. Members may have noticed—I am sorry that the document's pages are not numbered, but I am referring to text at the bottom of roughly page 4—that a confirmation is given that
"a major review of Health and Statistics … has now been launched."
I say one cheer to that, because as we have all agreed, that is absolutely needed. I will reserve my two cheers, partly because the question is raised why the department has taken so long to undertake a review and has had to be dragged kicking and screaming into it.
Where will the review go from here? Does the Auditor General have any comment on or insight into how the department intends to develop it? Will Audit Scotland be involved? How will we ensure that we have in place robust—but I hope not over-engineered—data collection systems that give ministers and in turn the Parliament the performance information that is desperately needed for the NHS?
In the response, I see again much information about consultation and process. A huge number of people will be consulted about what the system is to look like. It strikes me that if ever there was an area in which what was necessary was not a huge amount of consultation but a bit of sharp action to put in place the systems, this is it. I would very much welcome comments from Audit Scotland, because I know that this is an area in which it has considerable expertise.
I will respond first to the questions that George Lyon asked. We have a similar interest in the way in which the consultant contract is implemented and the way in which the benefits are gained. We are consulting on a study of the implementation on the contract, which will be carried out over the next 18 months and we will come back to the committee on that. That is probably the only way to answer George Lyon's questions, because the underlying information is simply not available nationally at the moment.
Are you suggesting that we cannot ask the Health Department how many consultants currently work the 21 hours under the old contract?
Absolutely not. I am saying that we are consulting on a study on how the new consultant contract will start to deliver some of the changes to which the department refers in its response. The only way to explore detailed information on that and, for example, on the number of one-stop clinics available is to ask the department. I will ask Barbara Hurst to answer the question on the review of statistics and information.
Barbara Hurst (Audit Scotland):
My understanding is that the information and statistics division of the health service kicked off work on that a while ago. We are keeping in touch. We have not conceptualised the work in the way in which the department has in its response to you, but we are certainly aware that it is going on. I am happy to do a bit of follow up work to find out what is happening and bring it back to the committee, if that would be helpful.
I have a comment to offer—I might be stating the obvious, but it is probably worth putting on record. As I am sure Susan Deacon will acknowledge, it is for management in the health service to determine what management information is needed to run the service. It is not the role of anyone in Audit Scotland to second-guess the role of management. However, if we can provide support to help to ensure that the right sort of information is collected in a way that is both robust and informative about some of the performance issues, we will do so. That is a role that we are happy to play throughout the public sector but, ultimately, it is for management to determine what information it wishes to collect.
I just want to clarify a point. I am grateful for the Auditor General's response and, given Barbara Hurst's offer to find out more, I wonder whether we could get clarity about the department's definition of "early action". It says in the response that it will
"take early action where possible, and … make recommendations for further developments in a report in April 2005."
It will take the best part of a year to hear recommendations for possible further developments that will not have been actioned at that stage. The lag time for changing data collection systems is years, not months. It is in keeping with the discussion that the committee has had for us to get clarification, which I would very much like, on the early action that we can expect.
It is clear that members feel that a number of questions have yet to be resolved. I propose that, although we have further NHS work before us, the route open to us is to draft a letter to the Health Department, including the Official Report of today's meeting and outlining the topics raised. At that stage, we will have to ensure that members are comfortable that the points that they are concerned about are being raised. I will then send the letter to the department on the committee's behalf seeking clarification.
I am not entirely convinced that we will get all the answers that members want. The response might simply reveal that some information is not being gathered or that the department is not at a stage to answer our questions. However, that might satisfy members, as it would reveal that the department does not know the answers. I can see no other way of satisfying members' demand for further information. It is the department's job to answer the questions; Audit Scotland can only point to what has been going on with regard to its process. As the Auditor General points out, Audit Scotland is not responsible for the information that is compiled. Would members be satisfied if the clerks drafted a letter on the committee's behalf? Normally we can just send letters off because we are quite clear about the points, but so many points were raised that we will need to circulate the letter first, so it might take a week before we have it ready. Is that agreed?
Members indicated agreement.
That covers agenda item 2. Just before we move on to agenda item 3, I offer apologies from Margaret Jamieson, who is unable to make today's meeting.