“An overview of the performance of the NHS in Scotland”
Item 3 is consideration of the report "An overview of the performance of the NHS in Scotland", which was published while we were in recess and on which we will receive a briefing from the Auditor General for Scotland.
The report, which came out on 5 August, is our first integrated report on the overall performance of the NHS in Scotland. We have compiled it by drawing on a range of information that is published by the health service in various ways. As I said earlier, the report complements our series of financial overview reports. The next of those overviews, which will relate to the financial year 2003-04, will be published in December this year.
It goes without saying that the NHS in Scotland is a large and complex organisation and it is hard to provide a comprehensive picture of performance. However, in the report we comment for the first time on the NHS in Scotland's performance against the objectives and targets set by the Scottish Executive. We have covered seven areas that we believe are important to NHS patients and the public in general and on which we could find reliable information. The main headings are: how the NHS is organised; how performance is managed; health improvement and public health; NHS resources; NHS efficiency; waiting times; and outcomes and joint working.
I suggest that the report provides evidence to support many of the committee's findings in its eighth report, which was published on 2 July.
It is pleasing for me to be able to report that the NHS in Scotland has already met some of its key targets and is on track to meet others. For example, targets to reduce the number of deaths from cancer, coronary heart disease and stroke have been met or are likely to be met. However, the NHS will need to do more to achieve some of the other targets by the deadlines set.
On the resources theme, as members know, the NHS in Scotland spent around £7 billion in 2002-03, which is equivalent to £1,400 per person. Spending is due to increase by around £2.7 billion over the three years to 2005-06, which is equivalent to £1.8 billion after the amount has been adjusted for inflation. It is difficult to track where the new money is being spent, but, as the evidence that the committee took before the summer demonstrated, much of the additional investment is likely to be absorbed by cost pressures such as pay modernisation and the rising cost of drugs.
On page 17 of the report, in exhibit 7, we summarise the information that came from the Health Department for the report on the estimated future cost pressures. I should say that those numbers are not audited, not least because they are projections, not expenditure incurred. However, we hope that it is helpful for the committee to have some indication of those figures.
On page 16 of the report we refer to the costs of the consultant contract in particular. We say that average consultant earnings are likely to increase by around 20 per cent as a result of the basic contractual commitments, according to the current cost projections. In the table on page 17 of the report you will see that the consultant contract is expected to absorb £63 million in 2003-04, £85 million in 2004-05 and £100 million in 2005-06, making £248 million in total by the end of that planning period. For that reason, the new consultant contract is a candidate for a future study, as Caroline Gardner said a little while ago.
Part 3 of the report examines the information that is available on all the cost pressures and on staffing levels and vacancies. Although new money is being made available, we suggest in the report that in a number of areas and disciplines the new staffing targets will be challenging for the NHS in Scotland to meet.
Part 4 of the report draws on available information to attempt to address the question of how efficiently the NHS in Scotland uses its resources. For example, although bed numbers are falling, Scotland still has more NHS beds per head of population than other parts of the United Kingdom. In the acute sector, Scotland has more beds per 1,000 people than England, but fewer beds than Wales and Northern Ireland. I should point out that that situation varies among acute specialties. However, compared with other countries in the UK, our continuing care sector still has the largest number of beds.
Occupancy levels have increased only slightly, which suggests that there is no overall problem with bed capacity in Scotland, certainly as far as the acute sector is concerned. However, the levels vary from 58 per cent in one acute specialty to 95 per cent in another, which means that there might still be too many beds in some specialties and excessive pressure in others.
Acute activity in Scottish hospitals has fallen slightly over the past few years and exhibit 17 on page 29 highlights the trend since 1991. It is interesting and—I suspect—quite important to note that overall activity in hospitals is showing early signs of decline just as the service is starting to receive extra resources through the new pay deals and so on. The many reasons for that decline relate to changes in clinical practice and success in keeping people out of hospital. However, the data collection systems are not keeping pace with changes in patient care and it is difficult to find evidence to explain exactly what is happening. For example, we know that some patients who would previously have been admitted to hospital are now being treated as out-patients. In one census, the NHS recorded nearly 4.7 million attendances at out-patient clinics in 2002-03, which was around a 2 per cent reduction on the previous year. However, a recent survey carried out by Audit Scotland indicates that, in fact, there were more than 10 million attendances. That example highlights one of the areas in which information systems need to be urgently improved. Frankly, we are not entirely clear about the true picture in that respect.
Exhibit 17 also illustrates the quite marked changes in the pattern of admissions since the early 1990s. The number of planned admissions fell by almost 30 per cent while the percentage of emergency admissions rose by the same amount. That increase is accounted for mainly by older people.
We have included some analysis of cost data, which shows some wide variations across Scotland and among health boards in the costs per case. There are questions about the reliability of such data, and the NHS in Scotland needs to address the absence of robust and relevant cost data in certain important areas. Because such questions need to be tackled, members will not find that the report contains a great deal of comparative cost analysis.
In part 5, we examine the issue of waiting for care. The main message is that, although in-patient and day-case waiting-time targets are being achieved overall, work still needs to be done to achieve the waiting-time targets for the national priorities of coronary heart disease and cancer. In that respect, I find it very interesting and significant that in the year up to April 2003 the Golden Jubilee national hospital undertook many more procedures than was expected.
Part 6 summarises the available health outcome data. Health outcomes have continued to improve ever since the national health service was established and the rate of improvement shows no signs of slowing. We recommend that the Health Department might develop better outcome targets for the important area of mental health, in which the only main target is for reducing deaths from suicide.
The final section of the report considers the issue of joint working and the pressures on health and community care services as the number of elderly people increases. For example, almost all the increases in bed days occupied by emergency in-patients relate to people who are 80 or older, and more than 90 per cent of delayed discharges occur after emergency admissions. There are many fewer NHS long-stay beds, and average occupancy levels in care homes have risen to 90 per cent. The number of people who receive home care from councils has fallen by a third since 1995, but those clients are receiving more and more intensive services. Given the projected increases in the numbers of very elderly people and the fact that fewer people are receiving more intensive services, it follows that there is likely to be a capacity issue in future.
In conclusion, our report confirms that much is being done to improve health services in Scotland. However, a recurring theme—which the committee has already explored this morning—is that better information is needed to track the effect of increased investment and changes in service delivery. Better information is required on costs and activity across the whole health care system and on the quality of services from the perspective of patients. The national and local challenge for the NHS in Scotland is to ensure that spending increases lead to better outcomes and services for patients and to reduce the persistent health gap between affluent and deprived communities in Scotland.
As always, convener, my colleagues and I are delighted to answer members' questions.
Thank you very much. Of course, the committee will discuss our response to the report later in the meeting. If members wish, they may now ask any questions that might be pertinent to the report and help our later discussion.
Auditor General, you mentioned that local authority support for elderly people had fallen by a third in one sector. Will you expand on that comment?
On page 43 and 44 of the report—[Interruption.] I am sorry; I was being led up an alley. That matter is addressed in a short section from paragraph 207 onwards. Paragraph 209 says:
"Since 1995 the number of people receiving home care provided or purchased by councils has decreased by about a third."
That comment refers to council services, not to what is happening in the private care market. For a few years now, the local authority performance indicators, which we record, have shown quite a noticeable decline in the number of people who receive local authority home care services.
Paragraph 209 goes on to say:
"The number of home care hours has increased by around 13% since 1998",
which means that although the number of hours has been increasing the number of clients covered has been falling. As a result, councils are targeting home care on those who need most help. We point out in paragraph 209 that
"The number of clients receiving more than 10 hours of home care per week has increased by 50%, and two in five users now receive more than 19 hours of home care each week."
The general pattern is that local authorities are providing more intensive services, but to fewer people.
The report does not contain any information on what is happening outwith the local authority sector but, given the growing number of elderly people and the fact that intensive care packages are costly to deliver and resource-intensive, there must be a concern about capacity issues in future. Moreover, there is a question mark over what might be called less intensive care packages for the elderly who are becoming frail and need support to be maintained comfortably and well in their homes in order to avoid being admitted to hospital. That section of the report raises some probably quite significant issues.
Yes, and the question is how to collect information about what has happened to people who might have received support in the past but who are not receiving any support at the moment.
You are absolutely right. Over the summer, we published a report on commissioning community care services in which we started to explore some of those issues. We are also collaborating with the ISD in Tayside on a very detailed and interesting piece of work that examines how decisions made at one end of the system have an effect further along. We are calling it a whole-system approach to delayed discharge, but we are also trying to collect very detailed information that might answer some of your questions.
I want to confirm that I am getting this right. According to your figures, the system has experienced a 31 per cent increase in consultants since 1995, a 5 per cent increase in nurses and a 37 per cent increase in allied health professionals and we seem to have more beds per head of population than England and Wales, yet the amount of activity in the system is reducing. Has the Health Department made any attempt to explain why, given that there is a £2 billion increase in investment in the work force, activity levels are dropping? The number of day cases has plateaued since 1999 and is now heading downwards. That is extremely worrying and, economically, in some ways it is madness. Does the Health Department have a real explanation of what is going on in the system? Another factor is the Golden Jubilee national hospital, which treated 9,300 patients last year, yet there is no addition to the overall total activity in the system. What is going on?
I will have a go first, and I will ask Barbara Hurst to pick up on the bits that I miss out.
We know that activity is tending to move from in-patient care down to day-case care and on to out-patient care. We also know that, as we have discussed already this morning, the systems for collecting information about which services are being displaced into out-patient care are not good enough. Let me give as an example a procedure such as a cystoscopy, which was regularly carried out on patients who were admitted overnight 10 years ago. Five years ago, cystoscopy was regularly carried out on patients who were admitted as day cases but now, in most cases, it is performed on patients as out-patients.
Our work suggests that information on out-patient activity is not collected systematically enough to be clear on the number of such procedures that are carried out. To complicate the issue further, a lot of that work is not carried out by consultants or doctors; it is carried out by nurses and other practitioners. We know that information about some of that out-patient activity is being lost. That said, that probably does not account for the entire gap. A number of theories are being promoted, not only in Scotland but United Kingdom-wide—at the moment they are no more than theories—about what is going on.
We were interested in those figures, too. Obviously, the drop in hospital activity raised a number of questions. In particular, it links back into our earlier discussion about the poor information that is available to show us what is really happening in the health service. For example, in the day-case report we found that, in terms of targets for some of that activity, the results were very mixed. In addition to the lack of information, there are clearly underlying issues that we need to look at.
I come back to the point about the Golden Jubilee national hospital because it is crucial. All members of the committee thought that when we bought the Golden Jubilee national hospital its work would be additional to what was already being done in the service and would give us a lift in activity, but it is clear that that has not happened. That work must be a substitute for activity that was going on elsewhere in the system.
It is not as straightforward as that, because of the other complexities. As well as cases being substituted or displaced out of in-patient care, it is likely that the case mix is getting more complicated because people who are now being admitted as in-patients are, on average, sicker than previous patients were, and lengths of stay are changing. The impact of delayed discharge is also important. A number of things are going on that mean that it is not a simple case of saying that fewer admissions mean that less health care is being delivered, but it is also true that neither the Health Department nor Audit Scotland can at this stage show how that new activity is made up compared to what was happening before.
I understand that, under the old purchaser-provider system, payment was made according to the activity levels in the system. What happened to that information stream? Was it discontinued?
How much of that information is still available is a question for the Health Department. I do not know.
I will raise two issues, the first of which is still on the subject of activity levels. I am concerned that a myth is perpetuated all over the place that hospital activity levels are the key indicator of activity and even sometimes, by extension, of performance generally within the NHS. Therefore, I welcome all the observations that Audit Scotland has made about some of the shifts in activity and about how much is happening in the community and in other settings.
My point follows on from our earlier discussion and some of the comments that I made. How do we accelerate the process of getting an accurate picture? Could Audit Scotland do anything else in that regard? I have a concern about some of your reports on the NHS, as you still look at hospital activity levels a great deal. I am sure that your response to that would be, "Well, that is where the data exist and are collected." Through the audit processes, what could the organisation do to shift some of the measurement towards non-hospital-based activities, which, as you have said, account for a growing amount of activity within the health service?
I will give an initial response to that point and I am sure that Caroline Gardner will develop it and, if necessary, correct me.
If Susan Deacon looks across the piece at the range of studies that we have produced on the health service, she will see that they cover a diverse range of topics—everything from general practitioner fundholding to the management of medical equipment and studies of community care. A recurring theme in each of the studies has been the inadequate nature of the data that we find to work with. It is commonly the case that we have to capture and clean up information in order to provide a report to the Audit Committee. Therefore, I would not wish the committee to form the impression that somehow we simply operate on the data that are available; a lot of our effort goes into capturing data.
I think that we are having some success in providing support to the Health Department and health boards because, once we have collected data, that makes a useful framework that can be taken up by health service managers to bed down information systems that will be of value in the future. Occasionally, we revisit topics. We have revisited day-case surgery a few times, drawing on information that is collected by the department following on from the study that we did back in the 1990s.
My other general comment in response to Susan Deacon is that often the figures are not the answer to the problems—they raise questions, as much as anything else. As she rightly points out, analysing trends in acute activity raises questions about whether we are looking at the right things. For example, it raises the obvious question of the need to go below that level to understand what is happening in health systems. That is why we do a lot of studies that follow from the general overviews and start to drill down. We intend to drill down in the whole area of how the consultant contract is being managed because, on the surface, the information is not there to provide a good picture.
It is fair to say that we share Susan Deacon's frustration about what we can and cannot look at but, as the Auditor General says, we try.
In our consultation programme on our future studies, there is a study on chronic disease management, which would provide a good opportunity to start to look at the treatment of people who would have been in hospital in the past but who are now being maintained in the community. I am hopeful that the quality and outcomes framework for the GMS contract should start to give us better information about what is happening in primary care. It is not all doom and gloom on that front. We are keen to explore how we can access some of that information.
I am grateful for the responses that I have received. It is worth reminding ourselves that this is not just an academic exercise to collect figures; the really frightening thing is that the data that are collected and used for performance measurement—in some cases they are even linked to people's pay—will drive what people give attention to, so my point is directly linked to George Lyon's fundamental question about what the additional investment is delivering. I am conscious that we need to get all those things facing the right way in the health service.
Before I raise my second point, I will ask a further question about data collection and activity levels. Would you like to say anything about information technology systems? I am conscious that relatively little is said about IT in both Audit Scotland's reports and the various pieces of information that we have had from the Health Department. However, surely IT is the key not only to accurate and effective data collection systems but to efficient data collection systems. Nobody wants to give pressurised health professionals additional burdens of work in relation to filling in unnecessary forms, but we see in all sorts of other sectors that IT allows data capture to be woven into people's way of working. Data are captured as people go, through good categorisation systems and the like. As I understand it, we are nowhere near that in the health service, although south of the border a huge amount of energy and investment is going in to ensure that modern and effective ways of working are in place and that full use is made of technology. Would you like to comment on that? Are you examining that area? Do you agree that it is a critical dimension to the debate?
I agree that it is a critical dimension. In most of the reports that we have brought to you during the past 18 months or so, the recurring theme is IT. We are keen to start to look at some of the strategic development that is going on and to link up with our colleagues at the National Audit Office, who are doing something similar in England. We intend to examine the matter—it is certainly in our consultation programme and I would have thought that it is a front-runner for us to pursue.
In paragraph 70, on page 16 of "An overview of the performance of the NHS in Scotland", you detail expenditure of
"£1.8 billion in real terms",
which is the expenditure that the Executive is putting in up to 2006. It is split into just over £1 billion for drugs costs, the consultant contract, the GMS contract, out-of-hours care and increased staffing; £250 million for primary care facilities and IT; and £90 million for tackling delayed discharge. That adds up to £1.4 billion, but you go on to say:
"this does not include … costs for implementing Agenda for Change or any additional costs arising from full compliance with the New Deal".
Further on in the report, you say that the estimated cost of the agenda for change is about £248 million—I take it that that is in real terms as well. That takes us up to £1.648 billion, which leaves only £152 million to cover the new deal for junior doctors or any unexpected pressures that come along. There is not much headroom. What are your views on that? Do you think that an extra bill will come in for the new deal for junior doctors?
Your summary of what the numbers tell us is accurate, although it should be borne in mind that they are projections and not actual numbers. The picture is clear: the new money, discounted for inflation, will largely be absorbed by pressures that are already in the system.
So there is no extra money at all for new investment, apart from what is accounted for.
We would not go that far, but there is certainly a lot of pressure in the system.
I am interested in how users of the health service are engaged in determining whether it is improving. I am a reasonably regular user of the health service—whether clinics, hospitals, my GP or whatever—and I have never been asked what I think about the service. How is that work done and what plans are there to improve it?
You would need to ask the Health Department about that. When we started scoping the report, we were interested in including information on that, given that a patient-centred service is one of the key priorities of the health service, but we did not find much information. In most of our studies, we are keen to include a patient or user view of the service. We know that that is difficult, but we expected to find more information when we tried to collect it.
In Paragraph 117, on page 24, under "Management and administration staff", a number of statistics are given on the increase in the number of staff, particularly on the clerical side. There has been a drop in the number of senior managers, which is not a surprise given that there has been a degree of reorganisation. My understanding is that the overall growth in the number of administrative personnel is greater than the growth in the number of clinical staff. We have heard questions about measuring outputs, and we know that some clinical staff have been recruited because of issues such as the working time directive and so they do not necessarily lead to an increase in output. Can you shed more light on why the administrative and clerical side seems to be growing at such a rate even though the people who are trying to run the service are looking for greater output on the clinical side?
Initially we were not going to add that paragraph to the report, because we were trying to consider the targets, but for completeness we thought that we should add it. I am not sure that we can shed much light on it, except that there are some issues around definitions. Sometimes there is movement—for example, someone who has been categorised as a nurse becomes a nurse manager—but that would not explain the clerical staff issue. The issue relates to the point that Robin Harper made about the reductions that would be expected to follow unified systems. I suspect that there might be some reductions under the shared services project, which examines bringing together back-room functions such as payroll and human resources. I am afraid that I cannot add any more than that at the moment.
We can say that if the increase in administrative and clerical staff is less than the increase in total costs, the obvious inference is that the increase in clinical staff is greater, simply because 70 per cent of total costs are direct staffing costs. However, as Barbara Hurst said, there are some definitional difficulties that make it difficult to make a straightforward comparison of the two.
That exhausts our questions. Under a later agenda item we will discuss how to respond to the report. I thank the Auditor General and his colleagues from Audit Scotland for answering our questions.