“Overview of Scotland's health and NHS performance in 2006/07”
The second item on the agenda is consideration of a report from the Auditor General, "Overview of Scotland's health and NHS performance in 2006/07". I invite the Auditor General to introduce that, please.
Mr Robert Black (Auditor General for Scotland):
I bring to the Audit Committee my overview report on the national health service, which was published on 14 December. Each year, we bring to Parliament an overview of the financial performance of the health service, and every second year over the past few years we have prepared a report that looks at NHS performance in the round, as well as at its finances. This year, it is a comprehensive report on the overall performance of the health service.
The commentary in the report, especially on financial performance, is drawn mainly from the reports by the auditors on each of the 14 health boards and the nine special health boards in Scotland. However, for the performance work, we also draw on our public performance reports and a variety of sources that are available to us.
The first three parts of the report look at performance and delivery, and the final part looks at financial performance. Members will appreciate that there is a lot of information in the report. Given the fact that this is the first time that the Audit Committee in this parliamentary session has had the opportunity to consider the performance of the health service in the round, I thought that it might be helpful if I took a few minutes to highlight some of the main findings.
The first part of the report considers the question, "How healthy are we?" The graphs and charts in the report attempt to summarise key features of the health of people in Scotland. Much of this information will be familiar to committee members from press coverage over the years, but the report attempts to pull it all together and share with you some of the high-level messages. The numbers of deaths from major diseases including coronary heart disease, stroke and cancer have decreased significantly and life expectancy has improved. Nevertheless, life expectancy is still lower than the European average and there are still big inequalities in health outcomes. There is, for example, still a seven-and-a-half-year gap between the life expectancy of men in East Dunbartonshire, at 78 years, and the life expectancy of men in Glasgow, at 70.5 years. Also, areas with a high level of deprivation continue to be linked to higher death rates, to higher levels of major diseases and to more alcohol-related problems.
Scotland is still ranked behind other countries in many areas of health and well-being. The United States is the worst in the Organisation for Economic Co-operation and Development group of countries for obesity levels, but Scotland is second to the US with more than 25 per cent of the adult population being classified as obese. For teenage pregnancies, Scotland has the fourth-highest rate in the OECD countries, with NHS Tayside having the highest rate in Scotland.
The second part of the report looks at how the NHS is performing. In previous reports, I have commented on the difficulty of getting an accurate and balanced picture of NHS performance in the round, and that is still the case. The best information is still found in the acute hospital sector. Overall spending in the health service as a whole rose to £9.4 billion last year, but in the acute sector the increased investment does not appear to be matched by increases in traditional consultant-led activity, according to the information that was available to us. For example, consultants' out-patient activity shows a downward trend.
Exhibit 12 on page 12 shows that, at the same time, the number of emergency attendances at hospitals has increased—by 50,000 in the past year. The number of day cases has also risen, but planned admissions have been on a downward trend over the past decade and recently have remained fairly static.
I draw members' attention to exhibit 11, on the same page of the report, which shows a significant increase in accident and emergency attendances over the past two years, taking them back to a peak that was last seen in about 2000. The data for 2007 are provisional, but the general picture is undoubtedly that there has been a big rise. In the primary care sector, contacts between patients and their general practitioners have remained static over the past three years.
The Scottish Executive, as it was then called, introduced 32 new performance targets—known as HEAT targets—for the NHS in 2006-07. There are four categories of target: health improvement, efficiency, access and treatment. In the report, I comment on performance against some of the key targets. Generally, performance against the targets is improving, but there are some exceptions. One is sickness absence levels, which continue to be high, with NHS 24 having a significantly higher level than other boards. Details can be found in exhibit 14.
One important primary care target is that people should have access to GPs or practice nurses within 48 hours. That target has generally been met, but under the new GP contract such information is no longer published. I am sure that that is a performance target of real interest to the public, who must want to know how long it takes to get access to primary care. I encourage the Scottish Government to ensure that it is reported on in future.
Performance against cancer waiting times has improved, with 87.3 per cent of all cancer patients being seen within 62 days, but that remains below the target that the Scottish Government has set. In the report, we touch on the fact that the Government has directed cancer support teams to boards with the poorest performance.
Performance on in-patient and out-patient waiting times is good, and the Government has already met the 18-week waiting time target for in-patients. However, the abolition of availability status codes could make it challenging for health boards to meet such targets in future.
Delayed discharges have decreased over time, but 40 per cent of the patients who are ready to be discharged from hospital still wait for more than six weeks to get out. Readmission rates for elderly people—those who have to come back to hospital after a fairly short time—have declined marginally, but there is still much work to be done to meet the target of reducing the figure by 20 per cent by 2008-09. The trend in readmissions is described in exhibit 19 on page 17 of the report.
The HEAT targets were introduced to improve the performance and accountability of the health service in Scotland. However, information on performance is not published for all targets and is not brought together in an accessible format. As members can imagine, bringing together the information in an understandable form in one place involved a lot of work for Audit Scotland. The Scottish Government has several initiatives in place to gather information on costs, inputs, outputs and outcomes in the NHS, but those initiatives are not yet fully co-ordinated to give an overall picture of the performance of the Scottish health service. It is essential that the initiatives also support the Scottish Government's wider aim of developing outcome measures across the main public services.
The third part of the report looks at how the NHS is planning for major changes. The health service is undergoing a period of what is often called service redesign. Central to that is the intention to shift the balance of care from hospitals to community settings, but we do not yet have evidence that resources are shifting in line with the planned changes. As we show in exhibit 20 on page 21, the split of spending between the three main sectors—hospitals, family health and the community sector—has not changed in the past three years. The amount spent in each sector has risen markedly, but the relative percentages have not changed. The information that is available to us indicates that resources are not moving in line with the strategy.
Community health partnerships were developed to help to make the shift happen, but they appear to be making slow progress. It is not unfair to say that so far they have concentrated mainly on establishing structures and processes. CHPs now need to focus on delivering benefits for patients.
Agenda for change is still being implemented and, by last May, 94 per cent of the workforce across Scotland had moved on to the new pay scales. We have commented in other reports on weaknesses in the plans to deliver the benefits of pay modernisation, and it is still not clear whether the full benefits of pay modernisation have been identified and are being monitored.
The final part of the report describes how the NHS performed financially in 2006-07. The financial performance of the NHS improved in 2006-07, with an overall underspend of £98 million. NHS boards underspent their annual revenue budgets by £113 million, and only NHS Western Isles overspent its revenue budget. In 2006-07 the boards had an underlying recurring deficit of £92 million, which represented only 1 per cent of recurring income. That is forecast to reduce to around 0.3 per cent of recurring income in 2007-08. However, NHS Western Isles and NHS Orkney have underlying recurring deficits that are substantially higher percentages of recurring income than is the case for other boards, and that represents a significant risk to those boards.
Despite the improving position overall, NHS boards had to use non-recurring funding and non-recurring savings to record an overall surplus. In previous overview reports, I commented on the extent to which health boards were relying on non-recurring funding in order to break even, but that does not now appear to represent a major financial risk. Boards generated £74 million by disposing of assets. In the past, profits from the sale of assets could be used to fund revenue spending but, starting from this year, those funds must be used for capital purposes. That will increase the pressure on revenue budgets, as the boards will not be able to use those profits to support on-going services.
The level of underlying recurring deficits is low relative to the level of recurring income and is forecast to reduce in 2007-08. Nevertheless, the challenge of meeting the forecasts should not be underestimated. Boards continue to face a number of cost pressures including service redesign, pay modernisation contracts, meeting performance targets—including waiting times—and drugs costs.
In conclusion, the NHS is making significant progress in its performance against Government targets and in improving its financial health. However, I encourage the Scottish Government to develop a more comprehensive system for measuring and reporting all aspects of performance together. The way in which services are delivered is changing, and the NHS needs to develop better ways of capturing and reporting the benefits of those changes. In particular, it needs to provide better information on quality and productivity.
As ever, convener, I am supported by the Audit Scotland team, and we will do our best to answer any questions that the committee may have.
Thank you very much. I apologise for my delay in getting here.
I invite questions and comments from members.
This is an extremely important and useful report from the Auditor General. It is comprehensive and there are a number of important messages in it.
Part 1 of the report, which paints the overall picture of how healthy we are, contains some striking and worrying statistics. We have probably seen them before, but when they are brought together and presented collectively they paint a fairly depressing picture of the health of the nation, especially in comparison with the statistics from other countries round about. For example, exhibit 6 on page 8 shows the obesity rates. Scotland's obesity rate is almost exactly double that of Ireland, which is quite a small neighbouring country with, I presume, a fairly similar population. If I remember correctly, Ireland spends substantially less on health than we do. Have the Auditor General and his staff considered any of the underlying reasons behind the statistics, or was the exercise simply about presenting the information in tabular form without considering the wider issues?
The short answer to that question is that what we are doing in this report is simply pulling information together into one place for the consideration of the committee and Parliament.
Why obesity levels in Scotland are so high and why they have been rising so rapidly are important and worrying questions. Obesity is a problem that affects many western countries. There are many reasons for that, which need to be investigated further and which are being investigated further by the Scottish health directorates.
Some of the data show obesity linked to deprivation. For example, they show that women in more deprived areas are significantly more likely to have problems with obesity. On the other hand, the trend is the opposite for men: those in the least deprived areas are more likely to be overweight or obese. It is a complex picture and more work needs to be done to investigate the links.
I am sure that I do not need to tell members of the committee that the way to tackle the problem is not just to look at health alone; there are big questions of education, lifestyle, matters related to poverty and so on that need to be taken into account. However, that is not something that we have looked at.
Thank you.
My second question is on an issue that you mentioned earlier—sickness absence rates. Exhibit 14 on page 14 of the report shows starkly the serious issue that exists at NHS 24 in comparison with other health boards. What makes that all the more worrying is that NHS 24 is, in effect, a call centre, so one would have thought that the working environment would be less conducive to people suffering from the kind of work injury that is caused by, for example, nurses lifting patients. I wonder whether you can add anything to what you said about the reasons why NHS 24 sickness absence rates should be so much higher than those in the rest of the health service are.
The board is certainly aware, as you might imagine, that it has a problem. There may be one or two issues related to how the data are captured by the Scottish Government; I will ask the team to help us on that. However, there are particular problems associated with sustained periods of out-of-hours working for staff in a call-centre environment. It is generally reckoned that such environments tend to have higher sickness absence rates than do other types of activity. I wonder whether the team can add anything to that.
Barbara Hurst (Audit Scotland):
No. The situation is as the Auditor General said. It may seem counterintuitive, but call centres tend to have a higher percentage of sickness absence. NHS 24 links its higher rate to the stress of the job. However, it is clearly something that it needs to manage.
My question relates to exhibits 2 and 3 on page 6. We can see from exhibit 2 that there is a general downward trend in mortality rates in Scotland for heart disease and cancers. However, exhibit 3 shows that the incidence of such diseases is much higher in our most deprived communities compared with the rest of Scotland. Is there any indication of a downward trend in our most deprived communities? Or is it an upward trend? It is hard to see that from the data that are presented in exhibit 2. Can you say anything further about that?
Can we help with this from our background knowledge?
Nick Hex (Audit Scotland):
I am not sure that we can analyse the data to that level of detail. What we have shown in exhibit 2 is that mortality rates are coming down. However, there is still an issue about the difference in rates between deprived and less deprived areas.
Exhibit 4 shows that there are issues in relation to year-on-year changes in alcohol-related diagnoses in the most deprived areas, but that is probably a separate issue. I do not think that we have anything specific to show, unless Gemma Diamond can add anything.
Gemma Diamond (Audit Scotland):
No. We have specific detail only for exhibit 5, on chronic liver disease, which shows that increases in rates seem to be much larger for the most deprived population than for those in the other deprivation categories, which may hint at the underlying issue to which Mr Coffey referred.
It is obviously a worry that we do not quite know what is happening with that category of people. A further worry is that, on the first HEAT indicator in the table in appendix 1, no data are available in any format to show whether health is improving among deprived communities. It must be a worry that we do not know what is happening with that group—we do not know whether we are meeting any of the targets or making a difference at all. How can we get a bit further towards having answers on that category?
Mr Coffey points to the important issue that we do not yet have evidence on whether the NHS is making progress on some of the important HEAT indicators. Clearly, that first indicator is a key one for the new outcome frameworks that are being promulgated by the Scottish Government. The Scottish Government must be concerned to ensure that it captures information that indicates whether it is making progress on that indicator, which is closely linked to one of the 45 indicators that the Government has established as the long-term outcome indicators in Scotland.
As part of our work, we found that the Government had created a ministerial task force to examine health inequalities. The task force met for the first time in October 2007, so it is obviously too early to assess how well it is addressing the issue, but we will keep an eye on it in further pieces of work of a similar nature.
I have a follow-up question on the issues that Murdo Fraser and Willie Coffey raised. Is there an indication that health boards are making a difference in parts of Scotland by taking different approaches, or do we have a relatively consistent picture throughout Scotland in which all health boards use the money relatively similarly? I realise that, with deprivation issues, there are concentrations of problems in places such as Glasgow. However, from reading the report, I did not find out whether evidence exists that health boards can make a difference through more effective and imaginative use of resources. Do you have a take on that?
It is correct that the report does not go to the level of considering individual health boards. In other performance reports that we bring to Parliament and the committee from time to time that consider particular aspects of the health service, we will include examples of good practice that seem to be working well, if we can find them. I wonder whether we can help to give a general sense of the approaches that are being taken.
I do not think that we can do that, to the extent that would answer the convener's question fully. To return to Murdo Fraser's point, we have given a fairly high-level review, but we use the information, too, for targeting our performance studies. We could well follow up on some of the issues, which would be how we would discover which health board activities contribute to some of the data.
I am puzzled by the fact that you talk about the outcome measures that the Government has put in place when, notwithstanding that, the boards may not be capable of making a difference by using resources differently in their areas. That raises the question of what the boards' purpose is, if the ultimate determining factors are decisions that the Government takes and central imperative rather than local initiative. What are the boards doing and what is their point if we cannot find anywhere in the country examples of resources being used to make a significant difference in an area simply through local initiative?
From our knowledge of what is happening in individual health boards, which we develop through the external audit and our on-going contact, we can say that a large number of interesting and significant initiatives are taking place in individual health board areas.
The approach to area management in Glasgow, for example, is comparatively advanced, with area structures established and fully joined up between the health board and the council. However, at this point in time, because it is too early and the information is not available, I cannot come to the committee—supported by Audit Scotland—and give you any kind of indication of the impact of the structures on service levels. It would be unfair to give the impression that there is a lack of innovation in the health service at board level, but as I hope I mentioned in my opening remarks, it is important that health boards and the directorates work together and find ways of indicating clearly what levels of activity are taking place and what impact they are having.
Overall, there is a lot of positive stuff in the report, although the obesity problem is still worrying. I would be interested to see whether the trend is getting worse or better.
In exhibit 11, there is quite a sharp increase in accident and emergency attendances. The report says that they
"have reached their second highest peak in ten years."
I would like to look behind that figure and find out what is actually happening. Is there a correlation with anything? One of my worries is that overworked doctors are passing cases to accident and emergency that they would normally have been able to manage themselves. That is anecdotal, of course, but is there any evidence for anything like that or any other reason for that sharp peak?
There are certainly a couple of points to make in answering that. As the report says, the level of GP activity has been broadly constant during the past few years; there has been no increase or significant change in volume. It has been suggested, however, that there might be a potential link between the out-of-hours contract and A and E activity. More work probably needs to be done to establish whether there is a long-term trend—exhibit 11 shows unaudited numbers—or whether it is a one-off peak.
A little while ago, we came to Parliament with a report on primary care out-of-hours services and, at that time, we said that there was no correlation between increases in A and E activity and out-of-hours care, or between Scottish Ambulance Service activity and the out-of-hours contract.
The Scottish Ambulance Service is completing more work to investigate the reasons for the increase in activity, and we certainly need to bear that in mind when we consider a forward work programme. As Barbara Hurst mentioned earlier, we find thorough strategic analysis useful in helping us to think about where we might do work in future.
If the peak is just a one-off, the service needs to explain why the activity peaked. If it is not a one-off peak, there is clearly an issue that needs to be addressed in the longer term.
I apologise for being late, like the convener, but I had transport problems. It seems to have got worse recently, but that has nothing to do with the change in Administration, of course.
I heard most of Mr Black's remarks, and I have read the report and his summary. All of the diagnosis is familiar—alcohol problems are increasing, as is obesity, and I have to declare an interest there as I could tell you a thing or two about how that comes about through too many Foreign Office dinners.
The question of inequality is also very familiar. Even Nick Clegg has discovered that people who are born in Glasgow die a bit earlier than people who are born in Kensington, which is a step forward.
What worries me is that the report identifies some serious problems and says that the Scottish Government
"needs to build on the current performance management system for the NHS to be able to report on productivity, cost and quality together. This should fit with wider work on developing outcome measures."
The report then says that
"there is no evidence that resources are shifting"
along with the change from hospital-based services to community-based services, which is a very serious concern. We all seem to support that shift; however, when it comes to money, we are all concerned about ensuring that the hospitals, not the community-based services, get the money.
Finally, the report says:
"Improvements are needed to the way the benefits of service changes, including CHPs"—
which you have dealt with, Mr Black, in terms of the transfer of resources not taking place—
"and pay modernisation"—
which mostly means more money for GPs—
"are identified, measured and monitored."
All of those are creating problems. How are we going to follow those up? Do you have a plan? Perhaps, being a new member of the committee, I have missed something. Do you or your colleagues have plans for pushing such issues forward through your performance reports, which you mentioned earlier, using examples of good practice and finding boards that are doing something—group working, for example—or areas in which there has been some transfer of resources? Are we going to follow this up with further reports?
We have done a limited amount of work on community health partnerships, which are generally regarded as central to achieving a move of resources, activity and services into the community. However, that work has been sufficient only to support general comments in the report. We are considering whether, in the future, we will need to do more work in the area, not least in the light of some of the report's findings. For example, I have mentioned the challenging issue for CHPs. They have put a lot of effort into setting up the structures and processes, but we should now start to see some evidence of their having made an impact.
When the unified boards were established a few years ago, I shared the thought with the previous Audit Committee that there would be a risk to the health service because of the cost pressures that it was under. In order to pay bills, drug costs and so on as the year progressed, the flexibility in the NHS budget would be reduced as its targets would have to be met. I made the point that, because of that, it might be difficult to achieve resource transfer into the community. As a general point, that still stands.
There will be significant challenges for the health service, working with its community planning partners in local government, in trying to free up resources for transfer because of things such as double running costs. As well as developing more services in the community, the health service will still have to provide services in the acute sector for, for example, the frail elderly. It is difficult to see that happening at the moment. A few years ago, there was a special fund to enable that to happen, but that has been removed and rolled into the single-line budget. On the basis of the evidence that was available to us, I think that it will be a major challenge for the health service to achieve resource transfer quickly.
Probably the biggest challenge for you and for the Audit Committee, in the whole of Government expenditure, is the fact that the health service has received a bigger increase in funding, year on year for the past 10 years, than any other service, but we are not seeing the outcomes of that. That must be something to do with performance and not getting the right systems or efficient systems. That is where you can help us. When we come to item 6, will you be able to suggest to us specific areas that we can pursue, arising from the report?
I think that we should leave that until later. That is a specific item on the agenda, and we will need to give consideration to where we go from here. George Foulkes makes the valid point that we are not seeing commensurate improvements in performance and health relative to the investment that is being made in the health service. That is something about which we should all be concerned, and we will come back to that.
We should remember where we have come from. We have been seeking out islands of knowledge in a sea of ignorance. If it were not for Audit Scotland, we would not know about those issues. When Audit Scotland first looked at the health service, almost every authority was in annual deficit, but now only the Western Isles is not balancing its books every year—never mind the work that has been done on services. I express appreciation to Audit Scotland for mapping out the problems. We are at that stage of development, and I hope that we can help to encourage solutions.
The Auditor General states that it is for the Scottish Government to ensure that
"information on the performance of the NHS is publicly reported and brings together data on costs, outcomes, targets, productivity, patient satisfaction and experience."
You add that
"It should assess performance against all these elements together to better inform decision-making."
In other words, the data should be brought together and matched to outcomes, targets and all the other objectives. How easily can that be done?
The short answer, as you might imagine, is that the question is best put to the accountable officer for the health service. The Department of Health in London produces an annual report that is an interesting read as it pulls together a lot of useful and significant information. There is no equivalent in Scotland, so it is fair to conclude that there is a significant gap.
We expect local authorities to produce performance reports on best value—if not annually, certainly every three years. Those reports are subject to independent audit and commentary on the overall use of resources. That will be an increasingly important activity under the new outcome agreement framework, because the best value regime will be the means by which the public and Parliament can be assured about how well local authorities are using the resources. It is perhaps appropriate to pass comment on the fact that in the NHS there is no equivalent to the best value report on the use of resources over the whole health service in Scotland.
That could be the next stage that was requested previously.
You seem to think that current performance management systems are not as good as they could be, and your report refers to developing
"outcome measures across public services."
How easy is it to reach those targets? You want to see what you are measuring performance against and you want to ensure that the outcome measures are adequate. How difficult is it to establish agreed outcome measures and to begin to deliver them?
The short answer is that it is a very challenging project. As we mention in the report, a number of initiatives to address the matter are under way in the health service and in Government generally. We suggest that it could be done in a more joined-up way and that the results could be reported in a more integrated fashion, given that our report is the only one that gives Parliament and the public a general oversight of what has happened with NHS resources. It is clearly flawed, because in certain areas the data are not yet available.
We are watching work in progress.
I will ask about exhibit 18 on delayed discharge. The report states that delayed discharges have decreased in recent years, but that more than 40 per cent of patients in Scotland wait longer than the six-week target. Is that solely the responsibility of the health boards or do other bodies, such as local authorities, which would perhaps receive the individual, have a shared responsibility for dealing with the issue?
That is a very good question because it is one to which we can give you a very good answer, as it is an important issue.
A couple of years ago, we were aware that bed blocking was a significant issue in the health service. We therefore undertook a project, in partnership with Tayside NHS Board, to examine the whole system, which included not only hospital care but care in the community, social work involvement, health visitor involvement and so on. We produced a model, which was well received by the health service. Barbara Hurst can give the committee a more detailed indication of what we did and outline some of the key messages that came out about the role of the various agencies.
The work that we did was quite a new departure for us. It involved developing a model that looked at the knock-on effect of increased spending in, say, housing or supported housing on delayed discharges, the need for social care provision and all of that.
We cannot claim, on the basis of our work, that increased spending has led to a huge reduction in the number of delayed discharges, but it showed us that we cannot necessarily consider things in isolation, as Andrew Welsh's question seemed to imply. It is not just a health board issue; it is an issue for all public services in any one area. We are seeing some reduction in the number of delayed discharges, but I would have thought that it must be one of the most challenging issues for services to deal with, particularly for older people.
Would it be reasonable to see delayed discharges as a significant issue for community health partnerships?
Yes.
If they do not tackle that issue and make an impact, what are they for?
It is certainly an area in which one would expect to have a clear idea of what resources are going in from each of the partners. It may be that, just by moving some of those resources, a better end result could be achieved.
Did you find any examples of where the system is working well? You have spoken about developing a model. No health board seems to doing particularly well in this area.
No. We looked at the national picture, as well as Tayside. There were a lot of good examples of rapid response teams and early discharge schemes, which are being rolled out across the country. As you say, they may not be having as big an effect as we would like, but the picture of how they all fit together is complex.
The issue is clearly not just challenging, but critical to removing the blockages and resolving the problems. As more and more people get older—the demographic profile shows that people are living longer—over the next 15 to 20 years, we will face huge problems if we do not get it right.
Yes, indeed, convener. I hope to bring to the committee, at the end of January or early in February, a major piece of work that we have undertaken on free personal care. It examines some of the resource pressures and trends in more detail. That links back to the fundamental question about providing support in the community to keep people out of hospital and enable them to leave hospital sooner.
I have a brief question on exhibit 27 in paragraph 91 of the report. Are you able to provide the raw data for that, broken down by health board area, please?
Yes. We can provide the committee with the underlying information.
That is great. Thank you.
The report mentions that, in the future, health boards will not be able to use the profits from any disposals of assets to meet revenue costs. Paragraph 90 states that, in 2006-07, health boards generated a profit of £74 million from the disposal of assets. That is a small figure compared with the overall budget, but have you analysed how the future running of the health boards may be affected if they are unable to use that profit to meet revenue expenditure?
In previous overview reports, we have attempted to present an analysis of what we call recurrent costs and recurrent income, according to which there is a steady state if health boards' income matches the commitments that they must make. In the past, I have been concerned that there has been a continuing shortfall on what one might call a going concern basis. However, when we aggregated the figures up, we found that that problem seems to have substantially gone away for the moment.
It is undoubtedly true that, in the recent past, some boards have been using significant amounts of money to balance the books—paragraph 90 itemises the figures for NHS Greater Glasgow and Clyde, NHS Grampian, NHS Lanarkshire and NHS Lothian. In the future, that money will no longer be available to boards for revenue expenditure. If a board sells an asset, the profit from that will have to go into some kind of capital works, so there is no doubt that the change is another source of pressure on the boards, which, in turn, means that it is more difficult to find resources at the margin for service developments and resource transfer.
It is interesting that the four boards that you mentioned have, I think, the four largest underlying recurring deficits.
Indeed.
In the worst case, which is that of NHS Greater Glasgow and Clyde, there is an underlying recurring deficit of £30 million, but it could have been £60 million.
That is true. However, it is probably worth mentioning for the committee's benefit that, although the absolute amount in NHS Greater Glasgow and Clyde seems large, as a percentage of the spend it is relatively small. If we take Clyde out, the Glasgow system is in balance. The issue is inherited from the financial circumstances of Argyll and Clyde NHS Board when it was abolished. The Government has undertaken to assist the integrated board in the managing out of the deficit. The auditors say that the board is on track to do that.
I have one small point. The Auditor General mentioned one matter on which in England there is capacity that does not exist in Scotland. You are not prohibited in any way from talking with your colleagues in the National Audit Office or from getting good examples from England, either at national or local level, on which you can then report to us.
Indeed—we can do that and we have good contacts with the NAO.
Part 3 of the report, which is on planning for change, states:
"there is no evidence that resources are shifting"
to community provision. Is the reason for that a delay in putting systems and processes in place, or is something else going on?
In short, we do not know the answer. In answering an earlier question, my colleagues and I attempted to give an indication of the pressures on health service budgets, which will continue, making it difficult to achieve resource transfer. As exhibit 20 shows, in the past three years there has been remarkable consistency in the split of spend between the three major sectors, which are the hospital, community and family health sectors. We are not seeing a significant move in resources, which, I guess, takes us back to the importance of joint planning and good community partnership working to make it happen.
As we have no further questions, I thank the Auditor General and his team for the report. We will consider what to do with the report under a later agenda item.