“Moving on?”
On resuming—
I bring the meeting back to order. For agenda item 4, I invite Barbara Hurst to give the committee a briefing on Audit Scotland's report "Moving on? An overview of delayed discharges". Under agenda item 5, Caroline Gardner will give us a briefing on Audit Scotland's report "A Scottish prescription: Managing the use of medicines in hospitals".
Barbara Hurst (Audit Scotland):
"Moving on? An overview of delayed discharges" was the first report to be published over the summer; the second was the report on medicines. The report on delayed discharges was a slightly different piece of work for us. Increasingly, we have to work across organisational boundaries on health and social care issues. We want in-depth understanding of how partnerships work together, partly to ensure that we do not make simplistic recommendations in our reports and partly because of the genuine need to examine the real barriers to organisations' working well together.
As a result, we asked for a partnership in Scotland to volunteer to work with us so that we could examine the delayed discharges in that partnership's patch. The overwhelming response that we received shows the importance of the subject to partnerships. In the end, we decided to work with Tayside NHS Board because it met our key criteria: it covers a number of council areas; it is committed to making a difference on delayed discharges; and its situation is fairly typical of the picture throughout Scotland. Most important was that it already possessed good information that we could use to carry out some of our whole-systems work, which meant that we did not have to waste time collecting a lot of new information. I must put on record our gratitude to NHS Tayside for working with us in that way. Together, we built a model of the local system in Tayside so that we could examine different strategies for tackling delayed discharges.
I should point out that, because the model was built on NHS Tayside's data, its service delivery structures and assumptions about how its services interrelate, it applies as a whole only to Tayside; it cannot be taken and applied wholesale elsewhere. That said, some of our findings are applicable to the rest of Scotland. For example, we discovered that having only one or two strategies to tackle delayed discharges will not work. It is not enough simply to increase home care places or hours. Any approach to the problem needs to be more sophisticated than that.
Alongside that work, we produced a high-level report on the picture of delayed discharges throughout Scotland, which found that a lot of progress has been made. It appears that we are starting to see some success in this area. For example, from September 2000 to April 2005, the number of people who were delayed in hospitals fell by more than 50 per cent.
We also examined how the Executive sets targets and its effect on local partnerships. We felt that there was some perversity in the system in respect of the way targets were set: a target was set based on the good performance of partnerships that were performing well, which resulted in their having a more challenging target in the following year. We tried to explore some of that in the national report.
We also looked at what local partnerships were doing to evaluate systems that they were putting in place. The committee looked at putting systems in place early in order to evaluate measures of success when considering free personal care. We recommended that partnerships do the same.
We have had some interest and activity on the back of the report—we have promoted it at a couple of national conferences. We have been invited to participate in local seminars, not so that we can apply the model, but so that we can apply some of the processes and thinking behind the model. I hope that we will be able to apply that whole-systems thinking to some of our new work. We discussed out-of-hours services last week, to which that thinking is relevant, and we are starting a project on long-term conditions, to which it will apply equally.
The model is very interesting if people are anoraks like we are. We are happy to demonstrate it informally to committee members if they are interested. I will stop there and take questions.
On the evidence that we heard this morning, was it a formally established community health partnership in Tayside or was it part of the old way of working?
That is an interesting question, because when we did the work, it threw up questions about the numbers of partnerships. The Tayside model pre-dated the community health partnerships. It was a delayed-discharge partnership based on the board. It was made up of three joint-future partnerships with the board and the individual councils.
Did a message come out of the work about how one might identify earlier the people who are most likely to be affected by delayed discharge? Is it too simplistic to say, for example, that it is more likely that those who have multiple needs will be most difficult to place? Did a pattern emerge from your work?
It is not too simplistic to say that. A clear message emerged that older people who have a range of different needs are most likely to be difficult to place, especially older people with dementia. There are particular problems in putting in place specialist services for such people. However, there is a strong body of research that boards and their partners can use to target people who are most likely to be delayed in hospital.
First, I welcome the report. No one here is in any doubt about how critical tackling delayed discharge is to the functioning of the entire health and social care system. I was particularly heartened to hear the feedback about how the work is being used as part of a learning process. That is tremendous.
Are you connecting your approach and the work that you are engaged in with preventing unnecessary hospital admissions? There are many parallels. My second question is about targets. I note that your recommendations focus on reviewing how national targets are set. I do not want to put you in a difficult position by asking this question, but you seem to be leaning towards saying that national targets are unhelpful if local systems take ownership of driving forward improvement. What are your views on that?
On unnecessary admissions, the answer is yes, absolutely. We have to look at the whole system and not just at the tail end of it, so we have to consider who is coming into the system and how we can stop them coming in. Partnerships are focusing strongly on that issue. There has been a lot of work on rapid response teams and setting up services before somebody has to go into hospital. I can reassure the committee on that.
We did not go as far as to say that national targets are unhelpful, but our report acknowledges that each local partnership will have issues that are particular to it. For instance, issues in the Lothians are completely different to those in Argyll and Clyde. Services will depend on the market and on how quickly alternative services can be developed. We stopped short of saying that local targets would be more helpful, but we raised the question because of the variation across the country.
Was there uniform improvement in Tayside, or did improvement vary between the different council areas?
As far as I am aware—although I will bow to Angela Canning's superior knowledge—each council had different circumstances. The model considered the picture across NHS Tayside, but it was able to drill down into each council area. It was interesting to consider how the expected growth among the older population in each council area affected any strategies. It was possible to build up a picture of how long, if one or two particular things were done, you could stay out of trouble in terms of delayed discharges. The picture across Tayside is interesting and complex; if we expand it to cover all Scotland it becomes even more complex.
Tayside has an interesting mixture or rural and urban areas, together with a large city.
As there are no further questions, I thank Barbara Hurst and Angela Canning for the work that they have done and for briefing the committee.