Item 3 is evidence taking on the Auditor General's recent report "Tackling waiting times in the NHS in Scotland". I thank all the witnesses for coming to our cosier Audit Committee meeting—it is good of them to make the effort. I welcome and thank our hosts, who are Jill Young, the chief executive of the Golden Jubilee national hospital, and Dr Kenneth Ferguson, the medical director and deputy chief executive of the hospital. I also welcome Dr Kevin Woods, who has visited our committee several times—he is the accountable officer for and head of the Scottish Executive Health Department and the chief executive of NHS Scotland. We also have John Connaghan, the director of the Scottish Executive's national waiting times unit, and Dr Bob Masterton, the medical director of Ayrshire and Arran NHS Board. We hope that the session will be valuable and will allow us to gain further knowledge about tackling waiting times.
I will not elaborate too much on what you said about the members of the team, convener. John Connaghan has recently been appointed director of the delivery group, which we have talked about previously. The committee may wish to return to that for an update on what we are doing. Dr Bob Masterton is the medical director of NHS Ayrshire and Arran. We thought that it would be helpful to have someone who is closer to patient care to talk to the committee about what are important issues. Jill Young and Kenneth Ferguson have significant roles in organising and running the Golden Jubilee national hospital and will be able to give the committee an insight into some of the issues and developments.
Thank you, Dr Woods. Our first question will come from Andrew Welsh.
I want to pursue the issue of future waiting time targets. The introduction of the future waiting time targets is only one year and nine months away, and it is clear that they are demanding. The new target of 18 weeks between the first out-patient appointment and treatment as an in-patient or day case is to be introduced by the end of 2007. Waiting time targets for other treatments are also being reduced. The targets are demanding, but are they realistic?
Yes, I believe that they are. As I hope that I illustrated in my remarks, we do a lot of detailed work on understanding the likely demand that is associated with the targets through our capacity planning work, which is done at the board level. We look carefully at how we are going to meet that demand through the services that are available largely within the NHS but also using the facilities here at the Golden Jubilee national hospital and, at the margins, making some use of the private sector. We are confident, on the basis of the analyses that we have done, that we are on track to meet the target of 18 weeks for in-patients, out-patients and diagnostics, and to abolish the ASCs.
I hope that that is the case. Can you assure us that the proposed targets will be met with existing staff levels?
The NHS workforce is larger than at any time in history and we are continuing to invest in its expansion. However, it is not a question just of workforce numbers; it is also about capabilities within that workforce. As I have explained to the committee on other occasions, we have a number of programmes that are designed to extend the scope of many of our clinical staff. For example, the Auditor General's report on waiting times refers to the scope for extending the roles of practitioners in the area of orthopaedic work—podiatrists and so on. Extending those roles creates more capacity in itself, which is bound to help. I have described previously the work that we have been doing to train non-medical endoscopists, which we discussed in the context of colorectal cancer. Those are a couple of examples of how we are increasing not only the number but the scope and capacity of the workforce. We think that we should be okay.
Let us be clear. Can the targets be met with existing staff levels, or will there be increases in the number of certain staff?
Each health board and region of the health service is currently preparing a workforce plan. We want to be sure that the planning that is going on in relation to waiting times is reflected in those workforce plans. In order to deliver the targets, it is necessary not only to increase the number of staff but to increase the capability of the existing workforce.
You say that there are plans, but there is a difference between theory and practice. In one year and nine months' time, there has to be practice. What cost calculations have been done by the department to meet the new targets? What resource studies have been done to ensure that you can deliver them?
In planning our budgets, we think carefully about the additional pressures that the service will face. We set that out in the budget book. The more detailed planning takes place locally, in the context of local delivery plans. In the next few weeks, we will examine those local delivery plans, which will include specific financial investment proposals, to ensure that we can—across the NHS—meet the case load and workload targets that are set out in them through the financial resources that are allocated. It is the principal responsibility of the boards to achieve a balance between capacity planning and the use of financial resources.
I understand the complexity, but there are cases in which the initial estimates of finances have been wildly out and have had to be revised and further revised. I seek reassurance that the costings will produce what we all want to see.
I was not present for the earlier item, but I assume that you are referring to some of the costings for the consultant contract.
And other instances.
Leaving that to one side, I would say that we need greater precision in the costing of the work that we do. We attach a lot of significance to that. We need to keep the balance between the pressures on the service and the resources that are available under continuous review. My colleagues may want to say a little more about how that can be done in the context of local delivery plans and capacity planning for waiting times.
I will pick up on two points. Kevin Woods spoke about capability, demand and capacity planning. I would like to add to what he said by mentioning our redesign work. It is a question not simply of having more staff but of handling the work more efficiently and effectively. One example is one-stop clinics: instead of having to make several visits, patients make only one visit to hospital to have a number of things done. Well over 500 one-stop clinics have been established in Scotland.
We have an enormous range of things to cover so we will move on.
The recording of availability status codes is done at local level as a result of the interaction between patients and the service. There are different categories of ASCs. Some codes relate to patient unavailability. They might include patients who did not turn up, or they might include patients who required a very rare, complex and difficult operation for which resources throughout the whole of the United Kingdom were very limited.
The report showed that the number of people with ASCs increased by 24 per cent between June 2003 and September 2005. At the end of December 2005, ASCs accounted for just short of 35,000 people waiting for care. You have explained to us how the figures have now come down; perhaps you could tell us where we are now, in relation to the figures that I have mentioned. The evidence is that ASCs are not being used inappropriately, which is encouraging. The committee is not challenging their use or suggesting that they are being misapplied. However, we are curious as to why the figure increased. The answer to that might also suggest how you have been able to reduce the figure.
There are two principal reasons why the figure increased—although we must bear in mind that multiple decisions are made across the NHS in relation to individual patients on these codes. One reason is the transition from the previous counting method—which was, I think, called a deferred list.
I do not but, to confirm what Kevin Woods said, it is inevitable that doing a great deal more out-patient work not only puts patients on to the active waiting lists but increases the number of patients with ASCs. That was certainly one of the biggest drivers for change in my area.
If you are able to tell us the nature of the change—the reduction in the number of patients with ASCs—that would be useful.
Excuse me, do you mean the individual categories?
No, I was talking about the global total.
I will give you the up-to-date figures, if you like. My understanding is that the total waiting list in Scotland at the end of December was 108,548 and the number of people with ASCs was, rounding up, 35,000. Therefore, the number of people waiting with guarantees at the end of December was 73,571, which is lower than the 2002 target, which is the old target on waiting lists.
It would be useful if we could have those figures broken down by board in writing, if that information is available.
We would be happy to provide that. In fact, we have already published all those figures, so there is no difficulty with that.
You have received the plans on abolishing ASCs from the boards but, given that there was an increase in their use—albeit that you have explained that that is now turning round—the situation seems to fluctuate. Can you be confident that they will be abolished on time?
Yes, we are confident that that will be achieved. However, you are right that there is bound to be some fluctuation. That is because patients are being seen all the time and because the use of ASCs depends on individual circumstances and the individual clinical conditions that patients have.
You have anticipated my next question.
I am sorry.
No, that is fine. We would prefer to have the guidance in written form. That would be useful.
It is very detailed.
I rather suspected that, which is why I would prefer to have it in writing. We would like to take a look at it.
Dr Woods referred to the health boards preparing workforce plans. When will the plans be complete?
We have received drafts of the regional plans and we are due to receive drafts of the individual board plans shortly. We want the definitive versions of the plans by, I think, September.
Good. We will now have questions on the Golden Jubilee national hospital and its role in helping to satisfy waiting times targets. Mary Mulligan will start.
I suspect that my questions are probably best directed to Ms Young. However, I heard what Dr Woods said in his opening statement about activity increasing at the Golden Jubilee. Our information is that the activity was not as planned as it could have been. Can you tell us why that was the case?
I am happy to say something, but I am equally happy to hand the question over to someone else. Who would you prefer to answer?
Whoever can give me the answer.
I will let Jill Young do that, as I have said a lot.
As has been said, we have exceeded our targets. We are relatively new to the NHS family and are just coming into our fourth year. We are heading towards having done 63,500 procedures in our hospital since we became an NHS facility. All that activity is planned a year in advance.
However, there seem to have been a number of cancellations by health boards. Why do you think that was? How do you respond to that?
We monitor our cancellations carefully to improve the services and to learn. We work closely with all the boards, but we do so particularly with the west of Scotland regional planning group, on which all the boards in that region are represented. The cancellations are made for numerous reasons. We have a breakdown of the ASCs, which we can share with you if that would be useful.
I appreciate what you said about the reasons why people did not cancel, but it would be helpful for the committee to see your breakdown of why people cancelled. What would you say was the main reason for cancellations?
I am not sure whether one reason stands out in isolation. There is perhaps a spread of about four or five reasons. On some occasions, the patient decides to accept an offer that they received locally. Patients get numerous offers; we are only one of the options for care. Perhaps after getting our offer, the patient decides that they would rather wait. Capacity is sometimes made available locally, so the local hospital can make an offer to patients. We would be informed of that and would then seek to substitute other patients for the activity. The numbers of cancellations therefore are broken down evenly over about three or four categories.
I see from the figures that capacity was never reached. Was that planned? If so, what is your safety margin?
Capacity has been exceeded year on year. All our activity targets have been exceeded every year since we became part of the NHS, although the specialties within those targets have changed. For example, we plan for X number of heart bypass operations a year in advance, at which point those patients are not in the system. Six months into the year, the board may realise that it does not require the number that it had booked and may change those planned operations into orthopaedic or other operations. There is a difference between the planned specialties and what is delivered.
If planned patient numbers and the mix of procedures are not realised this year, will the effect on costs and income be difficult for you? How would you respond to that?
We are on target for the current year, 2005-06. I can assure you that we expect to meet the target for the current year of 26,000 procedures being carried out. Those procedures are all planned in great detail. We have what we call our booking office, which is also known as a management referral centre. It has a robust, tight management team, which is in daily contact with every hospital and board that refers patients to us. As soon as we know that there might be a cancellation or that a patient cannot take up their appointment for some reason, the team immediately contacts the hospital or another board to see whether other patients are willing to take that slot. Within days, we can turn that round and fill the slot.
It is entirely right that we should get the advance planning as good as possible. Increasingly, we are doing some of that capacity planning regionally. I do not know whether Dr Masterton wants to say a bit about what is going on in the west of Scotland in that regard, but capacity planning is an important component. Case study 5 in the Auditor General's report helpfully sets out the Forth Valley NHS Board example. We see such arrangements in many parts of Scotland; they are not limited to Forth Valley. However, if people are going to be offered the opportunity of treatment at the Golden Jubilee, that is a good example of the work that can be done locally to ensure a smooth transition.
To pick up Jill Young's point about why patients sometimes do not come to the Golden Jubilee, it is about patient choice. As waiting times have got shorter, patients have become happier to wait another couple of weeks to have a procedure performed nearer home. In addition, the planning that Kevin Woods spoke about invariably leads to increased capacity nearer patients' homes. I am part of the regional planning group that Jill Young mentioned—we work closely. An additional element that the Golden Jubilee provides for us, which has not been touched on yet, is flexibility. From time to time, as a result of consultant illness or for some other reason, such as someone retiring, we are unable to perform procedures that we had intended to do locally. The Golden Jubilee offers us flexibility. It is a significant comfort to us to know that we can have that flexibility. We need to build it into the planning.
The first task in the work programme of the west of Scotland regional planning group, which I chair, is a west of Scotland demand and capacity plan, to which all the boards are contributing.
From exhibit 20 in the Audit Scotland report, it is clear that use of the Golden Jubilee hospital varies considerably between health boards and that such use is becoming increasingly variable. What are the reasons for that? In particular, what are the reasons for that increase in variability?
Currently, boards in Highland, Grampian and Tayside are able to meet their waiting times targets with more local resources. Our aim is to try to provide patients with the opportunity to be treated locally, if at all possible. The more demanding targets that we are setting, however, might mean that that is increasingly not possible in the future and that more use of the Golden Jubilee might be required. That is also why we are planning for an additional treatment centre at Stracathro.
Has there been research or discussion with boards about that?
Yes.
Boards might be concerned about the effect on local capacity of using the Golden Jubilee. What is the risk to boards of a loss of local capacity as a result of increased use of the Golden Jubilee?
I ask Mr Connaghan to answer that question.
It might be best if I explain how we construct the annual plan for the Golden Jubilee. Around the start of the calendar year, we ask boards to advise both the national waiting times unit and the Golden Jubilee of their requirements a year in advance. We then match that to the available capacity in the Golden Jubilee—it is very much a bottom-up plan.
If I am right, it was stated earlier that capacity is exceeded every year. I thought that your system was subject to peaks and troughs and then we heard that, because of the new system with its new targets, there will be more patients in the future. If your capacity is exceeded every year, you are subject to peaks and troughs and you are going to get more patients, how does that all add up?
What I was trying to say is that, in the current planning context that John Connaghan described, we are exceeding the activity targets at the Golden Jubilee hospital. The three boards to which I referred have not had to use much of the resource of the Golden Jubilee to deliver the existing targets, but as we move to 18-week targets, embedded in which is a nine-week diagnostic target, those boards have said in discussions with us that they would value having access to additional capacity at the Stracathro development. That is what I was trying to explain—I am sorry if I did not quite capture it for you.
Those are targets, as opposed to capacity.
Yes, but the activity target implies a throughput rate, which requires a degree of capacity. That is factored into the planning that John Connaghan described.
It appears that costs at the Golden Jubilee are relatively high compared with those at other hospitals. We are aware from the report that concerns about unused space are being tackled; there are cost concerns about the way in which doctors are paid; and as a result of the case mix here, many of the procedures that are undertaken are of the more expensive type. What more can be done to reduce costs at the Golden Jubilee so that the comparison with other facilities is more favourable? Is there a role for other boards and, indeed, the Health Department in helping to bring down those costs, rather than the Jubilee hospital doing that on its own?
The key data in that regard are set out in exhibit 19, which shows that the principal factor is the overhead cost. That is a function of the fact that we have acquired a whole building and are progressively filling it up with new clinical services.
Would you characterise that adjustment as dramatic? Are you expecting there to be a significant change?
Yes, because we would be dealing with high-value complex cardiothoracic cases.
The level of complexity in orthopaedics is high. Some 68 per cent of our total orthopaedic work is hip and knee replacements, which have the highest cost of any orthopaedic work. In addition, we have no accident and emergency department, which means that we tend not to deal with the more minor procedures, such as sprains and the application of plasters. Such work tends to bring down the average costs in other departments.
Have you encountered any reluctance from health boards to place with you work that would enable you to reduce your costs by increasing your productivity?
We currently meet—indeed, exceed—our activity capacity. There is no such reluctance on the part of health boards. We constantly strive to do more and to push the boundaries, which is why we work with boards to find out whether we can do things differently, such as redesigning services or offering alternative services. The overall position depends on the specialties that are involved because, in a session, we could do either two hip replacements or five or six cataracts. We have an agreement with the boards with regard to demand. That enables us to push the activity further.
Your capacity is met, but it would appear that boards are able to fill in the capacity by picking up the slack where gaps fall. Are there any examples of boards not taking up the capacity that was planned, which would mean that your capacity is being met by other boards who favour giving you the work?
I am not sure that I could give you specific examples without referring back to the detailed information. If, a year in advance, a board cannot use the capacity in a specialty—say, cardiac—we go back to that board to fill that capacity with another specialty. Only if the board could not take up that capacity would we offer it to other boards.
Is your ability to plan your capacity governed by the willingness of boards to work with you?
No.
To contextualise the data that are shown in exhibit 19, which relates to how the case mix affects the cost of orthopaedic surgery, it might be helpful to the committee to know that the tariff price for a hip replacement is £6,759; for a knee replacement, it is £7,545. You can see that, if a disproportionate number of those operations are being done, that is bound to have an impact on the cost profile.
We heard from Dr Masterton about the flexibility that the Golden Jubilee offers and from Mr Connaghan about how its planning is bottom up, not top down. One can see the efforts that are being made with regard to forward planning. Jill Young described how the hospital is able to respond on a month-to-month and week-to-week basis. As a national facility, it seems to provide what one might describe as a useful safety valve. For a variety of reasons, the hospital offers other boards flexibility when they are planning to bring down their waiting times. Is it fair to say that it provides that useful service?
I am hesitating about the use of the term "safety valve". The hospital provides us with flexibility and additional capacity for certain things. As I said in the context of capacity planning, we are trying to position the hospital in an overall context, so that we can get a close match between what we anticipate we need to do and actual needs, and therefore make best use of it. The term "safety valve" is perhaps a slightly pejorative way of describing what we are trying to do. We want a facility that is flexible.
I certainly did not mean my phrasing to be pejorative, but I had a reason for choosing that soundbite. What might the future role of the Golden Jubilee hospital be, once it has delivered an effective solution to the difficulties that boards have had in the past with waiting times?
That is the point at which I was driving. Clearly, the hospital will be a major centre of excellence for cardiothoracic work. It will undoubtedly have a continuing role in relation to orthopaedics, general surgery and ophthalmology, partly as a function of the fact that, with an aging population, there will be an increasing requirement for such surgery. Beyond the flexibility that the hospital provides in other specialties, it will have an important role in relation to diagnostics. In recent times, there has been major investment at the hospital in imaging, for which we have excellent facilities. Increasing our capacity around diagnostic imaging and so on is an important component of our overall approach to delivering on the nine-week diagnostic targets that we have set. John Connaghan or Jill Young may want to elaborate on that point.
Dr Woods has said the very things that I intended to say. I will re-emphasise one point. The investment at the Golden Jubilee in areas such as orthopaedics and ophthalmology is designed to keep track of where we consider the greatest pressures will be in future years. We have an aging population and anticipate that there will be growth in demand for knee replacements, rather than hip replacements—that is a European trend. In the detailed modelling that boards and departments have done in relation to the delivery of future targets, we recognise that an element of non-recurring as well as recurring capacity is required. It is fair to say that, for the west of Scotland and beyond, the Golden Jubilee provides a significant proportion of recurring capacity.
Surely that will have knock-on effects on health boards. What is the thinking about the future relationship between the Golden Jubilee hospital, as services develop, and health boards elsewhere in the country? In other words, what are the effects on the overall system?
The circle is squared by regional capacity planning, which we are doing at the moment.
What does that mean?
We must think about the capacity that we have here in the context of the capacity that exists in individual boards. As John Connaghan described, we must work from the bottom up, decide what can be done in local capacity, what may need to be done at the Golden Jubilee hospital and what small amount of work may need, on occasion, to be done in the private sector. That perspective must be anchored in local analyses of trends in demand and an understanding of capacity.
As part of our regional planning, we are evolving ways in which local boards, in particular, work with the Golden Jubilee. Flexibility has been a key element of the Golden Jubilee's provision, but we are working to highlight the importance of sustainability and the need to continue to achieve the targets. The issues that Mr Welsh has raised are not sources of tension in our discussions with the Golden Jubilee. After all, NHS Ayrshire and Arran could never provide a cardiothoracic centre by itself. Such a facility is needed, and because we want the best that we can get for our patients, the centre will be based here. Similarly, additional elective orthopaedic activity and cataract work are not points of tension, but aspects of NHS's on-going capacity planning.
Before we leave exhibit 19, will you tell me why your medical staff costs are about twice the Scottish average?
Jill Young or Dr Ferguson might wish to elaborate on the matter, but I should point out that those costs partly reflect the hospital's transition from a reliance on visiting consultants to having a more stable and permanent workforce.
Our medical staff costs have fallen quite significantly since the period that is covered in the report. For example, at that time, we employed only one orthopaedic consultant and had to depend on visiting consultants, who cost more. We now have four orthopaedic consultants and all the work is done under standard pay terms and conditions. We are looking to recruit our own consultants in general surgery and ophthalmology this year. Moreover, when the cardiac unit transfers, all the medical staff will already be in place.
The issue is linked to capacity planning and service sustainability; after all, to be able to recruit consultants, we need some sustainability. Because we are now linked into that, we will be able to reduce costs significantly.
Sustainability and recruitment are issues everywhere. The west of Scotland has been mentioned quite a few times in that regard, but surely Highland, Tayside and Grampian face the same problems. Have you thought through any knock-on consequences? Where is the system going?
Since the NHS took over the hospital, we have recruited 10 full-time equivalents, only one of whom has come from an existing NHS consultant post in Scotland. The rest have either come from outwith Scotland or were not in those posts. As a result, we have introduced some additionality to the consultant resource. We are very much committed to that approach and to linking in with proper regional and national workforce planning and the department's projects in that respect.
I thank the witnesses for answering those questions on the Golden Jubilee hospital. We now move on to discuss the issue of involving patients in the decision process.
Bob Masterton mentioned patient choice, which forms an important aspect of the committee's examination of the Audit Scotland report. That report seems to suggest that NHS boards believe that patients are unwilling to travel for treatment; indeed, it says that only 5 per cent of people are asked whether they want to do so. However, according to the patient survey, under the right circumstances, patients would be willing to travel—sometimes considerable distances—to alternative hospitals to reduce their waiting times. Obviously, your use of the Golden Jubilee is an attempt to pick up on that, although the report suggests that you have not quite got things right. Perhaps a number of patients have not been asked and their views remain untapped.
You raise several interesting points. I agree that patients are prepared to travel to receive treatment if they can receive it more quickly, but they prefer—understandably—to be treated locally if possible. Our approach is intended to ensure that local treatment can be offered, whenever possible.
I will pick up on two points about continuity of care. A pathway of care operates when we send patients elsewhere—they start and end with us. We do pre-operative investigations. If a patient goes for theatre or a diagnostic intervention, that goes into the notes, wherever the relevant board is. That is part of a pathway and a continuum.
The statistic that nearly half of all the patients who had been surveyed felt that they had not been involved in the decision about their treatment surprised as well as disappointed committee members. What came through from the report was a sense that there were not common standards for patient involvement in decisions of that kind. Some patients are getting access—at board level or at GP level—to more involvement in such discussions and decisions than patients in other parts of the country are. What exactly are you doing to introduce some kind of standard to ensure that patients will have that involvement in future?
We have already published two things. You have asked for the guidance that we published on ASCs, and in one of the sections of that—in appendix A—there is a page that deals with what is a reasonable offer of appointments and admission. It lays down some pretty clear, patient-focused guidance. Also, about three years ago—I cannot remember the exact publication date—we published a guide to good waiting times practice, from the national waiting times unit, which laid out some guidance on how patients should engage with their general practitioners. That guide has been followed up since by one or two Health Department letters, as I recall, that dealt with that territory. There is guidance to boards, and we expect them to follow that.
Given what is in the Audit Scotland report, I presume that you will be taking up the issue with boards to ensure that they make use of such guidance in future.
The first thing that I would say is that we are not about compulsion at all; we are about trying to meet patient needs, which we think are best discussed by the patient and the referrer, who is usually the general practitioner. We can provide information to help with that, but skilled interpretation in the light of individual circumstances is extremely important. As we make the transition from availability status codes to the new ways definitions, we are setting out clearly what we expect of boards in the offers that they make to patients. That is quite detailed, and I will ask John Connaghan to outline our note briefly for you, because I think that it will give you the reassurance that you seek. We will be glad to let the committee have a note of that, because we want to ensure that people are given reasonable offers that they have a reasonable chance of fulfilling, without any sense of compulsion at all.
As I said, the committee will receive a copy of the note, which was issued to the service in March last year. I will read out two sections that may clarify the matter. The document begins with the question of what is a reasonable offer of an appointment, and states that
When patients have come to the Golden Jubilee hospital from other parts of the country, particularly when they have had the full package of decision making and travel as well as receiving treatment, what do you do to monitor feedback on their experience?
We continuously monitor patients' experience. In the most recent patient satisfaction survey, 3,295 forms were returned by patients who had been treated at the hospital over the past year. The responses revealed that 100 per cent would recommend family, friends and other colleagues to have their treatment at the hospital and 99.8 per cent were absolutely delighted and satisfied with the care that they received.
I put on record that Ms Young did not know that I was going to ask her that question.
We can also put on record the fact that we found the hospital easily.
I noticed that one sign still has the fateful letters HCI on it, but we will move on swiftly.
It is a heritage sign.
I am struck—
Good, there is a question.
Give me credit. That was not the point that I intended to make.
First, it will be evident to the committee that we are in a state-of-the-art facility. There is bound to be some connection between the quality of the care environment and how people feel about it. Members know about the various things that we are trying to do across the NHS to improve the service.
I know that Andrew Welsh wants to make a point, but we must move on to address the whole-system approach. We have quite a few points, so we will have to discipline ourselves and put our questions briefly.
I have a general introductory question about the issue. We all sign up to the whole-system approach, but the feeling is that such an approach has not been taken. The initiatives so far have tackled symptoms such as waiting times; they have not examined the system as a whole and addressed the needs across the system. What is being done to move towards a whole-system approach?
As I indicated at the beginning—forgive me if I am repeating myself, but it bears repetition—"Delivering for Health" is essentially about adopting a whole-system approach to the management of the health needs that we have in Scotland. I will not rehearse all the features of "Delivering for Health", but we believe that it is important to invest in primary and community health services and to develop more anticipatory care services to avoid, if at all possible, demand for hospital admission. After all, although the Golden Jubilee hospital generates a high level of satisfaction, most people do not want to be admitted to a hospital—they would much rather receive their care somewhere else.
I have further questions about the whole-system approach. I genuinely congratulate everybody who was involved in reaching the targets for the end of December 2005, which was an achievement. We have invested a lot in dealing with waiting times, particularly the long waits, and the numbers have now dropped, although people are still waiting. How does the Health Department aim to move from simply providing funds to reduce waiting times, to funding delivery of the service?
In answer, I may well go over ground that I covered earlier. The issue comes back to understanding the case load that we expect to arise in particular places and building up capacity plans from that. We then need to be clear about the contribution that local services, the Golden Jubilee hospital and, if necessary, the private sector will make. Within that, we are trying to shift the balance in our health care system even more towards non-hospital settings. If, instead of a consultant appointment, we can provide an appointment with another appropriate member of staff—I mentioned earlier the example of a podiatrist—that is highly desirable, especially if it is in a community setting. That is the direction in which we want to go. Over a period, we are trying to shift investment in that direction to support such models of care. That will not happen instantly overnight; it will have to be worked at for a long period.
It could be argued that continuing to fund boards that cannot treat people locally, even though it is often people's preference to be treated locally, as you said, compensates—I had "bails out" in my first jot—boards that do not redesign as quickly as possible. How do you encourage boards to redesign so that they do not have the sort of demand that produces difficulties with which the Golden Jubilee has to deal?
In the redesign work, we have adopted a collaborative approach that includes everybody—large numbers of people are involved. For instance, the diagnostic redesign work will reach into all kinds of places. However, particular circumstances sometimes arise for boards. A recruitment difficulty might make a service less available than the board thought it might be, in which case the Golden Jubilee might need to be used. It would not be appropriate to penalise a board in that situation.
You said that the increase in services such as the cardiothoracic unit that will come to the Golden Jubilee will change the balance between responding and planning. Do you have a vision for the division of labour within the hospital? Should services be planned or should they be responsive to other issues in the system?
The cardiothoracic work will be carefully planned and the major specialties of orthopaedics, general surgery and ophthalmology will be integrated into the capacity planning. However, there will always be circumstances somewhere—perhaps recruitment difficulties or the long-term sickness of a consultant—that cause the local capacity plan to be under pressure. In such cases, it might be easier to provide a replacement service at the Golden Jubilee using capacity that is brought in specially.
I think you said that the Health Department's contribution to the Golden Jubilee is about £74 million.
The total budget is about £50 million. About 80 per cent of that comes from the Health Department.
I think you said that in the previous year there was £116 million, and that—
That was the total spend on waiting times initiatives. It was not the budget for the Golden Jubilee.
Of that, about £74 million was recurring spending and about £44 million was non-recurring. Do you envisage that that balance will change?
There will always be a need for recurring spending, but the precise split will vary from year to year. We are trying to get on top of the backlogs so that we do not need to use as much non-recurring resource to sort out problems. I would not like to predict precisely what the split will be, but we are moving towards using recurring resources for good advance planning of capacity and supply.
Andrew Welsh has some questions on value for money
In seeking value for money, it is difficult to make financial comparisons between public and private providers. When will the 2005 NHS tariffs for Scotland and for England be published?
As the tariff in England has recently been withdrawn because of a variety of problems with the coding and so on, I cannot give any answers about that. However, I can confirm that we have progressively introduced tariffs for orthopaedic and cardiac procedures in 2005-06 and we intend to continue to roll those out. We have information—which John Connaghan has just passed me—that compares, for some major joint replacements, the cost under our tariff with the private sector equivalent, which is what the question was about. As I mentioned earlier, the current draft tariff for a hip replacement is £6,759 under the NHS whereas the price in the Scottish independent sector in 2005-06 was £6,733. Thus, the two figures are about the same although the figure for the independent sector is slightly lower. For knee replacements, our tariff figure is £7,545 whereas the independent hospital price is £7,425. For cataracts, our tariff is £1,087 whereas the independent hospital price is £1,600.
Can we be given those figures?
We will be happy to provide a note on those if that would be helpful.
That will be excellent. Susan Deacon has some questions on building in incentives.
All my questions relate to delivery and whole-system working, but I may move between the two issues.
I express thanks for those comments about the NHS's achievements. First, we have a tremendous asset in the vocation of NHS staff and their sense of commitment to the service, to their patients and to doing everything possible to reduce waiting times. Without that asset, our improvements would not have happened.
I apologise if I am interrupting, but it is simply because I am conscious of time and I do not want to be cut off. No one doubts that a great deal is being done to share knowledge, but events, dialogue and discussion of that nature have been going on for some time—the key is ensuring that they are translated into practice. I would welcome further comments from you on that. Some people will grasp the opportunities to learn from others—they will take the ball and run with it and apply the lessons in their area of service delivery—but others will not, so how can change be made to happen? You have mentioned Health Department letters and guidance, but they are not the same as having incentives, rewards or mechanisms to ensure that change happens.
The best way to answer such a question is to turn to what is happening in practice. The biggest redesign programme in Scotland in recent years is the out-patient programme, because it covers 1.2 million new out-patient attendances annually, as well as 33 major hospitals and a number of minor clinics. It is a prime example of how good practice, innovation and redesign have become embedded in normal practice.
You mentioned the out-patient programme, so I will pursue it, as it is a good example to explore further. What I am about to say does not detract from the progress that has been made. Paragraph 101 of the Audit Scotland report tells us that the centre for change and innovation's capital expenditure budget on that programme was underspent, and that one of the main reasons for that was that boards said that they could not meet the future running costs of some of the projects that were proposed and, I presume, deemed to be desirable locally and nationally.
I cannot say what the specific capital projects were, as I do not have that detailed information with me. The capital dimension of the CCI is comparatively small.
I want to draw some of the strands together. The delivery group was mentioned, and the director of delivery is sitting in front of us. What will that position and that group add to the previous efforts and mechanisms to increase delivery? One mantra might be that delivery is everyone's job. What will that mechanism add to delivery? To what extent will it look outwith the boundaries of what we have been talking about today—the aspects of performance improvement and management that lie directly within the bounds of the Health Department—and consider things, such as training, that lie at the hand of others and that will bring about sustained culture change?
I start my new life as a civil servant on 1 April, and I would be delighted to come back in six months' time to give you better reflections on that question. I will answer by setting out the ambitions of the delivery group, to which Kevin Woods alluded in his answer to the previous question.
On training and education, you did not mention links to the various professional bodies and to NHS Education for Scotland and so on.
The best way for me to address that is to give you a good example, which was worked up jointly by CCI and the national waiting times unit, and which is connected to the delivery of one of our key targets—the diagnostic target. In our risk assessment of the target, we looked at endoscopy services. I believe that the committee has discussed those services in relation to colorectal and bowel cancer. We realised that we needed to provide a little more pump-priming funding to increase the number of non-doctor endoscopists—nurse and allied health professional endoscopists. We have constructed a programme with NHS Education for Scotland, funded by the national waiting times unit and CCI, to increase the number of endoscopists this year and in future years. That is a prime example of how we look not just at capacity but at redesign and new ways of working.
As members have no further questions, I thank all the witnesses for coming through today or for hosting us. Thank you for your evidence, which was very useful. Our clerks will be in touch with you for follow-up information and to clarify which written material we would appreciate. At a future date, we will deliberate on our response to the Auditor General's report. Your evidence was helpful in enabling us to get behind some of the detail in it.
I thank the convener and other committee members for their acknowledgement of the significant progress that NHS Scotland has made.
I suspend the committee for five minutes to allow witnesses to leave. We will resume in private session.
Meeting suspended until 12:06 and thereafter continued in private until 12:31.