Section 23 Report
“Day surgery in Scotland—reviewing progress”
The next agenda item is a briefing from the Auditor General for Scotland on "Day surgery in Scotland—reviewing progress".
Mr Robert Black (Auditor General for Scotland):
Barbara Hurst, who led on the project, will introduce the item.
Barbara Hurst (Audit Scotland):
Over the years, we have carried out several reviews of day surgery. The most recent short follow-up review compares progress against the targets that we have considered previously, which are for 19 procedures that are widely accepted as suitable to be carried out as day surgery. The targets were set 10 years ago and the procedures include cataract removal, internal investigative procedures and keyhole surgery. The procedures represent about 30 per cent of all surgical procedures, so we think that they are a fair representation of performance against day surgery targets.
Given medical advances, some of the procedures can now be carried out in out-patient settings. In the report, we have combined the data on day surgery and out-patient activity, which is known as same-day care. For the purposes of the review, we analysed national published information that was based on the national health service board of treatment. Exhibit 1 on page 3 outlines the benefits to patients and the health service of using day surgery or same-day care as the norm for appropriate procedures. Obviously, some patients have a range of health conditions and may still need to be treated on an in-patient basis. Equally, some complex operations will continue to be done on an in-patient basis.
I come to our findings. First, there is evidence of progress throughout Scotland as a whole, with the rates of same-day care continuing to increase for most procedures. The 1998 targets were achieved for 10 of the 19 procedures, compared with just seven in 2002-03. That is shown in exhibit 3 on page 7. However, Scotland still tends to have lower rates than those in England, which suggests that there is room for continuing improvement. Secondly, all boards have improved, but there continues to be wide variation among boards. That is shown in the exhibits on pages 8 and 9 and in appendix 2. For example, Dumfries and Galloway NHS Board carries out almost 100 per cent of cataract removals as same-day care, which is the highest figure in Scotland, but it performs less well on the target for arthroscopy. It is not that any one board is brilliant at everything; there are obviously differences between specialties.
A national target that 75 per cent of planned operations should be carried out as same-day care has recently been introduced. Using the health service's own estimates for the cost of an overnight stay in hospital, we have calculated that it could free up around £8 million of resources per year if it achieved that target.
It is good to see that the health directorates have taken a far more active approach over the past two years to encourage greater use of same-day care. They have introduced a directory outlining more procedures for which same-day care is appropriate and have carried out detailed work on setting case-mix adjusted targets for wards.
Appendix 3 gives some information about the work that boards have been doing, which shows that Fife NHS Board continues to be the best-performing board, irrespective of the way in which performance is measured.
We continue to have concerns about the limited recording of out-patient activity. We first highlighted that in a report on out-patients back in 2003. This is not about collecting information for the sake of it: if medical advances are leading to different ways of delivering services, how we collect management information needs to keep pace with those changes. At the moment, that looks as if it is in danger of lagging behind, because we are not getting a good picture of what is happening with out-patients.
As ever, we are happy to take any questions that the committee has.
You said that Fife NHS Board is consistently up there in terms of performance. Is it doing anything obvious that the others could copy?
We did not go into individual health boards to investigate what was happening on the ground; we just carried out a data analysis exercise. However, the factors that emerged from previous audits were how boards organised their day-case unit and operating list and whether the clinicians were willing to carry out day surgery. For Fife's performance to be what it is, all those things must be operating better there than they are elsewhere.
I was very interested in what you had to say about the cost savings to the NHS of increased same-day care. I was also intrigued by exhibit 8, which shows a comparison between rates in Scotland and rates in England. There are substantially better rates in certain procedures in England, such as the treatment of hernias, varicose vein stripping or bunion operations. It is difficult to tell from the graph exactly what the percentages are, but it is clear that there are substantial differences and that England is well ahead of us. Were you able to detect any reason why Scotland does not perform as well as England does in terms of the number of same-day care cases?
We think that there are probably two reasons for that, although there may well be others. England started looking at the issue earlier and was more active in promoting day surgery in the past. We think that day surgery was targeted in England because there are significantly fewer hospital beds in England than there are in Scotland, Wales or Northern Ireland.
That is interesting. You managed to put a figure of £8 million on the potential savings to the NHS if the target of 75 per cent of procedures being carried out as same-day cases was achieved. Did you consider what cost savings could be made if we achieved the same rates as are being achieved in England?
No, but that would have been an interesting analysis.
You would not like to speculate on what the ball-park figure might be.
Absolutely not. Next time round, we will try to do the analysis that you suggest.
The summary of the report states:
"In 2006/07, the 1998 targets were achieved for ten of the basket of 19 procedures across Scotland."
It has taken about 10 years to achieve about half the targets. Were the 1998 targets unrealistic? How were they arrived at? What criteria were used? Why is NHS Tayside so far behind the other boards?
The procedures that were chosen for the targets came through a detailed piece of work that the Audit Commission in England did with the British Association of Day Surgery. That work was comprehensively consulted on and the discussions ensured that there was buy-in from the clinicians in relation to the procedures being the appropriate ones. The targets were reached in the same way.
I may have missed a question. If I have, please tell me.
NHS Tayside was one of the poorer-performing boards back in 2002-03. We have had discussions with the board about that. In its view, its performance measurement may be being skewed because it does not include the number of patients who are sent to Stracathro hospital. As I said in my opening remarks, the data are based on the board of treatment, so we have not included Stracathro hospital or the Golden Jubilee hospital. All boards send patients to either of those hospitals in order to meet their waiting times targets.
We are quite pleased that, following the discussions that we have had with NHS Tayside, the board is actively considering whether part of the reason for its apparent poor performance is the fact that it is not submitting the correct information. We think that that is a good exercise for it to go through. The real difficulty is with out-patient activity. If the right figures for that activity are not collected, it might look as though the board is performing less well.
NHS Tayside also argued that it had to deal with more complicated cases. However, appendix 3 of the report, which shows the case-mix adjusted targets, makes it clear that the board still has a long way to go. It needs to start looking at how it carries out day surgery and same-day care.
I will encourage it so to do.
On the subject of comparisons with England, the report says that NHS boards should
"establish where same-day case rates are low and take action as appropriate."
What kind of action?
Sorry, where is that?
On page 10, the recommendation is:
"NHS boards should monitor the levels of same-day surgery by hospital and specialty, establish where same-day case rates are low and take action as appropriate."
What action?
Boards should analyse whether people are being treated on an in-patient basis when they could be treated on a day basis. Also, they should work with their consultants to increase the rate of same-day care.
That seems easy, straightforward and common sense—if it is done.
This is another fascinating report from Audit Scotland. I read it on the train, on the way back from an exciting visit to Manchester, and I was enthused to see not the comparisons with England, but the differentials within Scotland. Having read it carefully, I believe that it raises a big question that it does not answer: why do those differentials exist? NHS Fife achieved 83 per cent of its targets for same-day care, whereas NHS Tayside achieved only 29 per cent—there is a huge differential, yet those health boards are next door to each other and a lot of their indicators are significantly similar.
It occurs to me that there might be two reasons for such differentials. One might be the clinical expertise of the consultants or registrars who deal with cases. The medics would need to examine that, and it could be a delicate matter. The other possible reason, to which Barbara Hurst has alluded, is the structure of the organisation and the way in which it deals with the throughput—whether it can get more patients through. However, all the recommendations are about improving the information system and monitoring. If we want to do something about the situation, I wonder whether one of the recommendations should be that we undertake a further study to find out why the differentials exist.
I accept your point that the report simply analyses the detail without getting underneath it.
The health directorates are doing a lot of work on encouraging boards to look at the matter actively and increase the rates of same-day care. However, your point about the expertise of medical staff is totally outside the area that we can comment on. In any case, I suspect that that is not the issue, because the procedures in question are fairly standard. It is much more likely that the issue is to do with organisation in hospitals and willingness to carry out such procedures under same-day care rather than under in-patient care.
Boards have many opportunities to influence the increase in same-day care rates. For example, under the consultant contract, all consultants must have agreed job plans, and boards could legitimately work with their consultants through those plans to increase the rates.
That is very helpful. I know that we will consider ways of following up the report under our final agenda item.
I have to say that I would not completely rule out the possibility of differences between clinicians. I might be straying into hearsay, but in Ayrshire there was a lot of belief—I think that that is the word I am looking for—that while one of the orthopaedic surgeons was very expert and could get through a lot of work quickly the other, who had been around for a long time, struggled a bit and took a lot longer over his work. Of course, I realise that that issue is more difficult to examine.
Should we also look at the various structures? In previous meetings, we have discussed NHS Lothian's work with GE Healthcare Ltd on—
I think that it is called kaizen.
That is right. I wonder whether NHS Fife has some structure, procedure or way of working that is more efficient and effective than that in Tayside and which we might be able to examine and include in our recommendations.
Barbara Hurst will remind me of the details, but in our main report on day surgery, which was published some years ago, we were quite struck by the fact that for some interventions there was no relationship involving sparsity and highly populated areas and found it quite remarkable that boards such as Highland were doing quite well in one or two interventions.
It is important for the health boards to grasp the issue. As Barbara Hurst rightly emphasised, the new consultant contract provides an opportunity for health boards to use their clinical strategies to question in a supportive though challenging way established clinical practice and to set it alongside performance in other parts of Scotland to see whether it can be moved on. I am reasonably optimistic that the situation will continue to improve, although I do not know whether that improvement will be rapid enough.
I should also point out that it is up to clinical directors, supported by bodies such as NHS Quality Improvement Scotland that consider clinical standards, to take up some of this work and drive it forward. After all, if one NHS board is doing significantly better than others on the high-level numbers, the other boards should be addressing the issue themselves without Audit Scotland having to use its scarce resources to support them. That said, I absolutely agree that the issues raised by Lord Foulkes should not be simply left here.
That is very helpful.
In a nice contrast to where George Foulkes read the report, I read it on an exciting train journey to Glenrothes.
I want to ask about the BADS information system to which you refer in the report. It says clearly on page 5 that the health directorates introduced the system two or so years ago, but on page 15, it says that not all NHS boards have adopted it yet. Why is that the case if the system was introduced two years ago? What was boards' problem with adopting the system? You stress the urgent need to improve the collection of data on out-patient activity. Does the BADS management information system incorporate such data, or is it simply a good system that may need to be extended to include such a process?
Two things are going on; Nick Hex might be able to help me explain. The BADS system is almost like a clinical tool for making sure that the procedures that it says can be done as day surgery or same-day care are grouped and for doing the case-mix adjustment. The information system that we are talking about that captures out-patient activity information is a different system. I invite Nick Hex to comment if I stray outside my comfort zone, but the BADS system is really about the procedures that boards would be expected to consider actively as same-day care procedures.
Appendix 3 is an interesting if relatively complicated analysis of all those procedures, where boards currently sit and where the health directorates expect them to move. Ayrshire and Arran, which is at the top of the list, is currently doing 72 per cent of those procedures as same-day care. The health directorates are saying, "Actually, we think you can do 82 per cent." It is a more comprehensive tool than the system with individual targets that our report talks about, but it will include those procedures.
Nick Hex (Audit Scotland):
The BADS system encompasses about 160 procedures, and there are around 320 surgical procedures in total. Many more procedures are included in the BADS directory than are in the basket that we have looked at over the past 10 years.
As Barbara Hurst pointed out, the system now sets more specific targets for boards. It examines issues such as case mix, so it is much more sophisticated than a simple look at a straightforward percentage of procedures carried out as day surgery. We are recommending that, because the system is fairly new, all boards need to start to look at their information because it is more sophisticated than previous information was, and they should try to use it to improve their overall performance on day surgery.
That is interesting. I asked because the system was introduced two years ago, but not all boards have adopted it yet. How can we improve the collection of patient procedures data, which you said was crucial? What is your recommendation? You say that the boards should do that, but how should they do it?
Back in 2003, or whenever we did our out-patients report, we pushed strongly for boards to try to understand what was happening with out-patients because of the perverse incentive. If the target focuses just on day surgery, there is a bit of a perverse incentive, because although medical advances might mean that certain procedures can be done in the out-patients department, a board will not do them in that way because it wants to hit its day surgery target.
We have been thinking through that situation and working closely with the Information Services Division. It collects all the national data and quality assures them. It has been working actively with the health service to develop some of the out-patient activity data that are collected. I think that the difficulty was that a lot of that out-patient activity was not just consultant-led. There was a complicated set of discussions around whether just the consultant-led activity data should be collected, or whether data for all the other health care professionals should be collected. However, in day-case data only the consultant-led activity is needed, because that is what we are talking about.
The ISD has done a lot of work. Clearly, however, there are still some glitches, as we do not see all the activity. We made some adjustments in the data to allow for some underreporting. That needs to be worked on. The next step will come as activity moves from out-patient services into the community. If the data do not keep up with all the changes in how services are delivered, we will have no idea how productive the health service is.
My point follows on from one that George Foulkes made. I refer to paragraph 17 on page 8 of the report. Would it be reasonable to suggest that health boards should plan, fund and provide assurance to hospitals and their staff—perhaps using five-year or 10-year plans—so as to guarantee that hospitals have a future and that services will be provided at them? That would remove any potential animosity or conflicts, and more targets could be met.
That is very much beyond what we considered. As I understand your point, you are suggesting that if more gets done in out-patient services, there is less need for district general hospitals. Is that behind your question?
I was thinking about some of the issues around hospitals and services that have arisen in the west of Scotland in recent years, and the lack of a future for services or the lack of a guarantee that services will be provided at particular hospitals. I was also thinking of the effects on those hospitals.
It is difficult for us to answer that question on the back of our work on the report that is before the committee. We considered the activity that is being carried out and performance against targets. We did not consider how hospitals are configured to provide different services and whether they have a future. I am sorry that I cannot answer the question.
That is no problem—thank you.
I thank Audit Scotland for the report. We will return to the subject.