We resume the meeting for agenda item 4, which is consideration of the Auditor General for Scotland's section 22 report on Argyll and Clyde NHS Board's accounts for 2003-04.
I will be reasonably brief. The first issue that we would like to explore is financial recovery plans, because evidence from the accountable officer of Argyll and Clyde NHS Board, Neil Campbell, and the previous accountable officer of the Health Department, Kevin Woods's predecessor, Trevor Jones, indicates that two areas of disagreement underlie the failure to agree the financial recovery plan for Argyll and Clyde NHS Board: the time period over which the savings should be achieved and whether the cumulative deficit can be recovered locally. When do you expect to reach agreement on the financial recovery plan with Argyll and Clyde NHS Board and what are the practical consequences if you fail to reach agreement on the plan?
I ask Dr Woods to respond. If he has any preamble on the general subject, he should feel free to make it now.
My preamble addresses some of those points, but I will try to answer the question more directly, if I may.
Certainly. I am sure that it would be of interest to the committee to hear your views on that matter.
As I understand it, at the start of the financial year 2004-05, the board expected to overspend on its recurrent revenue by £46.4 million. It is aiming for, and is well on the way to making, recurrent savings of £10 million in the current year, which suggests that it will finish the year with a recurrent, underlying deficit—that is a really important point—of £36.4 million.
Thank you. That is helpful.
I refer to the evidence that Trevor Jones gave us a couple of weeks ago. It is clear that there was a fundamental difference of opinion about the financial recovery plan that was presented to the Health Department. The committee's question is about the basis on which the department evaluates the plans and decides whether they are robust. The answer was not made clear in the evidence from your predecessor. We should not forget that the recovery plan envisages 180 job cuts in Argyll and Clyde NHS Board, five hospital closures and ward closures throughout the primary care sector. The question that occurred to us after the evidence-taking session two weeks ago is: how many more cuts will there be and where do you believe that the board has not made enough progress on recovering the financial position? It is clear that big changes are going ahead in Argyll and Clyde.
As I understand it, the difference centres on the timescale within which changes should have taken place. The department's view is that changes should have happened sooner, whereas the board's view is that that was not possible. Its priority was to stabilise the situation—as it would describe it—to get it under control and to put in place a series of service plans that entail the changes that you describe. I recognise that that has been going on for two or three years and that I have not been part of it, so I invite Dr Collings to talk about the financial issues. Carmel Sheriff might want to add something on the nature of service planning.
As Kevin Woods described, the issue between us and the board has been the pace at which the in-year deficits can be brought down. George Lyon said that there is no agreement about how to handle the accumulated deficit. I have consistently said to Argyll and Clyde NHS Board that it should not spend all its time worrying about that issue. When we have a clear plan for getting down to in-year balance, we can consider the range of non-recurring ways to eliminate the accumulated deficit. The priorities on the financial side are to get the in-year deficits down as quickly as possible so that the accumulated deficit is as small as possible, and to produce a plan that will deliver and in which we all have confidence.
Is that figure based on full-time equivalents or on head count?
It is based on full-time equivalents. After the new management team came in, systems were not in place adequately to control the increase in staffing and, for a while, the number of staff continued to rise, albeit more slowly. It is only now that the number is reducing. There is a graph to link clearly the financial issues with what the board did on employment.
First, I should say that service planning has not taken place in Argyll and Clyde for a number of years. NHS Argyll and Clyde now finds itself in the position of having to reduce its spending base through a mixture of good housekeeping initiatives—which include measures to make administrative and non-clinical savings—reductions in spending in service areas and the reprovision of services that are modern and more appropriate for where we are today.
I want to be clear about which part of the recovery plan you disagree with. Do you disagree with the timeframe or with the proposals themselves? A team was put in place to evaluate what was going on in Argyll and Clyde, then the four chief executives resigned and the new management came in. That took place a few years ago. Are you arguing that that should have happened on day one, or do you disagree with the actions that NHS Argyll and Clyde proposes to take?
My reading of the evidence is that our principal disagreement is with the timing. The department's view was that recurrent savings should have been secured sooner.
It might be helpful if I explain how we assess those proposals now that we have them. As I said, the proposals are passed around the department for comment and consideration by colleagues in policy and other areas of interest. We consider the adequacy of consultation, whether that consultation has been carried out in adherence with Executive guidance and whether the proposals fit with policy in the areas of service that I have described, including mental health services, learning disability services and services for older people.
On a point of clarification, you mentioned earlier that there are no schemes to help with double-running costs. However, it is clear that the schemes that are envisaged in the plan will require double-running costs, because the community mental health facilities will have to be put in place before the institutional facilities are closed. How would the board deal with that matter? Is that part of the discussions?
Yes. The board has asked us to consider options for giving some assistance in that regard. We have asked for more detailed figures on the costs and what the money would be spent on. At that point, we will determine whether there is a way in which we can assist the board.
On the second point of disagreement, how does the department envisage the recovery of the cumulative deficit, which Dr Woods stated will stand at £60.8 million at the end of this financial year?
Fundamentally, that needs to be done through non-recurring means. In other cases in which boards have deficits, we are clear that money will come from profits on asset sales because they have disposal programmes for surplus assets. NHS Argyll and Clyde also has a significant asset disposal programme. It does not look like it will be sufficient to cover the deficit, but we think that it will go towards recovering it. We will consider a range of other options and put them to the board and to ministers.
The accountable officer of NHS Argyll and Clyde has told the committee that it would be impossible for the board to retrieve the cumulative deficit without there being serious consequences for local service. Have you and the board carried out a joint assessment of the impact on services of recovering that cumulative deficit as part of the financial recovery plan?
We have made it clear to the board that we do not expect it to deal with the deficit by making recurring surpluses, which means that it has not been necessary to carry out such a joint assessment. Together, we will examine any non-recurring ways of eliminating the deficit, because it is impossible for the board to run by substantially underspending its budget on a recurring basis.
Do you accept that, currently, the deficit cannot be repaid?
I accept that it cannot be repaid by making recurring surpluses. As I said, there are a number of other ways in which it might be repaid, the most obvious being asset disposal, which we are examining with the board.
In his evidence, Trevor Jones confirmed that the department did not provide the board with written assurances that it would receive enough cash to meet the costs of its in-year operational activities through to 2007-08. Does the department plan to provide written assurance in that regard?
To be honest, I think that that is unnecessary, because the minister gave the Health Committee such an assurance, so it is in the Parliament's Official Report. That deals with the very precise point.
What is the status of that assurance and how do you account for it? How does the department justify cash allocations and payments from public funds that are based on verbal assurances?
As I said, that assurance is in the Official Report. We can certainly give Argyll and Clyde NHS Board an assurance on that point, but we felt that the minister having put the assurance on the record should be adequate for the board and its auditors.
Is that not an unusual accounting position?
Nobody could be comfortable with the position, but nobody could be comfortable with the size of the deficit.
The important point is that the minister is trying to convey the fact that, as I have said, he wants the situation to be resolved once we have gone through all the evidence. He wants to give an assurance that no precipitate change will occur because of a cash problem in the board. I understand that the financial regime under which we operate enables him to give that assurance. The assurance that cash will be available to pay bills and staff and that we will have in place plans to achieve a recurring balance is important.
I return to the previous issue of the cumulative deficit. Is the department concerned that NHS Argyll and Clyde's use of non-recurring resources to offset in-year deficits will reduce its ability to use such resources to address the cumulative deficit? Is the board selling assets, which means that it will not have them to address the cumulative deficit? Is the board using non-recurring resources inappropriately?
For a range of obvious reasons, I wish that the board was not using non-recurring resources to the extent that it is. Julie McKinney can correct me if I am wrong, but I think that any profit from one significant asset disposal in the programme will be used to help to fund some of the changes that the board needs to make. The other asset disposals are a fair way down the track.
The board's five-year plan includes asset sales. Other sales are still outstanding, because the board does not know their timing or how much it will receive for them. Some use of non-recurring resources from asset sales is built in.
The member puts her finger on the important question whether using non-recurrent resources in the short term will leave scope to deal with the accumulated deficit later. We need to assess that with NHS Argyll and Clyde and have clarity on that matter, and we will do so.
Does the department have a view on the percentage of non-recurring resources that NHS Argyll and Clyde should use? Trevor Jones has said that the department accepts that health boards will use non-recurring funds on occasion to keep themselves in balance.
I do not think that there is a formula—a fixed sum—that one can apply. In his report, the Auditor General drew attention to the danger that people can become too reliant on using non-recurrent resources to sustain a weak underlying position. It is a matter of judgment in specific circumstances, and that rests on the quality of the dialogue, our understanding of what is proposed and the way in which we test those plans. I do not think that there is a rule of thumb beyond saying that, in an ideal world, non-recurrent resources would be used as little as possible. We fully accept that they are a useful tool for financial management; however, we should not become dependent on them to sustain weak recurrent positions. It is important that boards deal with those weak recurrent positions, difficult though that might be.
I want to pick up on the statement about Argyll and Clyde NHS Board having had no service planning for many years. How many years are you talking about? Five years? Fewer? More?
I will use the example of the proposals that we are currently considering around mental health services, services for older people and services for the learning disabled. Many places in Scotland are much further forward in having done that redesign work. Argyll and Clyde NHS Board is considerably further behind other places in Scotland in that respect. That is evidenced by the amount of money that the board spends on institutional care, as Dr Woods said, which is no longer appropriate for people in those service areas. That is one example of an area in which progress would, ideally, have been made considerably earlier.
We are all aware of performance assessment frameworks and all the boxes that have to be ticked. Why was the matter not picked up before? Why is it an issue now, when we have performance management throughout the system?
I am not sure that I know the answer to that in relation to Argyll and Clyde NHS Board. My understanding is that the board has needed time to consult and engage in dialogue with all the interested parties locally to get agreement and ownership of some of the substantial changes. I suspect that, if you were to go through the accountability review letters—you have probably done so—you would find quite a lot of dialogue in them about the need for service plans to be developed to support changes. I am not sure that I can tell you, from this vantage point, why that has taken longer in Argyll and Clyde than it has taken in other places.
For me and other members, that calls into question the robustness of the performance assessment framework and the action that can be taken when somebody fails in some part of that.
I do not know whether the problem is the robustness of the performance assessment framework—which is, essentially, an information tool—or the quality of the dialogue about service planning changes. That is something on which we need to reflect.
Given the evidence that you have provided, are you close to having a target for when agreement might be reached with Argyll and Clyde NHS Board?
I would like to make two points, if I may. First, I am pleased that the chief executive of the board believes that we are now working more effectively on these things. That is an important statement, which he has made in the correspondence around the accountability review. I regard that as an important step forward. Secondly, I reiterate what I said at the beginning, which is that, although the minister regards the situation—as I do—as a matter of great seriousness and priority, it is not the sort of thing that should be rushed or on which hasty decisions should be reached. He wants the benefit of the conclusions of the committee to help to inform his consideration of the issues. It is important that we get to the bottom of this, agree a way forward on the recurrent position and think about the accumulated deficit; however, we need to make progress at an appropriate pace and not reach hasty decisions that might not be sustainable.
That ends our questions. I thank you and your colleagues—and the witnesses who appeared earlier in the meeting—for helping us with our inquiries. It has been a most helpful exchange of views. What was particularly refreshing was your positive attitude in trying to heal things and come to conclusions on the case of Argyll and Clyde NHS Board.
Thank you for those comments, convener. I reiterate my opening point: I hope that we will develop a dialogue during my tenure in my present position. I would be happy to arrange for briefings and so on for the committee on specific issues, as we are dealing with extraordinarily complicated and changing situations. I am happy to engage with the committee in a way that the committee considers appropriate.
Very good. The committee will consider that. Dialogue is guaranteed because, once we produce our report, there will be an opportunity for the department to respond to it.
Meeting continued in private until 12:56.