“Overview of the National Health Service in Scotland 2002/03”
Agenda item 3 is discussion of the committee's eighth report in 2004, on the "Overview of the National Health Service in Scotland 2002/03". Members have received the Executive's response to our report and will have had a chance to read it. I invite members to comment on the response, after which I will invite observations from the Auditor General and his team. Do members have any comments to make with regard to the letter from the Executive?
I have concerns about the way in which the response is framed. The Executive could have rolled together all the questions that we asked and just said, "It's nothing to do with us." Throughout the response, we hear about "anticipated cost" or "anticipated increase" that it is "not possible … to predict". Given the fact that a significant amount of money is going into the health service, one wonders what exactly we will get out of the system if the Scottish Executive Health Department treats the committee in that way. The Executive also gives examples of practices that it is seeking to pursue but which have been in place in some health board areas for several years.
I do not know where we go from here. If we ask the Executive the questions again, we might well get the same absolute rubbish that we have already got. Throughout the letter, dates are not given. I do not know the Auditor General's view on the information. We have, at last, managed to get the latest information on the number of one-stop clinics. We know that, as at June 2004, we have 471 of those clinics—something that we did not have before. There is that little chink of light. However, I am concerned about the terminology that is used in the letter; everything seems to have been plucked out of the air.
We will discuss how we will respond to the Executive under agenda item 7. Before we do that, this is our opportunity to ask the Auditor General and his team for their comments in public.
I have great difficulty with the responses that we have received from the Executive. Sir Humphrey Appleby would be quite proud of them. The responses are deliberately obfuscatory, they do not answer the questions that were posed, and I almost do not know where to start in looking at them.
On the budget, the Executive says that planning is carried out on the basis of
"an indicative increase in unified budget … which equates to additional funding of £447 million"
with anticipated cost pressures of £81 million, payroll figures, and so on. However, unless my arithmetic is wrong, when the figures are added up it becomes clear that the Executive is planning a £13 million-plus deficit before it even starts.
We asked how the Executive measures the improvements and whether the efficiency savings are real or imaginary. However, it is absolutely unclear from the response how the Executive's agenda for change will directly benefit health care users and how such benefits will be measured other than by potential financial savings. Paragraph 2 on page 2 of the letter is an example of that type of answer. It states that the agenda for change will still
"play a part in such change"
but that,
"because it is an enabling tool … rather than a direct agent of delivery, it is not possible to attribute specific changes/benefits directly to it, or to predict precisely what they might be, how soon they will flow, in what volume, and with what impact."
In other words, the Executive does not know. That is typical of the verbiage in the letter. I would like plainer English rather than the Executive hiding the fact that it does not know.
We are told that the action that is being taken is an additional letter
"outlining the approach to and monitoring of integrated benefits",
which is
"currently in initial draft form"
and will be followed by meetings and an assessment framework. However, in the table that details the framework, under the heading of "Developmental Issues", we are told that the expected benefits are unknown because future assessment
"will focus on the emerging issues and on realising the benefits derived from the new contracts."
By the Executive's own admission, those benefits are unknown. The response talks about demonstrating the benefits but, at the foot of page 3, we are informed that the indicators are "currently being developed" although they "will outline specific objectives". The Executive is definitely giving a promise, but everything else tells us that the matter is up in the air.
How are staff to be incentivised? I almost do not know where to start. All that I can say is that this response is most unsatisfactory. It is time that the Executive got out a dictionary and was subjected to the Plain English Campaign, so that we could be given a better view of what has happened. I do not know whether the committee wants another example, convener.
No, I think that we have got the message about the agenda being only for possible change.
I point members to the Executive's answer to question 9.2. In the Auditor General's report, we were told that
"total investment is not known and it will be difficult to measure whether targets are being met … targets need to be more measurable and timely."
We asked for the Health Department's response to that. The response states:
"Health improvement is an opportunity and a challenge for the Community Planning Partnerships (CPP). Local Authorities have a duty of wellbeing and the NHS has a duty to deliver health improvement. CPPs and Community Health Partnerships (CHPs) produce Joint Health Improvement Plans (JHIPs) and Regeneration Outcome Agreements. Local Health Plans for each NHS board reflect local JHIPs."
There is a lot of planning and many acronyms, but a dearth of action. The response continues:
"SR2004 restates the Health Improvement objective ‘working across Scottish Executive Departments and with other delivery partners to improve the health of everyone in Scotland and reduce the health gap between people living in the most affluent and most deprived communities'. CPPs involving all partners including Health Boards and local authorities work to deliver that objective for each of their local communities."
In other words, it is an additional target that supports the previous targets. I wonder whether the Executive has hit any targets yet.
I find the response completely unsatisfactory. It is endemic in the health service that people speak in acronyms and that, when we ask for details and action, we get verbiage. I really think that a Plain English Campaign guide would be of benefit to the Executive. I would like answers that actually mean something.
Does Robin Harper have any comments to make?
I think that it has all been said.
Are there any comments that the Auditor General and his team want to make?
There is very little that I can say that would be of help to the committee at this stage. One of the general themes that came through in the performance overview that we published in the summer was the difficulty that the NHS has with its information systems, which are lagging well behind developments in the modern NHS. It would, therefore, be somewhat surprising if the Health Department was able, in such a short time, to produce a great deal more information that would be helpful to the committee. As you can imagine, when we wrote our report we analysed thoroughly all the available data sets and attempted to pool them for you.
We will use the Executive's response as a source of information in undertaking our performance audits in the health service, so the analysis that it contains will be used to the best effect that we can make of it in that regard. It may be appropriate for the committee to take that into account in deciding whether it wishes to take the matter any further at this stage.
I remind the committee that this is the second response to the committee's request for information, as the first response generated a need for further questioning.
Given that agenda item 7 is on a related, although separate, overview report, I signal to the committee that we perhaps need to consider how much further we can go in our deliberations with the Health Department if this is the type of response that we receive at the second time of asking. Perhaps a different approach is needed. We can discuss that under agenda item 7.
Does the Auditor General believe that the department cannot give us an answer at the minute? For example, paragraph 9.3 states:
"a key strand of work being taken forward … is workforce redesign, looking at the co-ordinated development and facilitation of new roles in ways which will improve service delivery and have real impact."
That is certainly what should be done, but that does not seem to be the reality. In other words, it seems like the deckchairs are being moved.
Does the Auditor General believe that the information is not known and that the department cannot be more specific? The department says that it is relying on a report that will be published next spring and on other planners planning planning. We were told that the health service had specific objectives to move on and that unless the changes work, the health service will not be improved. There seems to be some tail chasing going on. If that is the case, the department should make it plain or it should tell us the timetable for when the planners will be able to plan the planning. To be given such a response to our very specific questions is inadequate. Is there something that makes it impossible for the Health Department to tell us what it is doing?
Health service work-force redesign is hugely complicated, so it is important to understand what is happening in different aspects of the service. Work force redesign includes: the general medical services contract, on which planning is moving ahead comparatively well; the consultant contract, on which Audit Scotland may well do a specific report; and agenda for change, which is the most significant initiative because it covers the bulk of staff who are employed in the service. Agenda for change is business that is very much in hand at the moment, so it is true that the department is not in a position to advise what the outcomes are likely to be. Caroline Gardner can expand on that.
Caroline Gardner (Audit Scotland):
All three of those contracts are UK-wide initiatives, as the committee will know from its previous discussions on their impact. The consultant contract and the GMS contract are being rolled out or are in place, but negotiations are still continuing on agenda for change, which will affect the largest group of staff in the health service and which will probably provide the most scope for changing roles and responsibilities across professional boundaries. However, there is still work to be done on that. If the committee wants to know more about what information the department has and what issues are genuinely still work in progress, that is a question for the department. Perhaps the issue is how best the committee can put that question to the department to get the information that it seeks.
I still wonder whether there is something endemic in the health service whereby CPPs talk to CHPs and health boards about JHIPs. There seems to be a systemic problem in the NHS that things end up in endless conversations but not much action.
There are certainly lots of meetings.
Indeed.
With that observation, we have probably exhausted agenda item 3, although we may continue the discussion under agenda item 7. I thank committee members and Audit Scotland for their contributions.