NHS Lanarkshire (Safety and Quality Review)
The next item of business is a statement by Alex Neil on the publication of a review of the safety and quality of NHS Lanarkshire. The cabinet secretary will take questions at the end of his statement, so there should be no interventions or interruptions.
14:13
In August of this year, the Scottish Government asked Healthcare Improvement Scotland to undertake a rapid review of NHS Lanarkshire’s services. The report that HIS published this morning is the culmination of that review, and I would like to make a statement that sets out the Government’s response.
The HIS report uncovers a number of areas in which, at times, the standards of care have fallen short of the Scottish Government’s expectations for patients. All health boards in Scotland have been instructed that they must ensure that patient safety is their top priority. To support that, the Scottish patient safety programme has been working for more than five years to deliver ways to make Scotland’s healthcare safer.
As part of the patient safety programme, hospital standardised mortality ratios are collected and published regularly online. The HSMR is based on a complex model that looks at the ratio of observed deaths within 30 days of admission to an acute hospital to the number of predicted deaths. Although a high HSMR is not, by itself, a definitive measure of the quality and safety of care, it serves as an important prompt for further investigation. HIS’s report today states:
“a higher than predicted HSMR cannot be used to make judgements about the quality and safety of health services ... Instead it should be used as a ‘smoke alarm’ which alerts an NHS board to potential problems and leads to a more detailed review of safety and quality issues.”
I highlight that the concerns about the progress in NHS Lanarkshire were identified thanks to our patient safety programme. The HIS rapid review was instigated on the basis of concerns about what the safety programme raised with regard to the HSMR figures that are routinely collected. It is worth noting here that, overall, NHS Lanarkshire has improved its HSMR. However, the rate at which Monklands hospital in particular is improving is insufficient and it lags behind other boards in Scotland. Wishaw hospital’s HSMR has reduced by 17.6 per cent, which is greater than the overall change across Scotland of 12.4 per cent, whereas Hairmyres hospital’s reduction is 7.1 per cent and Monklands hospital’s is 4.3 per cent overall.
In conducting the rapid review we asked HIS, first, to provide an independent expert diagnosis of the factors that may underlie the HSMR figures, including assessing any systemic factors that may be impacting on the safety and quality of care and treatment being provided to patients in NHS Lanarkshire’s acute hospitals; secondly, to consider whether the existing action by NHS Lanarkshire to address any key issues identified in the diagnostic phase is adequate and whether any additional steps should be taken; thirdly, to advise whether any additional support should be made available to NHS Lanarkshire to help strengthen and accelerate its improvement programme; and, fourthly, to advise on any areas that may require further action.
In reaching its conclusions, the HIS expert review team listened to the experiences of more than 300 patients and carers and of more than 200 members of staff, visited 40 clinical areas and reviewed 152 patient records. The team concluded that a broad range of improvements is necessary for NHS Lanarkshire to continue its commitment to deliver safe and effective patient care. That includes the need for stronger focus and leadership in implementing robust patient safety interventions and in the redesign of services.
Today’s report makes 21 specific recommendations for NHS Lanarkshire to follow to improve its performance. To help NHS Lanarkshire deliver on those important recommendations, I am putting in place a governance and improvement support team to help NHS Lanarkshire make the changes necessary to improve its performance for the people of Lanarkshire. I have spoken this morning to the chair and chief executive of NHS Lanarkshire, and they have accepted the 21 recommendations from HIS in full and have welcomed the availability of the improvement support team to help them deliver the rapid and sustained improvements that are now needed. I expect those improvements to be made urgently and I have asked to be updated regularly. To keep Parliament informed of progress, I will ensure that regular updates are laid in the Scottish Parliament information centre and made available online.
I have made clear this morning that there will be a formal review of progress against the recommendations by the end of March 2014. The improvement team will be led by Jeane Freeman, chair of the Golden Jubilee national hospital; Malcolm Wright, chief executive of NHS Education for Scotland; and Professor Sir Lewis Ritchie, director of public health at NHS Grampian. Their focus will be on two crucially important areas: leadership and clinical quality improvement.
NHS Lanarkshire has indicated that, throughout the review period, it was responding to concerns that were raised, and that it has already begun improvement work. That includes its planned investment of another £8.7 million to increase capacity, including the recruitment of 54 whole-time equivalent consultants, nurses and other clinical support staff in 2013-14.
While we should be under no illusion about the difficulties that have been highlighted, we should not lose sight of the commitment and dedication of staff across NHS Lanarkshire and indeed the whole of our health service. We have a record number of staff working in NHS Lanarkshire, including a record number of nursing staff. Today’s report highlights areas for improvement, which will further support the staff of NHS Lanarkshire in providing the standards of care to which they rightly aspire.
Our continuing commitment to quality means that we will shine a light on areas where our NHS does not achieve the high standards that we expect and we will provide clear opportunities for improvement. As a Government, we will continue to support our patient safety programme, monitor our health service and take action when necessary to ensure that the best service is provided for the people of Scotland.
The cabinet secretary will now take questions on the issues raised in his statement.
I thank the cabinet secretary for sharing his statement with me. However, such a brief statement that is devoid of much of the detail that we would have expected in a statement on such an important issue is a disgrace and an affront to the people of Lanarkshire, so will the cabinet secretary urgently bring the issue to the chamber in a debate so that we can discuss these life-and-death matters at length?
The report on NHS Lanarkshire should make the whole of Scotland sit up. It is a damning report that highlights problems with discharge information, poor levels of care, failures to escalate risks, failures to support patients whose conditions are deteriorating, poor quality of improvement systems, a lack of medical staff, a reliance on junior doctors, serious concerns about the level of nursing and a management regime and culture that appear at times to be completely out of touch with what goes on in the wards on a day-to-day basis. The review team heard that staff at all levels indicated that there was a state of perpetual crisis in NHS Lanarkshire regarding unscheduled care, yet that did not merit a mention from the cabinet secretary.
People have died unnecessarily in Lanarkshire due to failures in the NHS. I have no doubt that senior management will seek to pass the buck to those hard-pressed staff who try to provide care despite the failings of management, but the reality is that this happened in the Cabinet Secretary for Health and Wellbeing’s own constituency.
Can we get a question, please?
The question is: what confidence can people have in those who lead NHS Lanarkshire and the cabinet secretary’s ability to deliver safe healthcare across the rest of Scotland? Let us be clear that many of the issues that the report raises are not exclusive to Lanarkshire.
First, on the detail, that is all in the report and the executive summary. I do not think that it would add anything for me to come here and repeat what is already in the report. The purpose of the statement was to give the Scottish Government’s reaction to the report, which is what I did.
Secondly, I point out to the member that, under his Administration, we would not even have known what the problem was, because we did not have a patient safety programme and we did not measure hospital standardised mortality ratios. Those two initiatives alone are reasons why we now know what is going on.
Thirdly, I point out to the member that we have a record number of staff in NHS Lanarkshire—a record number of nurses, a record number of qualified nurses and midwives, a record number of consultants, a record number of accident and emergency consultants and so on. The report is about the management of those resources.
The budget for NHS Lanarkshire has been increased over the past six years by £180 million. It is getting £180 million more this year than it got in the year when Mr Findlay’s party left office. I believe that the onus is now on the board and the senior management team of NHS Lanarkshire to address the issues, to turn the situation round and to report back within three months on what I hope will be significant progress.
The report does indeed identify a number of very concerning shortcomings in patient care, staffing levels and the admission of emergency patients to their appropriate wards. In a number of cases, those concerns are identified as long standing. I therefore welcome the fact that the chair and chief executive of NHS Lanarkshire have accepted the 21 recommendations in the report and that the cabinet secretary has stated that NHS Lanarkshire will be closely monitored for progress.
When does the cabinet secretary expect that the first progress report will be available? How long does he expect that it will take to correct the most pressing concerns that are identified in the report? How long will the governance and improvement support team be in place?
I thank the cabinet secretary for the advance copy of his statement.
I have asked for a formal progress report by the end of March, and my team will monitor the situation on a week-by-week basis.
We anticipate that a number of the problems will be dealt with very urgently, in particular the way in which we measure the deterioration of particularly vulnerable patients. As I said in my statement, I have been assured during the review by the senior management team that action has already been taken to improve policies and procedures in relation to that. I hope that we will now see progress right across the board on the issues that have been identified, and that it will be visible to the Parliament. As I have said, I am happy to report to both the Health and Sport Committee and the Parliament more generally.
As members are probably aware, many members wish to ask the cabinet secretary a question. I am confident that we can get through the whole list, but it would be helpful if members were to confine themselves to one question.
What action is proposed to improve early detection for patients whose clinical condition deteriorates in the hospital environment, and what is being done to ensure that those proposals are achievable? What consultation is taking place with carers and close family members in relation to patients in hospital?
On the last point, the HIS team interviewed quite a number of patients and carers—I mentioned the number—and families, and, of course, it has gone through a number of files, including complaint files, to read what people had commented on. It also held a number of sessions in each of the three hospitals. Those sessions were advertised for patients, carers and families to attend.
An early-warning system is used in dealing with deteriorating patients. That is not a uniform system, as the early-warning system that would be used for particular types of disease is different from that which would be used for other types of disease. Therefore, there is not a single early-warning system, but the underlying principle is that the patient’s condition is measured using a number of parameters, on an hourly basis if necessary, to ensure that they are receiving all the medical support and attention that are required. That is a very robust procedure that has been in place since the patient safety programme was introduced. We are further expanding and developing the programmes on an on-going basis using examples of how the systems can be improved from across the board. We are also looking at international best practice to see where we can further improve in all aspects of the patient safety programme.
Does the cabinet secretary recall that, when I campaigned against the closure of Monklands A and E, I called for more investment and improvement in that hospital? Given that the report says that NHS Lanarkshire staff
“at all levels indicate that there was a state of perpetual crisis ... regarding unscheduled care”,
will the Scottish Government now commit to investing more funding as well as a support team to ensure that people get the care that they need? Will it also consider an additional minor injuries clinic at Coatbridge to help to alleviate the pressure on our A and E services?
We have put in substantial additional investment. If members compare the spending in 2006 with this year’s spending, they will see that there is a difference of £180 million. Next year, we have budgeted for another £25 million on top of that for NHS Lanarkshire.
In 2006, there were eight A and E consultants in NHS Lanarkshire; today, there are 29. There has been a 70 per cent increase in the number of paediatric consultants and a 55 per cent increase overall in the number of medical consultants. Monklands has had a substantial share of all those staff—including nursing staff—increases. As I have indicated, NHS Lanarkshire is in the process of recruiting further consultants and nurses, and a number of those will be allocated to Monklands.
The situation in the other two A and E units would have been much worse had Labour’s proposal to close Monklands A and E gone ahead. [Interruption.]
Mr Findlay will you stop chuntering away and shouting across the chamber.
I will try very hard not to chunter, Presiding Officer.
I note in the report published this morning both examples of good care in East Kilbride and bad practice in Hairmyres hospital. How will the cabinet secretary ensure that, both immediately and beyond the three-month period, the top level of NHS Lanarkshire is forced to face up to its responsibility to provide good management to very committed staff and good service to the Lanarkshire public?
As I said, I have spoken to both the chair and the chief executive of NHS Lanarkshire and I am meeting the entire board on Thursday. I have made it abundantly clear to the chair and the chief executive—as I will to the full board—that I hold them totally accountable for the quality and safety of patient care in NHS Lanarkshire and turning round the situation identified in the report, and that I expect significant progress to be made by the end of March 2014. I have explained to the chair and the chief executive that, if significant progress has not been made by then, I reserve the right to take whatever additional action is required.
The cabinet secretary has repeatedly spoken about increased nursing levels but we know that vacancy levels are rising, with the number of posts lying vacant for more than three months rising sharply. Does he agree that posts lying vacant for many months with the resultant high usage of bank staff and large movements of staff between wards has contributed to inconsistent care and led to avoidable deaths? What additional support will he offer to strengthen the local improvement programme?
Overall, one reason why there are so many vacancies is because we are recruiting so many additional staff. Today’s vacancy position in NHS Lanarkshire is 157 full-time equivalent nursing staff. That is because of the recruitment exercise that we are engaged in. By definition, if a board goes out to recruit staff, there will be a period before the post is filled when a vacancy technically exists.
At this time in 2006, there were 41 consultancy vacancies in NHS Lanarkshire; today, there are 17. Bearing it in mind that we have increased the number of consultancy posts by 56 per cent and reduced the consultancy vacancies by more than half, that is a substantial achievement. We cannot blame consultancy vacancies as a contributory factor to the report’s findings.
Recommendation 20 of the report calls for a
“balance between generating data and ... the capacity to interpret ... it”.
Will the cabinet secretary ensure that any lessons learned from a review of data use and its reporting across the system will be shared across health boards, so that best practice is undertaken across all health boards?
We have a data initiative that operates right across the NHS, and there are two points to be made about data.
First, the systematic collection of appropriate data is absolutely fundamental to a good health service. As a result of the data that we collect through the science of informatics, we have reduced the number of amputations resulting from diabetes by 40 per cent and the incidence of blindness resulting from diabetes by 80 per cent. Collecting systematic and comprehensive data is essential to a modern health service.
The second issue, to which Clare Adamson referred, is that we sometimes collect the same data too many times. Therefore, a number of initiatives are in place to ensure that the same data are collected only once and are stored appropriately, so that they are available for analysis. I take the point that we need to be more efficient in the collection and collation of data, not just in NHS Lanarkshire but across the whole system.
Confidence in Monklands hospital has plummeted in my community, and it is understandable that people are choosing to take family members to Forth Valley or Glasgow hospitals. In light of the report, does the cabinet secretary have full confidence in NHS Lanarkshire’s senior management, particularly given that it was noted that NHS Lanarkshire already has record staffing levels?
I think that I have made it clear that I hold the senior management team and board of NHS Lanarkshire entirely responsible for NHS Lanarkshire’s performance. If I am not satisfied after the March review, I will take any additional steps that I require to take.
There is no evidence of large-scale migration of patients from Lanarkshire to adjacent health board areas. Over the past six years there has been an 11 per cent increase in day patients across Lanarkshire, there has been a 2 per cent increase in in-patients, which is in line with the Scottish average, and the number of A and E presentations has remained static.
Will the cabinet secretary set out the steps that have been taken to ensure that NHS staff are supported and given the opportunity to escalate concerns about risks to the delivery of safe patient care? What further steps will he take locally to ensure that that is the case in NHS Lanarkshire?
As the member knows, I have been very open about the need for staff to feel that they can report, without fear or favour, anything that in their opinion is going wrong. I am glad to report that the staff survey that Mr Matheson published on Friday shows that, for the first time ever, more than half the staff across the national health service in Scotland feel that they can blow the whistle on or report anything that is going wrong, without fear or favour.
That is a very welcome development. I aim to get the percentage up further, because I want staff to feel that, if something is going wrong or something is happening that should not be happening, they can safely escalate their concern to the appropriate level of management at the earliest opportunity.
As I said, we are putting a support team into NHS Lanarkshire. Indeed, the review team and expert advisory group have been providing some support in recent times. We will continue to provide such support for as long as it is required; we will ensure that the HSMR in Lanarkshire at least reaches the Scottish average and that all the indices of performance are at the required level before we consider withdrawing the support team that we are putting in today.
I was concerned to read in the report that
“the management actions taken have not yet been sufficient to support safe, person-centred and effective care”,
and that
“consultants are finding the workload excessive.”
The report also notes:
“NHS Lanarkshire is particularly challenged as it needs to provide sufficient staffing across its three acute district general hospital sites.”
NHS Lanarkshire has indicated that it accepts all 21 recommendations from HIS. Given that this is a devolved matter, what support will the Scottish Government provide to ensure that NHS Lanarkshire continues to deliver high-quality patient care, particularly at Monklands hospital?
I think that I outlined in some detail the budget, the additional staffing, the facilities and the investment in Monklands, with £14 million invested in physical facilities over the past 18 months. There is no doubt about our commitment to Monklands—unlike that of the member, who wanted the Monklands A and E closed, campaigned for the mental health unit at Monklands to be closed and, I understand, is even suggesting that Monklands hospital should be closed. I will take no lessons from her about Monklands hospital.
Does the cabinet secretary agree that proper use of the NHS workforce planning tool has a role to play in helping to improve the board’s performance and in further reducing the HSMR, in particular at Monklands hospital, which serves my constituency? Does he agree that boards should regularly publish the projected staffing requirements that the tool produces?
I absolutely agree. The member will be aware that as of April this year I made the workforce planning tool compulsory for all health boards in all situations. We can already see that major improvements are resulting from that decision.
It is very important that we get the right mix of skills, and the right number of staff in the right place at the right time. That mix has to be based on evidence, and the workforce tool provides the evidence to allow managers to ensure the maximum and most effective use of our staff throughout the national health service at local and national level. Those matters are reviewed regularly, and I am happy to publish any additional information that members require.
The review report contains withering criticism of NHS Lanarkshire. It says that there is a
“disconnect between what they thought was happening and what was actually happening.”
It highlights practices that amount to an “under-reporting of risk” and unacceptable risk to patient safety. On medical staffing, it says that
“the inescapable conclusion is that the actions taken to date are inadequate.”
How could all that happen on this Government’s watch, especially given the repeated complaints and media attention that NHS Lanarkshire has attracted since 2007?
As I said earlier, on this Government’s watch, we have identified and quantified the problem and put a solution in place, none of which would have been possible without the patient safety programme and measuring HSMR.
The member raised a valid point at the start of her question that goes to the role of the board of NHS Lanarkshire. I have been meeting non-executive directors of boards up and down the country and making it absolutely clear to them that their job is to scrutinise and question, to make sure that the information that they are getting is accurate, and to visit the front line and make sure that the information that they are being given reflects what is actually happening in the wards, hospitals and national health service. That has not been happening sufficiently at NHS Lanarkshire.
When my colleague Michael Matheson did the annual review of NHS Lanarkshire two months ago, he specifically asked the non-executive directors whether they were getting all the right information, and he got a positive response. Something has clearly gone wrong, which is why I have asked the entire board to meet me on Thursday to discuss exactly those issues. In future, the board will need to be more effective in managing and monitoring performance.
The review report notes that NHS Lanarkshire answered 95 per cent of complaints within the target of 20 working days. The national figure is 61 per cent. However, the review also raised the concern that the board’s emphasis was on meeting the target rather than on undertaking a proper analysis of the complaint and responding in full to the issues raised. Does the cabinet secretary agree that a review of NHS Lanarkshire’s complaints procedure is required? What will the Scottish Government do to ensure that NHS Lanarkshire addresses the problem?
Yes, I agree entirely. That is a fair point and we are reviewing the complaints procedure across the country. I believe that complaints should be used as a management tool to inform the board and senior management team about where things are going wrong in a health board area.
A good example is NHS Grampian, which has devised a comprehensive complaints and concerns analysis system that does not look at just official registered concerns and complaints, but incorporates any adverse comments that are made in social, print and broadcast media of the services that it provides. I have asked the chairs of every NHS board in Scotland to look at NHS Grampian’s system and adopt it or adapt it by copying it into their system so that their complaints procedure, which must be robust, fair and comprehensive, is not just about answering individual complaints but uses the complaints system as management intelligence to highlight and raise the alarm when anything is going wrong.
The review team found that there is considerable variation in the quality and system of care that is being delivered within all three hospitals. NHS Lanarkshire needs to take further action to develop a culture in which every opportunity is taken to learn from mistakes with the aim of improving patient care. An example of that is in the passing on of information between shifts. Can the cabinet secretary explain how that learning process will be undertaken and give us some reassurance about how it will be assessed?
We have a body called the quality, efficiency and support team, which spreads good practice in the national health service in Scotland. We are working in a range of areas in which that kind of activity can be improved dramatically. A priority must be to improve it in Lanarkshire.
For example, at Yorkhill hospital, every morning at eight o’clock they have what is called a huddle, which involves a member of every ward in the hospital, usually the charge nurse. Accident and emergency is represented, too. They go through all the areas looking at the number of overnight admissions, the predicted admissions that day and the accident and emergency situation to ensure that all the requisite staff are being properly used, where they are needed, that people are in the right beds, in the right wards, and, generally, that the hospital is running efficiently. Another huddle is held at two o’clock every day.
Since that system was introduced into Yorkhill, there have been substantial and significant improvements in patient safety and the standard of care, as well as in the levels of patient satisfaction, as measured by children and parents. I want to see a huddle carried out in every single hospital, every single morning, 365 days a year, throughout Scotland, because it is one of the initiatives that can help enormously in dealing with issues, particularly the changeover of shifts. It is a very good example, in practice, of how that kind of improvement can be made.
Could the cabinet secretary reassure the tens of thousands of constituents that I represent in areas such as Cambuslang and Rutherglen that their transfer from NHS Greater Glasgow and Clyde to NHS Lanarkshire in April 2014 is being appropriately planned for and resourced, given the pressures that the essential improvements outlined this afternoon will undoubtedly create?
Absolutely. Again, while we need to take cognisance of and rise to the challenge of these problems, we should also get them in context. Even in Monklands hospital, which is the worst performer, the HSMR has improved by 4.3 per cent since 2007 against a Scottish average of 12 per cent. In Wishaw, it was 17.6 per cent and in Hairmyres it was just over 7 per cent. The objective here is to get NHS Lanarkshire up to and, ideally, beyond the Scottish average.
However, we should not lose sight of the fact that the HSMR in Monklands hospital has improved, albeit not nearly fast enough. On that basis I would be happy to recommend to any of Bob Doris’s constituents—using my extensive medical knowledge—that they be treated in Lanarkshire.
Can the cabinet secretary tell the chamber whether Healthcare Improvement Scotland reported directly to him in the first instance? Has the report that was published today changed in any way from its original draft? Did any discussions take place between the cabinet secretary’s officials and Healthcare Improvement Scotland prior to publication of today’s report? Was the report presented to the board of NHS Lanarkshire before publication and did NHS Lanarkshire have any opportunity to seek a redraft of the report?
The process for this report was exactly the same as for every other report produced by Healthcare Improvement Scotland. I emphasise that I did not see and had no part in any drafting of the report, and I did not see any draft until the final report was presented.
However, as is standard, once the review team has completed a draft report, it submits it to the senior management team—in this case, in NHS Lanarkshire—to check for factual errors. I believe that some redrafting was done as a result of that consultation, which we would normally expect. The report is amended if it is believed that the points being made at that stage—by NHS Lanarkshire in this case—are valid. There is always a bit of redrafting. Nevertheless, the conclusions and recommendations are entirely the work of Healthcare Improvement Scotland. It is an independent regulator and the report must be its report, which is what is published today.
The report notes that, at Wishaw hospital, the most common reason for breach of the four-hour standard was the wait for first assessment. However, constituents have told me that people sometimes give up and go away before they are assessed. What account does the report take of that?
Our objective is for 95 per cent—rising to 98 per cent—of people who present to accident and emergency to be seen and either discharged back into the community or referred and admitted to a ward within four hours. The latest published figures show that the overall figure for NHS Lanarkshire was around 92 per cent, which means that it still has a way to go to get to 95 per cent and then 98 per cent. However, we should not lose sight of the fact that 92 per cent of people were seen and discharged or admitted within the four-hour timeframe.
When there are breaches, that is unacceptable, and the objective is to have zero breaches. However, I was at Wishaw yesterday with a constituent, in my role as an MSP. That particular patient had been in A and E for a total of eight hours, but it was a medical decision to keep them there. On reflection, the medics now think that that was a wrong decision, but it was a medical decision. I hear all the time that the issues are because of a shortage of beds or a lack of assessment, but that case had nothing to do with assessment or beds. There is a multitude of reasons why a breach might happen, but we are making substantial progress towards achieving the 95 per cent target. We have achieved it with the Scottish average and we now want to get to 98 per cent.
I should point out that, in 2006, the one time that the situation was measured under the previous Administration, the equivalent figure was that only 86 per cent of people were discharged or admitted to a ward within the four-hour period. We have substantially improved the situation.