Health and community care bulletin

May 2006

Audit Scotland is a statutory body set up in April 2000 under the Public Finance and Accountability (Scotland) Act 2000. It provides services to the Auditor General for Scotland and the Accounts Commission. Together they ensure that the Scottish Executive and public sector bodies in Scotland are held to account for the proper, efficient and effective use of public funds. 

Foreword

Welcome to this first issue of Audit Scotland’s Health and community care bulletin. Although the bulletin is aimed primarily at non-executive health board members and elected members of councils, we hope that it will also be of interest to staff working in health and community care services. 

The bulletin sets out, in a concise form, the national performance audit work we have been doing in the NHS and community care over the past year and the key issues arising from that. It aims to help non-executive board members and elected representatives in their role of holding public bodies to account and helping them to improve. It also outlines the performance audit work we are currently doing.

Over the past year we have published five health reports on behalf of the Auditor General for Scotland (AGS), and one joint report for the AGS and Accounts Commission. This bulletin summarises the key findings from these reports, and the full reports are available on Audit Scotland’s website at: http://www.audit-scotland.gov.uk. In addition, each NHS body receives an annual report from auditors appointed by the AGS. These are also available on our website.

All our NHS performance audit reports are considered by the Audit Committee of 
the Scottish Parliament. Where the committee has produced its own report this is available on the Scottish Parliament’s website at: www.scottish.parliament.uk. Further information about this process is covered in this bulletin.

We will soon be consulting on our performance audit forward work programme and will be writing to all NHS bodies and local councils to seek feedback. As well as this formal process, we always welcome your ideas for areas that you think we should examine, and also suggestions for where we can provide further support to non-executive board members and elected representatives in fulfilling your roles. If you feel an Audit Scotland study could help improve the delivery of services for patients and service users, and help identify and disseminate good practice, we would like to hear from you. Please do not hesitate to contact me directly.

Barbara Hurst mailto:bhurst@audit-scotland.gov.uk.
Director of Performance Audit (Health and Central Government)

Waste management in Scottish hospitals
A follow-up report		
May 2005

Key findings

•	There was a positive response at national level to the recommendations in our 2001 baseline report. This included the NHS in Scotland’s Property and Environment Forum issuing an action plan to all NHS boards to implement our recommendations.
•	Progress has been made in developing waste policies, appointing waste management officers and recycling but there are still areas for improvement.

Good waste management and environmental practice matters for the NHS in Scotland. It reduces risks for patients and staff, and helps the environment. Managing waste effectively involves:

•	correctly identifying, segregating and handling clinical waste to avoid risks to staff, patients and the environment
•	not including domestic waste with clinical waste to avoid incurring unnecessary extra costs
•	segregating and correctly disposing of sanpro waste
•	maximising the benefits of recycling.
Spending on waste management at £8 million a year is low when compared with the health service as a whole. But costs are likely to rise because of Landfill tax and new regulations such as the Hazardous Waste Directive.

NHS board members need to be assured that:

•	board-wide policies on waste are in place and in line with national guidance
•	there are systems to ensure all clinical waste is secure from public access
•	policies exist for reuse, recovery and recycling of waste across all hospital sites
•	regular waste audits are carried out
•	staff are aware of the need to properly segregate waste.
Contact: Angela Canning mailto:acanning@audit-scotland.gov.uk
Report link: http://www.audit-scotland.gov.uk/index/05pf03ag.asp

Moving on?
An overview of delayed discharges in Scotland		
June 2005

Key findings
•	The number of patients delayed in hospital has reduced over the past few years, although it remains a problem across Scotland.
•	The Scottish Executive Health Department’s (SEHD) national target of a 20 per cent annual reduction in delayed discharges in all 15 partnerships potentially penalises partnerships that perform well against their target – the best performers are set a more challenging target for the following year.
•	Local partnerships use a range of initiatives to reduce delayed discharges in their areas. But these need better evaluation to assess their success and whether they deliver value for money.
Some patients stay in hospital longer than they need to because the ongoing care they need is not ready for them leaving hospital. The number of patients delayed in hospital has fallen over recent years, but an ageing population means further action is needed by the NHS and its partners to sustain progress.
Audit Scotland worked with the NHS board and three councils that make up the Tayside Partnership to: understand how the system works; identify key factors causing delays in Tayside; and develop a computer model to help Tayside test strategies to reduce delayed discharges. While the Tayside model cannot simply be used by other partnerships, they may benefit from adopting a whole systems approach to improve their understanding of a complex system.
Our report provides a national overview of delayed discharges and describes our work in Tayside. We also published a handbook about the Tayside model.
NHS board members need to be assured that: 
•	initiatives aimed at reducing the number of delayed discharges are fully evaluated, including an assessment of cost, quality and success measures
•	there are a wide range of strategies available for reducing delayed discharges, aimed at redesigning services as well as increasing capacity
•	a whole systems approach is taken to develop a shared understanding of the interdependence of services
•	delayed discharge planning is linked with mainstream capacity planning.
Following a recommendation in our national report, the SEHD changed the way it sets targets for reducing the number of delays in partnerships.
Contact: Mark Diffley mailto:mdiffley@audit-scotland.gov.uk
Report link: http://www.audit-scotland.gov.uk/index/05pf04ag.asp

A Scottish prescription
Managing the use of medicines in hospitals		
July 2005

Key findings

•	New medicines are being developed all the time and more conditions can be treated, often with better results. NHS boards must make sure that patients get most benefit from medicines and from the money spent on medicines.
•	There is a lot of good information about medicines available. But more needs to be done to make sure that staff who prescribe medicines get all the information they need, when they need it.
•	Spending on medicines is going up faster than in other parts of the health service and there is scope for NHS boards to manage this better, by improving planning and by making sure that staff who prescribe are aware of cost effective medicines.
NHS boards need better information to manage and monitor the use of medicines. This study identified a number of gaps which make it difficult for NHS boards to set budgets at the correct level, monitor whether medicines are used in line with best practice and share learning from mistakes or near misses involving medicines. 

With the increasing number and complexity of medicines, and with more staff groups able to prescribe, staff need access to up-to-date advice and guidance. This is not always in place. Clinical pharmacists are increasingly working with patients and staff, providing specialist input and advice, but only two-thirds of hospitals have a local service. 

NHS board members need to be assured that: 

•	systems are in place to manage and monitor spending on and use of medicines
•	staff have easy access to guidance and advice 
•	medication incidents are reported and acted on and lessons are shared
•	managers and board members are getting appropriate information and advice to allow robust monitoring and decision making
We have developed a paper suggesting questions that non-executive directors may want to ask related to the key issues. This paper includes some good practice examples. It is available on our website along with the report.
  
Contact: Tricia Meldrum mailto:tmeldrum@audit-scotland.gov.uk

Report link: http://www.audit-scotland.gov.uk/index/05pf06ag.asp

Overview of the performance of the NHS
in Scotland 2004/05				
December 2005

Key findings

•	Improvements in the quality and availability of treatment are resulting in better clinical outcomes and increased life expectancy. But the poor health of many people continues to be a problem.
•	Setting targets is helping to improve outcomes for patients. But a more systematic process for setting and measuring performance against targets is needed.
•	The NHS in Scotland faces significant challenges and cost pressures in the future. To ensure that it can continue to provide sustainable services it should improve its financial, workforce and performance management.
•	Improvements are being made in the collection of activity data. But a comprehensive picture of NHS activity, costs and quality is still not available and it remains difficult to assess whether the 
NHS is delivering value for money.
In 2004/05, the NHS in Scotland spent over £8 billion, representing around one-third of the total spend in the public sector. It is also Scotland’s largest employer with almost 150,000 staff providing care in community, primary and acute settings throughout the country.

The NHS needs to be able to demonstrate how it is using these resources to improve the quality of patient care. Our overview report provides an independent view of what progress has been made in key areas such as health improvement, clinical outcomes, waiting times, workforce planning, and financial performance. It also identifies emerging issues which need to be addressed by the service. 

Contact: Roddy Ferguson mailto:rferguson@audit-scotland.gov.uk

Report link: http://www.audit-scotland.gov.uk/index/05pf10ag.asp

Tackling waiting times in the NHS in Scotland		
February 2006

Key findings

•	The NHS in Scotland has made significant progress in reducing the longest waiting times for people with waiting times guarantees.
•	Trends in the number of people waiting shorter periods, and changes in the way waiting time guarantees will be applied from 2007, suggest that the NHS will face a major challenge in meeting the more ambitious future waiting time targets.
•	The NHS in Scotland could make more efficient use of the Golden Jubilee National Hospital (GJNH).
•	Involving patients more in decisions about where they are treated has the potential to help reduce waiting times.
•	The balance between short-term increases in activity and longer-term solutions should be reviewed. The NHS in Scotland needs to develop a whole system approach to tackling waiting times.
To achieve and maintain shorter waiting times, it is necessary to address the causes of long waits. Short-term increases in activity should only be used where permanent increases in capacity are not required, as part of a planned process for achieving and maintaining shorter waiting times.

Audit Scotland assessed progress in reducing long waits for outpatient and inpatient care and analysed the value for money and sustainability of the approaches used. The NHS in Scotland has made substantial progress in reducing the longest waits, through the targeted investment of non-recurring money, treating more patients at the GJNH and developing new ways of providing services that speed up diagnosis and treatment. The report highlights the need to maintain and build on this progress by moving further towards whole system approaches. The report makes recommendations for NHS boards, the Scottish Executive and the GJNH to support this process.

NHS board members need to be assured that:

•	robust plans are in place to assess and manage patients with an Availability Status Code before the codes are abolished at the end of 2007
•	capacity and processes are in place to achieve and maintain the 18-week waiting time guarantee by the end of 2007
•	the long-term role of the GJNH in supporting NHS boards’ waiting times strategies has been considered
•	patients are offered the option of travelling to the GJNH where clinically appropriate and where local capacity is not available to meet targets.
Contact: Neil Craig mailto:ncraig@audit-scotland.gov.uk

Report link: http://www.audit-scotland.gov.uk/index/05pf13ag.asp

Implementing the NHS consultant contract in Scotland		
March 2006

Key findings

•	The new contract represents a change in the way that NHS managers and consultants work together. It offers an opportunity to focus the work of consultants on priority areas, and improve patient care, but it is not yet being used to its full potential and there is limited evidence of benefits to date. 
•	Prior to the new contract, the annual pay bill for consultants was £257 million. This is projected to 
rise to £354 million in 2005/06, a 38 per cent rise over the three years. The cumulative additional cost over the three years is £235 million.
•	Planning for the contract should have been more robust. The SEHD initially underestimated the overall cost by £171 million for the first three years.
•	Prior to agreement of major contracts, NHS boards must ensure that robust planning and monitoring takes place to prepare for the cost and impact of such changes.
The new consultant contract aims to allow NHS boards to plan the work of consultants around the needs of patients and the service. To do this, NHS boards must have systems in place to accurately record the work of consultants. The new contract is based on a job planning process which clearly sets out a consultant’s working week and the amount of time spent on different activities such as direct clinical care. 

NHS board members need to be assured that:

•	systems are in place to monitor and manage the cost and impact of the new consultant contract
•	where consultants are working over 48 hours, a European Working Time Directive (EWTD) waiver is signed
•	where consultants are working more than their contracted hours, this is recorded and action plans are in place to reduce such work
•	detailed and accurate job plans are in place for all consultants under the new contract and that consultant work is linked to service priorities
•	detailed, specific and measurable plans are in place to achieve benefits for patients and the service through the new consultant contract.
Contact: Claire Sweeney mailto:csweeney@audit-scotland.gov.uk

Report link: http://www.audit-scotland.gov.uk/index/05pf14ag.asp

Forthcoming reports
We will be publishing a number of reports over the next few months

Meeting information needs: the effectiveness of Information Management and Technology in the NHS in Scotland
Many of our recent reports on the NHS have highlighted a lack of information and the need for improvements in this area. In order to achieve these improvements, Information Management and Technology (IM&T) is an essential tool. This study will examine the way in which the SEHD ensures information needs are identified within the health service, how it supports IT and how IM&T projects are managed. 

Contact: Rhona Jack mailto:rjack@audit-scotland.gov.uk

Publication planned for August 2006.

Project brief link: http://www.audit-scotland.gov.uk/audit/autumn.htm

Planning ward nursing: Follow up
We will be publishing a number of reports over the next few months		
More than £1 billion a year is spent on the 50,000 strong nursing workforce in Scotland. Our baseline report, published in December 2002, stated that there was a wide variation in the number of nurses caring for patients in wards with similar demands. It included a number of recommendations aimed at improving workforce planning and introducing measures of the quality of patient care. This follow up study will look at progress in implementing these recommendations. It will also consider the impact of more recent developments relating to the nursing workforce, including the introduction of new terms and conditions through Agenda for Change.

Contact: Neil Craig mailto:ncraig@audit-scotland.gov.uk

Publication planned for October 2006.

Hospital catering: Follow up
Our 2003 baseline report on hospital catering found that the NHS in Scotland provided a good quality catering service to patients and satisfaction levels were high. However, we reported that more work was needed to improve the nutritional care of patients. Our follow up work will review progress against our main recommendations and take account of NHS Quality Improvement Scotland’s (NHS QIS) review of its food, fluid and nutritional care standards.

Contact: Roddy Ferguson mailto:rferguson@audit-scotland.gov.uk

Publication planned for October 2006.

Overview of the financial performance of the NHS in Scotland 2005/06
The NHS in Scotland spends around £8 billion each year, around one-third of the total spend in the public sector. The Auditor General’s last overview report highlighted that the NHS faces significant challenges and cost pressures in the future. It recommended that the NHS should review and improve its financial management and workforce planning to ensure that it can continue to provide sustainable services. This overview report will focus on the 2005/06 financial performance and governance arrangements of the NHS in Scotland. 

Contact: Angela Cullen mailto:acullen@audit-scotland.gov.uk

Publication planned for December 2006.

Management of long-term conditions
Long-term conditions are those that cannot at present be cured but can be treated and controlled over a long period of time by medication and other therapies. Examples include chronic obstructive pulmonary disease (COPD), epilepsy, asthma and diabetes mellitus.

People with long-term conditions need ongoing clinical care and support from health and social care services. But there are concerns about the quality of chronic care in general practice; poor coordination of care between hospitals and the community; and the lack of integration between health and social care.

The overall aim of this study is to assess the current position in relation to managing people with long-term conditions, share good practice and make recommendations for improving services which will bring benefits to patients.

Contact: Mark Diffley mailto:mdiffley@audit-scotland.gov.uk

Publication planned for winter 2006/07.

Project brief link: http://www.audit-scotland.gov.uk/audit/autumn.htm

Out-of-hours health services in Scotland
The provision of GP services outside normal working hours has changed because of the new GMS contract. This allowed GPs to opt out of providing out-of-hours services and responsibility transferred to NHS boards. This study will examine how different NHS boards are providing out-of-hours services and how they are working with other services including NHS 24, the Scottish Ambulance Service and Accident and Emergency Departments. It will review the impact of the new arrangements on the cost of out-of-hours services, patient access to services and quality of care and it will identify good practice examples. The study will also look at how NHS boards and the SEHD are monitoring out-of-hours services.

Contact: Claire Sweeney mailto:csweeney@audit-scotland.gov.uk

Publication planned for early 2007.

Other information

What happens to Audit Scotland’s national performance audit reports for the NHS?
All our national performance audit reports for the NHS are presented to the Scottish Parliament’s Audit Committee. This is also the case for joint AGS and Accounts Commission reports covering NHS and community care issues. Following a briefing from the AGS, the Audit Committee may decide to take evidence from the Accountable Officer for the NHS and may call other witnesses. After taking evidence, the Audit Committee considers its findings and makes a report to Parliament. These reports are available on the Parliament’s website at: http://www.scottish.parliament.uk

The Audit Committee has taken evidence following our recent reports on waiting times and the consultant contract.

How the NHS works series
Audit Scotland is developing a new series of publications, How the NHS works, aimed at supporting continuous improvement in the NHS. Governance in Community Health Partnerships is the first in this series and will be published in May 2006. It is a self assessment tool designed to support NHS boards and Community Health Partnerships (CHPs) in developing their governance arrangements. It is based on good practice and statutory guidance, and will be available on our website.

Memorandum of understanding with NHS Quality Improvement Scotland (NHS QIS)
Audit Scotland has a memorandum of understanding with NHS QIS. Its purpose is to set out the powers and responsibilities of the AGS and NHS QIS, and the arrangements for joining up audit and review in NHS bodies. The document is available from our website:
http://www.audit-scotland.gov.uk/index/nhsnewsmemo0805.asp

If you require this publication in an alternative format and/or language, please contact us to discuss your needs. It is also available on our website: www.audit-scotland.gov.uk

Audit Scotland 
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