Health and community 
care bulletin
Produced by Audit Scotland – October 2007
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 Government and public sector bodies in Scotland are held to account for the proper, efficient and effective use of public funds.

Foreword		
Welcome to the second issue of Audit Scotland’s health and community care bulletin. 
The bulletin primarily aims to share information with non-executive health board members and elected members of councils, but it also provides a summary of our work that we hope will be of interest to staff working in health and community care services. 
The bulletin summarises the key messages from the reports we have published over the last year. It also sets out issues for non-executive directors and elected members to consider in relation to their own boards and councils. This is intended to support them in their role of holding public bodies to account and helping them to improve. We have recently started producing Issues for non-executive board members to accompany our national reports. These are sent to all non-executive directors of NHS boards to support them in their role.
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. The full reports are available on Audit Scotland’s website (www.audit-scotland.gov.uk). Each NHS body also receives an annual report from auditors appointed by the AGS. These are available on our website.
Earlier in the year we commissioned Double Loop Development to carry out a survey to obtain feedback on our national reporting work from a sample of non-executive directors of health boards. This showed that we could do more to support non-executive directors 
in their role.
In addition to producing Issues for non-executive board members to accompany our reports, we are attending health board audit committee meetings over the autumn to raise awareness of our work and to discuss how best we can engage with boards about our reports. There is more information about this at the end of the bulletin. The initial focus of this work is supporting non-executive directors of health boards, as most of our reports are health reports. However, we hope the summaries in this bulletin will also be useful to elected members of councils.
A number of our key findings reported in the bulletin refer to the Scottish Executive Health Department (SEHD). This reflects the organisational structure at the time of the reports.
We hope you find the bulletin interesting. If you would like any further information about our work, please get in touch with me.
Barbara Hurst
Director of Public Reporting 
(Health & Central Government)
bhurst@audit-scotland.gov.uk
Primary care out-of-hours services
Published August 2007    
www.audit-scotland.gov.uk/docs/health/2007/nr_070830_out_of_hours.pdf

Key findings
•	As part of the new General Medical Services (nGMS) contract, over 95 per cent of GP practices have chosen to opt out of providing 24-hour care to their patients, with responsibility passing to NHS boards. The opt-out offers an opportunity for NHS boards to change the way services are delivered and to improve patient care, although this will take time to be used to its full potential.
•	The new arrangements have increased costs to NHS boards. This has added to cost pressures, particularly in rural areas where they have had to meet a greater percentage of the costs. The cost to NHS boards in 2006/07 was approximately £67.93 million.
•	Due to the lack of national data available it is difficult to assess whether patients are benefiting, however, over 80 per cent of patients we surveyed are satisfied with the service they received. GPs are positive about being able to opt out, and 88 per cent of GPs are relieved to no longer have 24-hour responsibility for patients.
•	Other services have helped NHS boards to take 
over responsibility for out-of-hours care, including 
NHS 24 and the Scottish Ambulance Service. Links with these services are continuing to develop but must be strengthened to support the delivery of high-quality patient care.
•	Out-of-hours services are under continuing pressure 
as fewer GPs are reproviding services (ie providing out-of-hours services for an NHS board for a fee). 
New ways of working are required as there is a significant risk that current models of service delivery are not sustainable in the long term. The SEHD and NHS boards must adopt a much greater focus and commitment to investment in, and planning for, extended roles for health professionals and joint working.
Following the introduction of the nGMS contract in April 2004, NHS boards have been responsible for delivering out-of-hours services since 31 December 2004. Taking over this responsibility has been a challenge for NHS boards due to the timing and scale of the change and the additional costs involved. However, NHS boards have managed to sustain services for patients.
NHS board members need to be assured that:
•	contracts for out-of-hours services are regularly reviewed to ensure that services provided remain responsive to patient need and that contracts represent value for money
•	systems are in place to regularly monitor staffing arrangements for out-of-hours services to support service development and workforce planning and ensure that services are sustainable
•	routine monitoring of out-of-hours activity and call response times takes place.
Contact: Claire Sweeney
csweeney@audit-scotland.gov.uk

Managing long-term conditions
Published August 2007    
www.audit-scotland.gov.uk/docs/health/2007/nr_070816_managing_long_term.pdf
Key findings
•	In order to provide more community services for people with long-term conditions, NHS boards, through Community Health Partnerships (CHPs), need to redesign services and transfer resources from acute to community settings. But currently decisions on the best use of resources are being made on limited evidence.
•	Generally there is enthusiasm from staff for 
Delivering for Health as a guide to improving services for long-term conditions. Progress in developing community-based services for asthma and diabetes is good but there are a number of practical barriers to providing better community services for all patients with long-term conditions. 
•	People with more than one long-term condition are less likely to be receiving joined-up care across all the services they receive.
•	Patients want better information about their long-term conditions and many want a greater involvement in their own care.
Audit Scotland examined services for adults with long-term conditions across Scotland, focusing on two conditions in particular – chronic obstructive pulmonary disease (COPD) and epilepsy. Managing long-term conditions is seen as the biggest challenge facing healthcare systems worldwide. In Scotland, it is estimated that around a million people have at least one long-term condition. Over recent years there has been a move to treat more people with long-term conditions in the community. However, a considerable amount of care is still carried out in hospitals. Delivering for Health sets out a programme of action for the NHS in Scotland based on the recommendations made in Building a Service Fit for the Future (also known as the Kerr report).
NHS board members need to be assured that:
•	better information is collected on activity, cost and quality of services to support development of community services
•	different ways of providing services for long-term conditions are evaluated to ensure cost-effectiveness and to share good practice
•	the NHS board takes a more strategic role to ensure there is better working between CHPs and the acute sector to support community services
•	the NHS board has prioritised shifting the balance of care for managing long-term conditions.
Contact: Jillian Matthew
jmatthew@audit-scotland.gov.uk

Planning ward nursing – legacy or design? 
A follow-up report
Published January 2007
www.audit-scotland.gov.uk/docs/health/2006/nr_070125_ward_nursing_followup.pdf

Key findings
•	NHS boards and the SEHD are addressing the recommendations made in Audit Scotland’s baseline report, laying the foundations for better ward nursing workload and workforce planning.
•	Substantial work is under way to improve the information available for planning the ward nursing workforce, but further work is required before it can become a routine part of planning.
•	Most boards have not met national recommendations on building additional time into nurse staffing requirements to cover staff absence and protected time for senior nursing staff with team leadership responsibilities.
•	The SEHD, NHS boards and NHS Education for Scotland have implemented a wide range of recruitment and retention programmes. Vacancy rates vary among specialties and NHS board areas.
•	Between 2001/02 and 2005/06, the use of agency nurses fell but expenditure changed little. The use and cost of bank nursing increased substantially, partly due to measures taken by NHS boards to promote nurse banks. NHS boards need to keep the growth of bank nursing under review.
Nurses and midwives are the largest staff group in the health service. Effective planning of the nursing workforce is critical to the success of the health service in Scotland. In 2002, we published a baseline report that examined how ward nursing was planned in the NHS in Scotland and made recommendations about improving workload and workforce planning. In this follow-up report we analysed progress against those recommendations. 
We found that the SEHD had implemented measures to develop workforce planning in the NHS in Scotland, improve information on the nursing workforce and workload, improve recruitment and retention, and encourage the use of bank nursing instead of agency nursing to meet temporary staffing needs. Further work is required to develop tools for gathering nursing workforce and workload information at ward level. Limited progress had been made in developing indicators of nursing quality. 
NHS board members need to be assured that:
•	the implications of using workload measurement tools have been assessed and planned for
•	levels of nurse staffing are adequate to cover predictable absence levels
•	the growth of bank nursing is kept under review to ensure the quality of care is maintained and to ensure an appropriate balance between the use of bank nursing and substantive posts
•	strategies to manage the growth in demand for 
nursing staff to cover temporary staffing needs are integrated with recruitment and retention strategies 
and workforce planning.
Contact: Neil Craig
ncraig@audit-scotland.gov.uk

Overview of the financial performance of the NHS in Scotland 2005/06
Published December 2006    
www.audit-scotland.gov.uk/docs/health/2006/nr_061214_nhs_overview_financial.pdf
Key findings
•	Funding for the NHS in Scotland was almost £9 billion in 2005/06 and is planned to reach £10 billion by 2007/08.
•	The financial position of the NHS in Scotland (including the SEHD and the 24 NHS bodies) moved from an overall overspend of £32 million in 2004/05 to an overall underspend of £70.6 million against the health budget for 2005/06. Most of this relates to an underspend on capital. 
•	At the end of 2005/06, NHS Argyll and Clyde 
received £82.3 million from the SEHD to write off its £81.7 million cumulative deficit. Excluding NHS Argyll and Clyde, the total cumulative revenue underspend for the remaining 23 NHS bodies increased by 
£4.9 million to £69 million in 2005/06.  
•	Two of the 24 NHS bodies failed to meet one of their financial targets (NHS Lanarkshire and NHS Western Isles), and the annual accounts for NHS Highland 
were qualified.
•	NHS bodies are expected to contribute to the Efficient Government Initiative by making £523 million savings by 2007/08. Cash-releasing savings are being reported across the NHS; less savings have been reported from time-releasing activities.
•	Most NHS boards are making progress in setting up structures and governance arrangements to support single system working but the transition has been more challenging for some of the larger NHS boards. Governance arrangements for the new CHPs are at 
an early stage.
The NHS in Scotland spent almost £9 billion in 2005/06 (this is net of operating income), representing around a third of the total spend in the public sector. It remains Scotland’s largest employer with over 150,000 staff (almost 130,000 whole time equivalent) providing care in community, primary and acute settings throughout the country.
Despite record increases in funding, the NHS continues to face challenges over the coming years which will require robust long-term financial and service planning. These include a range of cost pressures such as the UK-wide pay modernisation agenda, the increasing cost of drugs and rising energy prices. In addition, technical advances in the way in which healthcare can be delivered, changing training requirements for medical staff and a growing older population all contribute to the need to change the way in which health and related services are delivered.
Contact: Nick Hex 
nhex@audit-scotland.gov.uk
Catering for patients - A follow-up report 
Published November 2006    
www.audit-scotland.gov.uk/docs/health/2006/nr_061130_catering_patients_followup.pdf
Key findings
•	Catering services are offering an improved level of choice to patients, including giving patients the opportunity to order meals less far in advance, offering a range of portion sizes and ensuring that snacks are available to patients outside normal mealtimes.
•	NHS boards still need to do more to ensure the nutritional care of patients. All patients are not yet screened for risk of undernutrition and many hospitals do not have systems in place to ensure a nutritional balance in the meals provided.
•	Not all NHS boards are carrying out quarterly patient satisfaction surveys. However, many boards are developing improved ways to get patients’ views on catering and use these to improve the services provided.
•	Catering costs have risen by a third since our baseline report in 2003. Catering staff costs have risen due in part to the low pay agreement, whereas the costs of food and beverages per patient day have remained stable.
•	Non-patient catering services are still being subsidised but NHS boards are improving their management information systems to allow them to manage this.
•	NHS boards have reduced the amount of food wasted due to unserved meals. 
Nutritional care is key in helping the recovery of patients in hospital and hospital catering has an important role to play in this. The quality of hospital food is a very important part of ensuring that the patient’s experience in hospital is positive. The report follows up the recommendations from our 2003 baseline study. We found that more choice is now available to patients but further work is needed to improve nutritional care.
NHS board members need to be assured that: 
•	systems are in place to ensure that nutritional screening takes place for all patients on admission to hospital
•	standard recipes are being used to ensure the nutritional value of all meals
•	protected mealtimes policies are in place to ensure that mealtimes are free from non-essential clinical activity and that there are enough staff on wards to help all patients eat a nutritious diet
•	a clear strategy is in place for the future provision of catering services
•	patient feedback is regularly monitored and used as part of quality improvement
•	pricing policies and income generation targets are in place that aim to at least break even on non-patient catering activities (or have a clear stated policy on the level of subsidisation).
Contact: Roddy Ferguson
rferguson@audit-scotland.gov.uk

Informed to care: Managing IT to deliver information in the NHS in ScotlandPublished November 2006    
www.audit-scotland.gov.uk/docs/health/2006/nr_061123_managing_it_nhs.pdf

Key findings
•	Delivering for Health signals a more corporate approach for Information Management and Technology (IM&T) in future. This is a significant shift in the way IT is managed in the NHS – from local autonomy to a more corporate approach – and will take time to plan and implement.
•	The SEHD recognises the need to review governance and management arrangements for IM&T throughout the NHS and is taking steps to improve them.
•	There is no overarching information framework or strategy to inform the development of integrated IT solutions in the NHS in Scotland. The overall IM&T strategy should be revised to take account of the full range of information needs and recent policy initiatives.
•	The NHS does not know exactly how much it spends on IM&T overall. The SEHD needs to improve the way it funds IM&T programmes by developing business cases, and introducing ‘stage gate’ funding for all projects so that funds are released on a phased basis as projects achieve specified outcomes.
•	The NHS recognises the importance of stakeholder engagement but it needs to do more to involve clinicians, managers and policy makers to ensure their information needs are met through IT.
•	The SEHD needs to ensure that existing good practice in project and programme management is applied consistently throughout the NHS in Scotland. This is essential to identify emerging problems, and inform IM&T what to start, stop or accelerate to achieve overall objectives. There is limited evidence that expected benefits are identified, monitored and delivered.
The planning and delivery of NHS services need to be underpinned by good information to ensure that patients get the best possible care within the resources available. Better information supports better care. 
The need for the NHS to work with partners, including local authorities, to plan and deliver joint services is an additional challenge. Arrangements for using IM&T to provide information to support recent changes, including the development of CHPs, need to be fit for purpose.
NHS board members need to be assured that:
•	local governance arrangements are sound
•	there are clear responsibilities and accountabilities for IM&T strategy development and implementation in 
their board
•	there are clear plans to bring any local IM&T solutions arising from past investments into line with the national strategy in an acceptable timescale
•	a gateway review approach for local IM&T programmes (in line with Office of Government Commerce good practice) is adopted for all business cases
•	capital and revenue spend on IM&T is identified 
and monitored.
Contact: Angela Canning
acanning@audit-scotland.gov.uk

Forthcoming reports
Project briefs can be downloaded at www.audit-scotland.gov.uk/work/forwardwork.php
Our current work programme includes the following studies

NHS recruitment of overseas staff
Publication planned for autumn 2007
Following the Glasgow Airport incident in June, the Scottish Government Health Directorates (SGHD) asked Audit Scotland if we would examine whether NHS boards are following existing NHS procedures on international recruitment. Existing guidance on pre-employment checks is designed to assess an individual’s suitability and capability to do the job rather than their ideological beliefs.
The SGHD is reviewing whether existing national NHS guidance complies with best practice, and whether NHS boards’ local procedures are in line with national guidance. The SGHD will report its findings separately.
The overall aim of our review is to examine whether NHS boards are following their pre-employment screening procedures for overseas (non-EU) staff. The objectives are to:
•	establish the number of overseas staff employed in NHS boards
•	examine whether five sample boards are complying with the required pre-employment procedures when recruiting staff.
The five sample boards are Ayrshire and Arran, Grampian, Greater Glasgow and Clyde, Lanarkshire and Lothian. These were selected as they have the highest number of non-EU staff, based on current information provided recently by NHS boards to the SGHD. The checks at the sample boards include examining whether there is evidence in personnel records that the following pre-employment checks have been performed:
•	identity checks
•	reference and regulatory checks
•	Disclosure Scotland checks
•	work permit/visa checks
•	arrangements for staff employed through agencies.
Contact: Angela Canning 
acanning@audit-scotland.gov.uk

Overview of the performance and financial management of the NHS in Scotland 2006/07
Publication planned for December 2007
Over the last few years the NHS in Scotland has undergone a period of significant service redesign. Single system working has been established to streamline health board structures; CHPs have been introduced to join up service delivery among relevant partners in the community and primary sectors; and pay modernisation agreements have been implemented to create new pay and grading structures and terms and conditions for most NHS staff and GPs. This service redesign is set to continue, with several boards announcing plans to redesign acute services provision in line with the recommendations of the Kerr report. These changes are designed to deliver service improvement for the NHS in Scotland but may also generate significant cost pressures.  
Since 2002/03, the budget for the NHS in Scotland has risen by 33 per cent in cash terms, and it is set to rise to over £10 billion in 2007/08. 
This report aims to provide a comprehensive and coherent picture of performance in the health sector, including commentary on efficiency, effectiveness and productivity. It will examine the links between performance and financial management in the NHS in 2006/07 to establish an integrated view of overall performance.
Contact: Gemma Diamond 
gdiamond@audit-scotland.gov.uk

Free personal and nursing care
Publication planned for January 2008
The Free Personal and Nursing Care (FPNC) policy was introduced in July 2002, through the Community Care and Health (Scotland) Act. The key aim of the FPNC policy is to ‘remove current discrimination against older people who have chronic or degenerative illnesses and need personal care’. It is intended to bring their care in line with medical and nursing care in the NHS where the principle of free care based on need is almost universally applied and accepted. Our study will examine the overall current and future costs and funding for the implementation of the FPNC policy in Scotland and evaluate its financial impact on older people, local authorities and the SGHD. 
Contact: Carolyn Smith
csmith@audit-scotland.gov.uk

Palliative care
Publication planned for summer 2008
More than 55,000 people died in Scotland in 2005. Palliative care aims to maximise the quality of life of people nearing the end of their lives. It looks to minimise the suffering and promote the dignity of patients, and provide support to their families and friends. This study will review the planning and delivery of palliative care services across Scotland and report on the experiences of those using these services. It will analyse levels of palliative care activity, how services are planned and resourced, and the scope for improvements in the efficiency of services. The study will examine whether NHS boards, Managed Clinical Networks, CHPs (including their local authority partners) and independent hospices have a joined-up approach to planning and delivering palliative care.
Contact: Roddy Ferguson
rferguson@audit-scotland.gov.uk

Review of the new General Medical Services contract
Publication planned for summer 2008
A new contract for GP practices across the UK was introduced in April 2004. This new contract changes how NHS boards and GPs work together to deliver general medical services to the population. This study will examine how the nGMS contract has affected primary medical services and other NHS services, such as prescribing and diagnostics. The study will also set out the costs of the contract and look at how NHS boards and the SGHD are planning, managing and monitoring the nGMS contract.
Contact: Iain Armstrong
iarmstrong@audit-scotland.gov.uk

Diagnostic services
Publication planned for summer 2008
Diagnostic services are an integral part of the healthcare system. NHS staff rely on the results from diagnostic tests to accurately determine an illness or medical condition and the appropriate care for each patient. They are crucial to the delivery of screening services, primary care, planned outpatient and inpatient care, and unscheduled care.
In this study we will review the efficiency and effectiveness of the three main diagnostic services – imaging, endoscopy and pathology – and the scope for improvement. We will analyse the performance of diagnostic services against waiting times standards for diagnostic tests. We will also assess the sustainability of the strategies that have been put in place to improve diagnostic services. 
Contact: Neil Craig
ncraig@audit-scotland.gov.uk

Asset management
Publication planned for autumn 2008
The NHS in Scotland owns assets valued at over £4 billion including land, hospitals and equipment. The way these are managed has a significant impact upon service delivery. The NHS is currently undergoing service redesign which will also have an impact on the way assets are managed.
The overall aim of the study is to consider the extent to which the NHS manages its assets strategically in order to ensure they are used as efficiently and effectively as possible. The study will highlight areas of good practice 
and make recommendations where assets can be used more efficiently.
Contact: Kirsty Whyte
kwhyte@audit-scotland.gov.uk

Mental health
Publication planned for winter 2008/09
The scope of the study has still to be identified but it is likely to incorporate the implementation of the new Mental Health Act and mental health tribunals.
Contact: Jillian Matthew
jmatthew@audit-scotland.gov.uk
Other information
Engaging with NHS boards		
The Public Reporting Group (PRG) is developing a strategy to work better with NHS boards. Staff will be attending audit committee meetings at all the territorial boards and some of the special health boards over the autumn. This is an opportunity to discuss how we can work better with audit committees, non-executive directors, executive directors and other board staff in relation to our national reports. We want to do more to make sure that boards are aware of the key findings and the recommendations in our reports and consider what actions need to be taken forward. 
We have also taken steps to support NHS boards and non-executive directors in assessing local performance in relation to our national reports. For our last two reports we included a self-assessment checklist for boards as an appendix. This is intended to help the boards identify actions and follow up progress. We have also produced Issues for non-executive directors which are sent directly to non-executives. These aim to help non-executives engage with executive directors and managers on relevant issues arising from our national reports.
If you have other suggestions for how we can work better with NHS boards, please get in touch. 
Contact: Tricia Meldrum
tmeldrum@audit-scotland.gov.uk

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