Health and community 
care bulletin
Produced by Audit Scotland – July 2008

Foreword		
Welcome to the third issue of Audit Scotland’s health and community care bulletin.		

The bulletin is intended to give a summary of our national studies, particularly the issues of most relevence to health boards. It also identifies issues that non-executive health board members may wish to consider locally.

Over the past eight months we have published three health reports on behalf of the Auditor General for Scotland (AGS) and one joint report on behalf of the AGS and the Accounts Commission. We have also published a review of major capital projects, a report that is relevent to all public bodies. 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 also available on our website.

Over the last few months, Audit Scotland has been doing a lot of work to identify potential topics for future national performance audit studies, including health and community care topics. This included discussions with executive and non-executive directors of health boards and with a variety of stakeholders from across the public sector. We issued a consultation document on our future study programme last month and we would very much welcome your feedback. The consultation document and details of how to respond are available on our website.

Over autumn and winter 2007/08, staff from my health team were pleased to attend audit committee meetings at all NHS boards and some of the special boards to raise awareness of our work and discuss how we can best support boards. The bulletin includes a summary of the main points arising from these meetings.
 
If you would like any further information about any of our work, please get in touch. 

Barbara Hurst 
Director of Public Reporting
(Health and Central Government)
bhurst@audit-scotland.gov.uk

Review of the new General Medical Services (nGMS) contract 		

Published July 2008
http://www.audit-scotland.gov.uk/docs/health/2008/nr_080703_general_medical_services.pdf	

Key findings

•	The nGMS contract cost more than expected. In the first three years of the contract, general medical services cost £160.4 million more than the Scottish Executive Health Department allocated to NHS boards for these services. The majority of the additional costs are due to the costs of implementing an incentive payment system for quality – the Quality and Outcomes Framework (QOF) – and ensuring that no GP practice was financially disadvantaged by the new contract.
•	The nGMS contract has the potential to develop general medical services for patients by introducing payments for improved or targeted services (known as enhanced services). NHS boards are spending more than the minimum required on these services. But shortfalls in funding could limit NHS boards’ ability to further develop general medical services to meet the needs of their local population.
•	There is a lack of basic management data on general practice. This makes it more difficult for the NHS to plan effectively and to carry out workforce planning. However, there is some evidence that the roles of practice staff are changing and that GPs are more satisfied with their income and working hours.
•	Securing patient benefits from the nGMS contract will take time, but better monitoring, particularly of access to primary care, is required. However, there is evidence of some improvement, for example the QOF is helping to provide consistency of care through better monitoring of patients with certain long-term conditions. 
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 report comments on the planning and implementation of the new contract, the cost and the impact on patients, GPs and on the wider NHS. 

The report recommends that the Scottish Government: 

•	collect robust data before implementing major schemes so that it can base decisions on accurate information
•	review the impact of the nGMS contract on referrals and prescribing rates in clinical areas covered by the QOF to inform the future development of the nGMS contract
•	continue to improve the contribution of the QOF to patient care and to achieving value for money by moving from a focus on processes to a greater focus on outcomes.
Non-executive directors of NHS boards need to be assured that the NHS board is:

•   monitoring the investment in enhanced services to make sure that they achieve value for money and meet local needs
•	collecting comprehensive data on GP and GP practice staff numbers to support workforce planning at a national and local level.
Contact: Claire Sweeney
csweeney@audit-scotland.gov.uk

Review of major capital projects in Scotland 		
Key findings

•	In general, the achievement of cost and time targets improved significantly as projects progressed. Early cost and time estimates at project approval stage were too optimistic for many major projects.
•	Performance against cost and time estimates is better after contracts are awarded, as plans are more certain and risks clearer.
•	Most completed projects have successfully delivered the required roads, hospitals and other assets. There is scope to use better measures of quality.
•	Project management and governance arrangements within individual projects are broadly effective, although there is still room for improvement. A more strategic approach to managing the programme of capital projects could improve value for money.
Public investment in infrastructure touches most aspects of Scottish life. It provides new and upgraded facilities such as roads, railways, hospitals, schools, prisons and major IT projects. Between 2002 and 2007, the Scottish Government, its agencies and non-departmental public bodies (NDPBs) and the NHS completed 43 publicly funded major capital projects valued at £811  million. There are currently 104 major projects valued at £4.7 billion in progress.

Non-executive directors of NHS boards and other public bodies need to be assured that:   

•	robust business cases are developed for every major capital project. The business case should be clear about the project aims and benefits and should include: an assessment of risks; the range of options to be considered; and a clear basis for assessment, review and reporting. Whole-life costs should be built into business cases and subsequent project reporting
•	action is taken to improve estimates of the cost and time of projects at early stages
•	an appropriate procurement strategy is developed for all major capital projects, which considers all procurement routes, competitiveness and capacity within the construction industry. Risk management strategies should explicitly consider and mitigate the risk of changes in scope after the contract has been awarded
•	appropriate project management and governance arrangements are in place for every project, including the involvement of project managers with appropriate experience and knowledge of effectively managing major projects from the outset
•	there is a clear plan with regard to the need for independent gateway or similar reviews at the key stages in projects 
•	project budgets are sufficient to allow for post-project evaluation in all projects
•	post-project evaluations are carried out within a reasonable timescale to determine whether projects have delivered the benefits intended. Evaluations 
should consider performance against cost, time and quality targets.
In addition to the report, we also prepared a good practice checklist for public bodies and a summary of projects reviewed. These can be found by following the links listed on the right. 

Contact: Jim Martin
jmartin@audit-scotland.gov.uk

Summary of projects reviewed:

http://www.audit-scotland.gov.uk/docs/central/2008/nr_080624_major_capital_projects_summary_projects.pdf

Good practice checklist:

http://www.audit-scotland.gov.uk/docs/central/2008/nr_080624_major_capital_projects_checklist.pdf

A review of free personal and nursing care (FPNC) 		

Published February 2008
http://www.audit-scotland.gov.uk/docs/health/2007/nr_080201_free_personal_care.pdf	

Key findings

•	Scottish ministers set the Scottish Executive challenging timescales for developing the policy but it achieved its deadline. Councils were successful in putting in place systems to implement and deliver the policy from 1 July 2002. 
•	FPNC was introduced at a time of significant change and developments in health and social care. This, combined with a lack of intended outcome measures, makes it difficult to evaluate the impact of the policy.
•	Ambiguities in both the legislation and guidance, together with an inconsistency between the two around charging for food preparation, have led to different interpretations by councils. This has led to variation across Scotland in how the policy has been implemented.
•	The act introducing the policy does not provide a robust assessment of the financial implications and risks of introducing FPNC. Initial cost estimates were difficult to make because of the poor information available at that time, particularly on personal care delivered at home. Monitoring the financial impact of the policy has been limited and central government has not updated the longer-term cost projections since 2001.

•	The estimated additional costs for the first four years of the policy are £593 million or £633 million, depending on the assumptions used. This means a shortfall in central funding by 2005/06 of either £45 million or £61 million. It is likely that demand for FPNC will continue to grow with the projected increase in the older population and this will have implications for the future costs of the policy.
•	Councils are using a variety of approaches to manage demand for FPNC. Differences in the use of waiting lists and eligibility criteria mean older people may receive different levels of service depending on where they live. Older people are unclear about what free personal care means in practice.
Free personal and nursing care was introduced in Scotland in July 2002 for older people aged 65 years-and-over cared for at home, and free nursing care in care homes for people of all ages. By March 2007, just over 72,100 older people in Scotland were receiving personal care services free of charge. We identified some key issues that need resolved to ensure the policy is better managed and funded to ensure its sustainability for the future. In May 2008, the Scottish Government announced that an additional £40 million per year will be put into meeting the shortfall in funding for FPNC across Scotland. 

We recommend that councils:

•	improve their information systems to enable them to collect comprehensive and accurate information on FPNC and other aspects of care and support services  
•	provide clear information to older people on what is covered by FPNC
•	publish clear information on eligibility criteria and the thresholds where services are provided, the operation of waiting lists and local care home and homecare charging policies.
Elected members and NHS board members need to ensure that the council and board work together to evaluate the longer-term consequences of reducing domestic homecare services, such as cleaning, shopping and laundry services. 

Contact: Carolyn Smith
csmith@audit-scotland.gov.uk

Overview of Scotland’s health and NHS performance 2006/07
Published December 2007

http://www.audit-scotland.gov.uk/docs/health/2007/nr_071214_nhs_overview.pdf

Key findings

•	Mortality rates for key diseases and overall life expectancy are improving, but other public health concerns, including drug and alcohol-related problems and obesity, continue to grow. Significant inequalities in health outcomes remain.
•	New performance measures were introduced in 2006/07 and the NHS is performing well against waiting times. However, other areas still need to improve including cancer waiting times, delayed discharges and reducing older people’s readmissions to hospital.
•	The Scottish Government needs to build on the current performance management system for the NHS to be able to report on productivity, cost and quality together. This should fit with wider work on developing outcome measures.
•	New ways of delivering services are being developed and implemented throughout the NHS, including Community Health Partnerships (CHPs) and a move from hospital to community-based services, but there is no evidence that resources are shifting along with these changes. CHPs now need to focus on delivering benefits for patients rather than structures and processes.
•	Improvements are needed to the way the benefits of service changes, including CHPs and pay modernisation, are identified, measured and monitored.
•	The financial performance of boards improved in 2006/07, with an overall underspend against the revenue budget. Only one board, NHS Western Isles, did not meet a financial target. Continuing cost pressures for the future, including service redesign, pay modernisation and drug costs, reinforce the need for strong financial management.
Expenditure on the Scottish health service in 2006/07 was £9.4 billion, an increase of 29 per cent since 2001/02 in real terms. There was little change between 2005/06 and 2006/07. The NHS in Scotland faced a number of challenges in 2006/07. NHS boards are continuing to redesign the way services are provided, with the development of CHPs and the implementation of pay modernisation contracts. All boards have been assessed against the new clinical governance and risk management standards by NHS Quality Improvement Scotland (NHS QIS) and the Scottish Government has introduced a new performance management framework including targets for boards to achieve.

The Scottish Government should:

•	ensure that information on the performance of the NHS is publicly reported and brings together data on costs, outcomes, targets, productivity, patient satisfaction and experience. It should assess performance against all these elements together to better inform decision-making
•	ensure the performance management system for the NHS in Scotland fits with wider developments around outcome measures across public services
•	ensure that the costs and benefits of major changes such as service redesign, pay modernisation contracts and the introduction of CHPs are fully identified.
Boards should aim to be in recurring financial balance and minimise the use of non-recurring income on day-to-day expenditure.

Contact: Nick Hex
nhex@audit-scotland.gov.uk

Overseas staff in the NHS – 
pre-employment checks		

Published November 2007http://www.audit-scotland.gov.uk/docs/health/2007/nr_071129_overseas_staff_nhs.pdf

Key findings

•	The NHS in Scotland does not have an accurate picture of the number of overseas staff employed. This means we are unable to give an assurance that the sample of personnel records we reviewed is representative. Our findings are therefore indicative only.
•	Boards reported 1,161 overseas staff in NHS employment across Scotland at September 2007. However, this is likely to be an underestimate as boards had difficulty identifying staff here on indefinite leave to remain. Of the overseas staff identified, boards estimated that 89 per cent of these were doctors or nurses.
•	We did more detailed work on compliance with pre-employment checks for overseas staff in five NHS boards. These boards had similar procedures, and there is evidence of high compliance in the sample of personnel records we reviewed. However, because of uncertainty about the number of overseas staff, it is not possible to place total reliance on these findings.
Healthcare professionals from outside the UK play an important role in providing care to people living in Scotland. NHS boards are expected to carry out a number of pre-employment checks on overseas staff to ensure they have the necessary qualifications, experience and authorisation to work in the UK. 
We examined compliance with key pre-employment screening procedures in five sample NHS boards (Ayrshire and Arran, Grampian, Greater Glasgow and Clyde, Lanarkshire and Lothian) and collected data from the 14 territorial boards about the number of overseas staff they employ. 

In December 2007, the Scottish Government produced guidance on the recruitment of staff, including the additional procedures that must be followed when recruiting staff from overseas. This policy is consistent with guidance from the Centre for the Protection of National Infrastructure (CPNI) and sets out the minimum requirements for NHS employers. Implementation of this policy is a requirement of the Staff Governance Standard.

The report was presented to the Scottish Parliament Audit Committee in December 2007. At that time, the Auditor General set out his intention to extend the review to the other NHS boards and special health boards not covered by the initial study. Local auditors have recently carried out this work and will report the findings to NHS bodies.

NHS board members need to be assured that:

•	local recruitment and selection policy has been amended to reflect the new Protection of National Infrastructure guidance 
•	the appropriate pre-employment checks have been carried out on overseas candidates, including overseas police checks
•	better information is collected on the immigration status of overseas staff 
•	copies of relevant documents are kept in line with good practice.

Contact: Angela Canning
acanning@audit-scotland.gov.uk

Forthcoming reports
Project briefs can be downloaded at http://www.audit-scotland.gov.uk/work/forwardwork.php

Review of palliative care services in Scotland
Publication planned for August 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 is reviewing the planning and delivery of palliative care services across Scotland and will report on the experiences of those using these services. All voluntary hospices and NHS boards provided information for the review, which analyses levels of palliative care activity, how services are planned and resourced, and the scope for improvements. User views form an important part of the study, which has included focus groups with patients and a large survey of bereaved families. The study also carried out more detailed work in NHS Borders, Fife, Greater Glasgow and Clyde, Highland and Shetland. This examined whether boards, palliative care 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

Day surgery update
Publication planned for September 2008
Day surgery should be the preferred option to inpatient care where it provides better and more acceptable care for patients, or where the care is of the same standard but the cost is lower. The Scottish Government has set out its aim of delivering efficiency savings in the NHS through improving day surgery performance.

Audit Scotland reported on day surgery performance in 2004. Reflecting change in clincial practice, our latest report will compare performance in same day care and therefore include both day surgery and surgical procedures undertaken in an outpatient setting.

Contact: Angela Canning
acanning@audit-scotland.gov.uk

Diagnostic services
Publication planned for autumn 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 are reviewing the efficiency and effectiveness of the three main diagnostic services – imaging, endoscopy and laboratory services – and the scope for improvement. We are analysing the performance of diagnostic services against waiting times standards for the eight key diagnostic tests, and we are assessing the sustainability of the strategies that have been put in place to improve diagnostic services. 

The study involves work at five sample NHS boards: Ayrshire and Arran, Greater Glasgow & Clyde, Lanarkshire, Lothian and Orkney. Where possible, we are making use of existing data sources and supplementing this by a data collection exercise followed by interviews at the sample boards. 

Contact: Catherine Vallely 
cvallely@audit-scotland.gov.uk

Asset management
Publication planned for autumn 2008
The aim of the study is to evaluate the extent to which the NHS manages its assets to support effective service delivery and ensure value for money. It will: 

•	assess the extent to which the Scottish Government provides leadership to boards on asset management and assures itself that the NHS estate is being used in the most effective, efficient and economic way
•	evaluate how well NHS boards strategically manage their assets to ensure effective service delivery
•	examine the extent to which NHS boards are achieving value for money from their estate
•	assess how well NHS boards work with other bodies to ensure efficient and effective use of their estate. 
We will be gathering data and information from all NHS boards as part of this process and we will carry out more detailed work at five NHS boards – Dumfries and Galloway, Fife, Grampian, Greater Glasgow and Clyde and Lothian.

Contact: Kirsty Whyte 
kwhyte@audit-scotland.gov.uk

Promoting and improving energy efficiency in the public sector
Publication planned for December 2008
It is now recognised that climate change is one of the most serious threats facing the world today. Most energy is currently sourced from the burning of fossil fuels and evidence indicates that this process strengthens the greenhouse effect, causing the climate to change unnaturally. It is widely accepted that improving energy efficiency is the easiest and most cost-effective way to reduce CO2 emissions.

The public sector is expected to lead by example in reducing greenhouse gas emissions through various measures. This study will assess the performance of public sector bodies, including councils and the NHS, in promoting and improving energy efficiency across their own estates. 

The key objectives of the study are to:

•	assess whether public bodies demonstrate sufficient commitment to, and set an example in, improving energy efficiency
•	examine whether public bodies are performing well against their objectives, plans and targets for improving their energy efficiency
•	identify whether public sector bodies exhibit best value and deliver continuous improvement in their efforts to improve energy efficiency.
Contact: Susan Lovatt 
slovatt@audit-scotland.gov.uk 

Financial overview 2007/08
Publication planned for December 2008

Our annual overview of the NHS in Scotland will focus on financial issues arising during the 2007/08 financial year. We will report the financial position of the NHS in Scotland and health boards and examine the main cost pressures affecting the NHS.

Contact: Nick Hex 
nhex@audit-scotland.gov.uk 

A Scottish prescription: Managing the use of medicines in hospitals follow-up study
Publication planned for February 2009
Medicines are part of the management of most people who attend hospital. NHS Scotland spent £245 million on medicines in hospitals in 2006/07. New medicines and new uses of existing medicines to treat a wider spectrum of conditions are increasing the choices available to clinicians and patients but putting pressure on budgets. There are many risks to patient safety from using medicines, through errors and near misses and through unexpected, adverse drug reactions. These risks must be closely managed and monitored. We reported on medicines management in Scotland’s hospitals in 2005 and made recommendations for improvements. We aim to assess progress against the key recommendations in this follow-up study. We will specifically look at progress made in relation to: 

•   implementing new information management and technology (IM&T) developments to support medicines management, including a national hospital electronic prescribing and medicines administration (HEPMA) system
•   financial management of hospital medicines, including promoting cost effective prescribing
•   promoting the safe and effective use of medicines
•   workforce planning and role development for pharmacy staff.  
Contact: Carolyn Smith 
csmith@audit-scotland.gov.uk

Civil contingencies planning
Publication planned for early 2009
The increasing likelihood of events such as flooding or pandemic flu poses significant social and economic risks to local communities and to the continued delivery of vital public services. The Civil Contingencies Act 2004 established a new legislative framework for civil protection across the UK, imposing new duties on public sector and other relevant organisations to ensure that effective arrangements are in place, both for dealing with emergencies and for the delivery of services in the event of disruption. Our review of civil contingencies planning will assess the efficiency and effectiveness of the arrangements in Scotland to deal with emergencies at national, regional and local levels and provide a baseline against which future performance can be assessed. Over the summer, we will survey all Category 1 responders in Scotland, including NHS boards and councils. We will also undertake documentation review and carry out interviews with a sample of Category 1 responders, Category 2 responders and other relevant groups.

Contact: Becki Lancaster 
blancaster@audit-scotland.gov.uk 

Overview of mental health services
Publication planned for winter 2008/09
Expenditure on mental health services is one of the biggest areas of public spending, amounting to around 11 per cent of all NHS and council social services spend. It is estimated that one in four people will suffer from mental health problems at some point in their lives and one in six experiences this at any given time. 

This overview will look at mental health services provided individually and jointly by the NHS, councils and the voluntary and private sectors. It will include mental health services across a range of settings including those provided in psychiatric hospitals (including secure units), general hospitals, primary care facilities and various community settings. The study will look at services for children and adolescents, adults and older people. As well as health and community care services, we will examine the extent to which Community Planning Partnerships are ensuring there are links to the wider services required to support people with mental health problems, including those relating to alcohol, drugs, education, leisure, employment, benefits, housing and criminal justice. It will also look at the role of other agencies that come into contact with people with a mental illness, eg the police and the Scottish Prison Service. We will hold focus groups with service users and carers as part of the study.

The objectives of the study are to:

•	assess the equity of access and availability of mental health services across Scotland
•	evaluate national and local planning arrangements for mental health services
•	review the performance of mental health services in meeting the needs of the population
•	identify total expenditure on mental health services and provide a breakdown.
Contact: Jillian Matthew 
jmatthew@audit-scotland.gov.uk 

Review of drugs and alcohol services
Publication planned for winter 2008/09
This review will examine how much is spent on drug and alcohol services in Scotland and will consider the role of partnerships in addressing drug and alcohol related problems. We will look at the contribution of all relevant public sector bodies to prevention, treatment, rehabilitation and enforcement. This study is at an early scoping stage.

Contact: Sally Thompson
sthompson@audit-scotland.gov.uk

Other information
Forward study programme
Every two years, Audit Scotland consults on potential topics for the national studies programme. The consultation is important in ensuring that our studies focus on the topics of most importance to public services in Scotland, and where we are best placed to add value through our work. 

In June 2008, Audit Scotland published a consultation paper on potential studies which will start over the period October 2008 to March 2010. This has been sent out to all NHS and special health boards, councils, the Scottish Government, MSPs, professional bodies, other audit and inspection organisations and other stakeholders across the Scottish public sector. We would welcome responses by 12 September 2008. We will be publishing our new forward study programme in Autumn 2008.

Engaging with NHS boards
As part of our action plan to provide more support to NHS boards, staff who are involved in national studies work attended audit committee meetings at all 14 NHS boards, NHS 24 and NHS Education Scotland (NES) and a board meeting at the Scottish Ambulance Service over autumn and winter 2007/08. The Auditor General also attended a meeting of the Audit Committee Forum in March 2008. 

At these meetings we gave a presentation on our national studies work. We also discussed the actions we are taking to increase the impact of our reports at local level by producing self-assessment checklists with our reports and producing separate papers on issues for non-executive directors to consider. We produced these for our reports on Managing long-term conditions and Primary care out-of-hours services.  

The audit committee members welcomed our attendance at these meetings and were keen to have closer links and regular local engagement with the teams working on national studies. The main areas of positive feedback across most boards were:

•	non-executive directors said they found the non-executive summary documents useful and helpful in thinking about appropriate questions to ask of executive directors
•	committee members welcomed the self-assessment checklists that were included with the Managing long-term conditions and Primary care out-of-hours services reports
•	our reports and key messages documents are easy to read.
Where our national reports have a focus for individual boards, we will continue to include the self-assessment checklists for boards and non-executive issues papers.

……………………………………………

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