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SP Paper 224
AU/S2/04/R9

Audit Committee

9th Report, 2004 (Session 2)

CONTENTS

REMIT AND MEMBERSHIP

THE REPORT

ANNEXE A – EXTRACTS FROM THE MINUTES

Extract from the Minutes – 6th Meeting 2004 (Session 2)

Extract from the Minutes – 11th Meeting 2004 (Session 2)

Extract from the Minutes – 12th Meeting 2004 (Session 2)

Extract from the Minutes – 15th Meeting 2004 (Session 2)

Extract from the Minutes – 17th Meeting 2004 (Session 2)

ANNEXE B – ORAL EVIDENCE

11th Meeting 2004 (Session 2), 25 May 2004

ORAL EVIDENCE

Mr Trevor Jones, Head of the Scottish Executive Health Department and Chief Executive of NHSScotland

Dr Peter Collings, Director of Performance Management and Finance, Scottish Executive Health Department

Mr Gerry Marr, Chief Executive of NHSTayside Acute Services Division

Remit and membership

Remit:

1. The remit of the Audit Committee is to consider and report on-

(a) any accounts laid before the Parliament;

(b) any report laid before or made to the Parliament by the Auditor General for Scotland; and

(c) any other document laid before the Parliament concerning financial control, accounting and auditing in relation to public expenditure.

2. No member of the Scottish Executive or junior Scottish Minister may be a member of the Committee and no member who represents a political party which is represented in the Scottish Executive may be convener of the Committee.

(Standing Orders of the Scottish Parliament, Rule 6.7)

Membership:

Mr Brian Monteith (Convener)

Rhona Brankin

Susan Deacon

Robin Harper

Margaret Jamieson

George Lyon

Mr Andrew Welsh (Deputy Convener)

Committee Clerking Team:

Clerk to the Committee

Shelagh McKinlay

Senior Assistant Clerk

Joanna Hardy

Assistant Clerk

Christine Lambourne


Audit Committee

9th Report, 2004 (Session 2)

Better equipped to care? Follow-up report on managing medical equipment

The Committee reports to the Parliament as follows—

INTRODUCTION

1. This report sets out the Committee’s findings in relation to the report of the Auditor General for Scotland (AGS) entitled “Better equipped to care? Follow-up report on managing medical equipment” (AGS/2004/2).

Evidence

2. The Committee held an oral evidence session on 25May 2004. The following witnesses gave oral evidence to the inquiry: MrTrevor Jones, Head of the Scottish Executive Health Department and Chief Executive of NHSScotland, DrPeter Collings, Director of Performance Management and Finance, Scottish Executive Health Department and MrGerry Marr, Chief Executive of NHSTayside Acute Services Division.

3. In taking evidence, the committee sought to examine:

· The Health Department’s leadership role in the management of medical equipment

· Information to support performance management and accountability for medical equipment

Key Findings and Recommendations

4. The committee’s key findings and recommendations are set out below:

Consistency and Adequacy of Provision – managing performance

  • The Committee considers that the tools currently used by SEHD for measuring performance in relation to the management of medical equipment may be sufficient to highlight possible gaps in provision, but are not appropriate for an assessment of future need. (Para20)
  • The Committee therefore welcomes the Department’s commitment to investigate the introduction of a common standard through the internal controls assurance process but considers that this does not go far enough. The Committee recommends that SEHD work with the service to improve information for assessing future need so that gaps in provision are identified and addressed. (Para21)
  • The Committee also recommends that SEHD review current responsibilities with NHS Boards to clarify how the consistent delivery of appropriate nationwide access to medical equipment can be ensured. (Para22)
  • SEHD should provide NHS Boards with clear standards against which their performance will be measured to ensure accountability. (Para23)
  • In responding to this report, the Committee further recommends that SEHD state specifically what action will be taken as a result of its consultation with NHS Boards on the profile of medical equipment. (Para24)

Information to Support Performance Management and Accountability

  • The Committee believes that current information and data gathering activity is inadequate to support performance management and monitoring, despite the considerable resource tied up in the collation of statistics.(Para29)
  • A nationally agreed minimum data set generating uniform, comprehensive information on the provision of medical equipment is needed if valid comparisons are to be made. The Committee recommends that SEHD take the lead in bringing this about by agreeing with NHS Boards what will be monitored at national level and what will be monitored at local level. (Para30)

BACKGROUND

5. The Auditor General for Scotland (AGS) published good practice guidelines and recommendations in his 2001 report “Equipped to Care. Managing Medical Equipment in the NHS in Scotland”. The latest report, Better equipped to care? Follow-up report on managing medical equipment (AGS/2004/2), reviews progress across Scotland since 2001, focussing on performance issues identified by the earlier report.

LEADERSHIP IN THE HEALTH DEPARTMENT

Division of responsibility: SEHD’s role

6. It is the responsibility of NHS Boards to ensure that the right medical equipment is available, properly maintained and that staff are appropriately trained to use it. However, NHS Boards need the support of SEHD to fulfil their role and SEHD must also ensure that NHS Boards are discharging their delegated responsibilities effectively. [1]

7. While briefing the Committee on his report, the AGS gave his view on how SEHD and devolved units should work together to manage the appropriate provision of medical equipment. He stated that “NHS operating divisions need to know what equipment they currently have and what they will need to purchase in the future. They also need to keep up-to-date with technological developments in equipment which can help deliver better outcomes for patients and the potential for less invasive treatments. This should all inform investment decisions and performance should be monitored. The health department and health boards both have roles to play in ensuring that this is happening at a local level”[2].

8. During evidence, Trevor Jones described how these responsibilities are carried out in practice. He stated that “First, the Department [SEHD] has the role of setting the broad policy direction for NHS services. Secondly, we ensure that NHS boards have systems in place to deliver those strategies and to provide safe and high-quality care. Thirdly, we allocate resources to boards to allow them to implement their local strategies”. He added that “…we would not expect to take a major role in the replacement of routine medical equipment…Our clear policy is to devolve decision making down to the most appropriate level”. (Col560)

9. SEHD gave evidence on the circumstances in which it is more actively involved in planning and monitoring the provision of medical equipment at local level. These are in key policy areas (such as cancer and heart disease) and where the purchase of expensive items of equipment funded from capital requires a business case to be approved.

10. The AGS report highlights a potential difficulty associated with focussing on broad policy areas in the planning and monitoring of the provision of medical equipment. Such facilities are often used across a number of policy areas (MRI scanners are used to diagnose a range of conditions) and it is therefore difficult to reliably assess the appropriate level of provision to meet patients’ needs by examining one key area at a time.

CONSISTENCY AND ADEQUACY OF PROVISION – MANAGING PERFORMANCE

High cost low volume equipment

11. During evidence, the Committee explored SEHD’s influence on securing consistency of provision of high cost items such as MRI and PET scanners across the service. SEHD now requires local health care systems to include information on medical equipment as part of their capital expenditure programmes. SEHD also use Accountability Reviews to raise issues of significant concern. For example, medical equipment issues might be brought to its attention through the observation of waiting times and the examination of performance against standards set by the Royal College of Radiologists and Quality Improvement Scotland. (Col575)

12. Gerry Marr described how in NHS Tayside a decision has been taken to move away from purchasing to leasing expensive items of equipment since it allows maintenance costs to be built into the cost of the agreement and avoids the problem of equipment going beyond its active life. (Col562) Trevor Jones confirmed that SEHD encourage NHS Boards to lease if the economic case for leasing was better than that for capital purchase.

13. Mr Marr also made a distinction between new and existing types of medical equipment. He suggested that in the past NHS Boards acquired new types of equipment in an “unregulated” way but that the service now took a much more co-ordinated approach which should help to ensure that such equipment is introduced in a way which is equitable for the population. he gave as an example his involvement in the positron emission tomography (PET) scanner project. (Col567)

14. During evidence, Trevor Jones stated “We would identify gaps in provision from a range of matters, the most obvious of which is waiting times” (Col 563). He later went on to elaborate on “a range of tools [which the department uses] to form a view about how a service performs” including data from financial accounts, discussions with clinical staff and meetings with NHS staff. (Col 579). He also said that “accountability reviews are used to address significant issues with NHS boards” and “I would not want to have a standard item on medical equipment in the accountability reviews.” (Col575)

Low cost high volume equipment

15. The Committee also explored the management of low-cost, high-volume equipment during evidence. Such items include IV systems (drips) and respiratory equipment and tend to be purchased from revenue funding. These items can have a major impact on a patient’s treatment, putting them at risk if they are used incorrectly or inadequately maintained. In particular, the Committee asked about managing risks and learning from incidents resulting either from human error or from faulty equipment. Mr Marr explained (Col569) that the national CNORIS system had not dealt with medical equipment very effectively so local risk management arrangements had been implemented and he accepted that risk management systems could be improved.

Managing Performance

16. Medical equipment is not covered by the Performance Assessment Framework, nor is it routinely covered in Accountability Reviews. The Department of Health in England has introduced a specific standard for managing medical devices as part of its controls assurance requirements for the NHS. In his report, the AGS recommended that SEHD adopt a system which would enable a coordinated approach to the governance of medical equipment, allowing SEHD to routinely monitor the management of medical equipment in Accountability Review meetings.[3]

17. Trevor Jones said during evidence that “As a result of the report, we are having debates across the service about the profile of medical equipment replacement; part of our discussions with boards relates to ensuring that the right governance systems are in place to ensure that that profile exists” (Col575) and “I am interested in the introduction of a standard through the controls assurance process…I suspect that we will move in that direction” (Col575).

18. The Committee fully supports devolved decision making in NHSScotland and agrees that SEHD should have a strategic role and not prescribe in detail the quantity and quality of medical equipment purchased by NHS Boards. However, the Committee agrees with the AGS’s view that this devolved approach requires to be underpinned by sound performance monitoring and accountability arrangements.

19. The Committee is concerned that in practice SEHD is too remote. SEHD needs to do more to positively influence the appropriate and consistent provision of both high cost / low volume and low cost/high volume medical equipment across Scotland, with due regard to local needs.

20. The Committee considers that the tools currently used by SEHD for measuring performance in relation to the management of medical equipment may be sufficient to highlight possible gaps in provision, but are not appropriate for an assessment of future need.

21. The Committee therefore welcomes the Department’s commitment to investigate the introduction of a common standard through the internal controls assurance process but considers that this does not go far enough. The Committee recommends that SEHD work with the service to improve information for assessing future need so that gaps in provision are identified and addressed.

22. The Committee also recommends that SEHD review current responsibilities with NHS Boards to clarify how the consistent delivery of appropriate nationwide access to medical equipment can be ensured.

23. SEHD should provide NHS Boards with clear standards against which their performance will be measured to ensure accountability.

24. In responding to this report, the Committee further recommends that SEHD state specifically what action will be taken as a result of its consultation with NHS Boards on the profile of medical equipment.

INFORMATION TO SUPPORT PERFORMANCE MANAGEMENT AND ACCOUNTABILITY

25. NHSScotland has a duty to demonstrate that it is making best use of its medical equipment. The AGS report[4] concluded that NHSScotland cannot do so because of a lack of information[5].

26. In order for SEHD to monitor the performance of local health boards and hold them to account, it must have reliable and consistent management information. For example, in order to be satisfied that national strategies for medical equipment - such as that for cancer - are being achieved, SEHD must be able to monitor what provision exists at local and national levels and whether it is appropriate.

27. The AGS report concluded that “All trusts lack the information to manage their medical equipment effectively. This means that it is still not possible to provide a clear picture of key aspects of the cost, availability and use of medical equipment and benchmarking is impossible”.[6]

28. During Evidence, Trevor Jones accepted the need to improve current arrangements for the collation of information on the provision of medical equipment. He said “We have to ensure that the appropriate information is collected…If the information is key and there are gaps, we will need to fix that”. (Col577) Mr Jones also stated in evidence that “As a consequence of the report, we have raised the issue with boards and we are now reviewing the boards' proposals to address the issue”. (Col576)

29. The Committee believes that current information and data gathering activity is inadequate to support performance management and monitoring, despite the considerable resource tied up in the collation of statistics.

30. A nationally agreed minimum data set generating uniform, comprehensive information on the provision of medical equipment is needed if valid comparisons are to be made. The Committee recommends that SEHD take the lead in bringing this about by agreeing with NHS Boards what will be monitored at national level and what will be monitored at local level.

SUMMARY

31. The Committee considers that the AGS report and our subsequent evidence sessions indicate that the management of medical equipment can and should be improved.

32. The Committee agrees with the evidence submitted that SEHD’s role in achieving and maintaining this improvement must be strategic and should not attempt to prescribe in detail the quality and quantity of medical equipment purchased by NHS Boards.

33. The Committee recommends that SEHD develop a strategic national approach to the management of medical equipment which;

· better manages risk, particularly in relation to low cost high volume items;

· improves information for assessing future need so that gaps in provision are identified and addressed;

· delivers a nationally agreed minimum data set; and

· provides NHS Boards with clear standards against which their performance will be measured to ensure accountability.

34. The Committee recommends that SEHD take the lead in bringing this about by agreeing with NHS Boards what will be monitored at national level and what will be monitored at local level.

ANNEXE A

AUDIT COMMITTEE

EXTRACT FROM THE MINUTES

MINUTES

6th Meeting, 2004 (Session 2)

Tuesday 30 March 2004

Members Present:

Susan Deacon

Robin Harper

Margaret Jamieson

George Lyon

Mr Kenny MacAskill (Deputy Convener)

Mr Brian Monteith (Convener)

Apologies were received from Rhona Brankin.

The meeting opened at 9.10 am

Medical Equipment: The Committee received a briefing from the Auditor General for Scotland on the report by the Auditor General for Scotland entitled “Better Equipped to Care? – follow-up report on managing medical equipment” (AGS/2004/2).

Medical Equipment (in private): The Committee considered its approach to the report by the Auditor General for Scotland entitled “Better Equipped to Care? – follow-up report on managing medical equipment” (AGS/2004/2). The Committee agreed to invite Trevor Jones, Head of the Scottish Executive Health Department and Chief Executive of NHSScotland, to give evidence at a future meeting.


AUDIT COMMITTEE

EXTRACT FROM THE MINUTES

MINUTES

11th Meeting, 2004 (Session 2)

Tuesday 25 May 2004

Members Present:

Rhona Brankin

Susan Deacon

Robin Harper

Margaret Jamieson

George Lyon

Mr Kenny MacAskill (Deputy Convener)

Mr Brian Monteith (Convener)

 

The meeting opened at 10.05 am

Medical Equipment: The Committee took evidence from-

Mr Trevor Jones, Head of the Scottish Executive Health Department and Chief Executive of NHSScotland

DrPeter Collings, Director of Performance Management and Finance, Scottish Executive Health Department

Mr Gerry Marr, Chief Executive of NHSTayside Acute Services Division

Medical Equipment (in private): The Committee agreed to consider the evidence taken on the report by the Auditor General for Scotland entitled “Better Equipped to Care? – follow-up report on managing medical equipment” (AGS/2004/2) at a future meeting.


AUDIT COMMITTEE

EXTRACT FROM THE MINUTES

MINUTES

12th Meeting, 2004 (Session 2)

Tuesday 8 June 2004

Members Present:

Rhona Brankin

Susan Deacon

Robin Harper

Margaret Jamieson

George Lyon

Mr Kenny MacAskill (Deputy Convener)

Mr Brian Monteith (Convener)

 

The meeting opened at 10.33 am

1. Medical Equipment (in private): The Committee considered the evidence taken on the report by the Auditor General for Scotland entitled “Better Equipped to Care? – follow-up report on managing medical equipment” (AGS/2004/2). The Committee agreed to consider a draft report at a future meeting.


AUDIT COMMITTEE

EXTRACT FROM THE MINUTES

MINUTES

15th Meeting, 2004 (Session 2)

Tuesday 14 September 2004

Members Present:

Rhona Brankin

Susan Deacon

Robin Harper

George Lyon

Mr Kenny MacAskill (Deputy Convener)

Mr Brian Monteith (Convener)

Apologies were received from Margaret Jamieson.

The meeting opened at 9.33 am

1. Medical Equipment (in private): The Committee considered a draft report on its inquiry into the report by the Auditor General for Scotland entitled “Better Equipped to Care? – follow-up report on managing medical equipment” (AGS/2004/2). The Committee agreed to consider a further draft at a future meeting.


AUDIT COMMITTEE

EXTRACT FROM THE MINUTES

MINUTES

17th Meeting, 2004 (Session 2)

Tuesday 5 October 2004

Members Present:

Margaret Jamieson

George Lyon

Mr Brian Monteith (Convener)

 

Apologies were received from Rhona Brankin, Susan Deacon, Robin Harper and Mr Andrew Welsh.

The meeting opened at 10.35 am

1. Medical Equipment (in private): The Committee considered a draft report on its inquiry into the report by the Auditor General for Scotland entitled “Better Equipped to Care? – follow-up report on managing medical equipment” (AGS/2004/2). The report, as amended, was agreed to.

The meeting closed at 11.25 am

Shelagh McKinlay

Clerk to the Audit Committee


ANNEXE B

11th Meeting 2004 (Session 2), 25 May 2004


FOOTNOTES

[1] Better equipped to care? Follow-up report on managing medical equipment, (AGS/2004/2) pg7, para2.7

[2] Written briefing by AGS on his report “Better equipped to care? Follow-up report on managing medical equipment (AGS/2004/2)” considered by the Committee at its meeting on 16 March 2004

[3] Page 12, para 2.9, Better equipped to care? Follow-up report on managing medical equipment (AGS/2004/2)

[4] Better equipped to care? Follow-up report on managing medical equipment (AGS/2004/2)

[5] Page 22, Better equipped to care? Follow-up report on managing medical equipment (AGS/2004/2)

[6] Page 6, Better equipped to care? Follow-up report on managing medical equipment (AGS/2004/2)