Health and Sport Committee

Meeting date: Tuesday, December 5, 2017

Official Report 550KB pdf

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Health and Social Care Targets and Indicators Review

Agenda item 3 is an evidence session on the final report of the expert review group on targets and indicators. I welcome to the committee Professor Sir Harry Burns and invite him to make an opening statement.

When I was asked to carry out the review, I think that there was an expectation that I would say that certain targets and indicators should be dropped and that others should be brought on board. As I began to tease out the whole issue—not just targets and indicators for waiting times and so on, but the whole landscape of health and social care and the indicators that are already out there—it became pretty clear to me that just dropping some targets and pulling in others would not change anything. I think that it was Einstein who defined insanity as carrying on doing the same thing and expecting different results. It seemed to me that the problem with targets and indicators was not what they were, but how they were or were not being used.

11:45  

A number of reports published outwith Scotland confirm the fact that when targets are applied, some change can be seen in how the system works, but very often a problem arises because all the attention is focused on the target and the target is just one slice of activity in a complex system. The length of time for which people wait in an accident and emergency department is determined largely by the number of people coming in and the number of people going out, yet we do not seem to pay too much attention to that. The focus is on whether the 95 per cent target has been met.

My recommendation therefore was that we keep the existing suite of targets—more or less, with one or two alterations—but that we use them not simply for judgment but for continuous improvement in pursuit of an aim. The other thing that I was not clear about was the aim. What is the purpose of health and social care? The only thing that was out there was the Scottish Government’s stated purpose, which is to ensure that all of Scotland flourishes through things like inclusive economic growth. If we want a more flourishing, economically prosperous, successful Scotland with low crime, high educational attainment and so on, let us step back and think about what is needed to achieve that and let us put in place targets and indicators; let us primarily put in indicators that will show progress towards that.

One thing that I recommended, which I think is extremely important in pursuing that aim, is the collection of data on adverse childhood experiences. The evidence from a number of international studies, of long duration and large numbers, is very much that if we want a population that is successful educationally and in the jobs market, that has low offending rates and so on, we need to pay close attention to the lives of children living in adverse circumstances. I can go into more detail on that, but advocating the collection of data on adverse childhood experiences is a problem because at the moment we have no system to collect that data. Therefore, I would hope to be able to work with officials to design a system for collecting data and for developing responses to situations where children are living in adverse circumstances.

Those are the main points that I wanted to make. This is about collecting data on processes and outcomes, not just slices of data that tell us where in a process 95 or 85 per cent compliance is being achieved.

Thank you very much. A number of members want to focus on the early years issues that you raised and I think that that is appropriate.

A number of people who have followed some of the work that you have been involved in throughout your career initially looked at the review with great interest, but there is a sense of people being underwhelmed by it—the review took quite a long time and we wonder what it is really saying. I think that you expressed that at the start, when you said that people had expectations of what the report would say, but that it has turned out somewhat different. Can you comment on that? Am I wrong to feel a bit disappointed?

I am quite excited, because there are very few systems in the world that are looking at health and social care as a complex system. It is an opportunity to take things further forward.

If folk thought that I should be advocating that the four-hour A and E target be dropped, they are very much mistaken to think that that would make a significant change. Apart from anything else, the four-hour A and E target at least has some evidence behind it. Let us look at an example using that target. Let us say that there are two hospitals, one of which achieves 95 per cent compliance while the other achieves 85 per cent compliance. Everyone looks at the 85 per cent compliant hospital and says, “Oh, it must be bad.” However, if we look at the system, we find that hospital A—the 95 per cent compliant hospital—sees 1,000 patients a week in its A and E department, and hospital B, which achieves 85 per cent compliance, sees 3,000 patients a week in A and E with only 50 per cent more staff. Which one is more efficient?

We might then look at the next bit of the system and see how many people are being admitted. If hospital B, with the 3,000 patients, is admitting more patients and they are staying longer, that probably tells us that hospital B is seeing sicker patients. However, at the moment we do not collect the data that tells us how hospitals are functioning. The system just looks at the 85 per cent compliance rate and the newspapers go crazy about it.

We have an opportunity to do something rational for a change, rather than just picking numbers out of thin air. I can tell you that the numbers are picked out of thin air, because almost 20 years ago when I was lead clinician for cancer in Scotland, someone came up to me and said, “We want a target for cancer care. Does three months sound about right?” That tends to be how targets were achieved in the past, but we have an opportunity to move beyond that. Either we have the nous—the will to do something quite radical around improving performance in health and social care—or we just want to sit back and say that we will stick with the original targets.

But you are sticking with quite a lot of the original targets. You are keeping them.

Yes, until we have the data that shows that they are influencing outcomes—very few of the targets are to do with outcomes. We do not measure. Again, I return to the four-hour A and E target. The main data that says that four hours is the right time comes from quite a big Australian study, which showed that mortality declined and was at its lowest in the three and a half to four-hour waiting time period and that as patients waited for more than four hours, their subsequent mortality increased. Is that because they waited in the A and E department, or were they in the A and E department getting investigation and resuscitation and therefore they were sicker and were more likely to die? We do not know that. If you were managing a business, you would not manage it with that kind of data.

Thank you for coming to talk to us. I share some of the convener’s concerns about what has been pulled together in the report. You mentioned business, which is my background. This stuff is second nature in business, because this is what people do.

I think that the process that you start to outline in paragraph 37 of the report makes sense. You need to know your objectives, your outcomes and your key performance indicators and then you set targets. There is a thing about how organisations are aligned so that we have the right people and we know who is responsible for hitting the targets, but that is probably out of scope. There should be a hierarchy of indicators, so that people know which are the important ones, which are secondary, and which are feeding into them; that then drives the improvement plans, which is the whole point.

Earlier this morning we had a session with NHS Ayrshire and Arran about how it is doing that work. That kind of structure makes sense and to my mind it is well understood. I think that you are saying that it is not well understood in the health service and that further work needs to be done to drive that understanding before we even go forward with reviewing the indicators. I think we all thought that we would get to that next.

It comes down to what is measured. You talked about A and E, and you are absolutely right to say that a waiting time might not be the right thing to measure but that there are things such as flow through and demand that should be measured. Perhaps the issue is not that we are not measuring something, but that we are measuring the wrong thing.

No—if I had thought that we were measuring the wrong thing, I would have said so. It is important to measure the four-hour waiting time, because the evidence that we have points to that. However, we need much more evidence about it.

You measure other things as well, perhaps.

Yes. We need to know what the process is in each hospital. Most businesses are far less complicated than society, because that in effect is what we are looking at here. What drives people into A and E departments? I discovered recently that there is one A and E department that has about 12 people who between them over the past five years have accounted for 2,000 of attendances there. That tells you something about those individuals, and the circumstances in which they are living. The answer lies not in doing something about the A and E department, but in all the other things that can support those individuals. We are looking at an immensely complex system and trying to bite off small chunks of it, and we are not doing the population any service by just narrowing it down in that way.

It is complex in one sense, but business problems are complex, too. I suppose the concern I would have is that you are saying, “It is too big and scary, we cannot do anything. Let us not do anything at all.”

No. I am not saying that at all.

If that is not what you are saying, what happens next? Who should do what next?

That is a good question and that is a matter for the folk up the hill.

What would you recommend that they do next?

Over the past few years, with an improvement-based approach to patient safety and the early years, we have seen significant reductions in infection rates and hospital mortality, and significant improvements in the stillbirth rate and infant mortality, by applying a co-production approach in which front-line staff work to see what change indicators they think are important.

The line I have used is that the data should be used for improvement, not for judgment. Instead of creating a blame culture that says, “You guys are obviously useless, because you are achieving only 85 per cent,” we should be creating a culture in health and social care partnership areas that says, “What are the drivers of demand? What is preventing people from being sent home so that beds are available?” and all that kind of thing. I do not have much sense that that is being done systematically, because all the focus is on the hard targets that folk know they will get a thick ear for missing.

Do you think that there is not an understanding that that culture needs to change?

There are plenty of folk who understand that that needs to happen, but the focus from the press and from politicians is all on saying, “You have failed.” It is the old view in which what is counted is what counts and therefore people put all their attention on the numbers that are being counted rather than on thinking about changing the broader system.

Do you think that politicians do not understand that?

I do not think that politicians do, from the way in which they respond to some of the data.

Obviously, the very first part of this is setting your objectives and what you are trying to achieve. Do you think that there is not clarity, at the top, about what we want the system to achieve?

The report takes the stated purpose of the Scottish Government, which I think has a pretty broad appeal across the political spectrum. That seems to me to be as good as you can get. There are few other countries that have set themselves a purpose in the way that Scotland has done.

But it is very broad and top level.

It is broad, but it has enough in it. There is the notion of a flourishing population—in which the kids do well at school, get into jobs and are creative, and in which there are low levels of offending. All of that adds up to the definition of wellbeing, and I would be content to go with that as a purpose. The statement in the report that that should be the overarching aim that all the targets should lead towards is the first time that I have ever seen that.

At least three frameworks have been mentioned—there is the national performance framework, the local delivery plans and health and social care. Is there a need to get them into one? If so, whose job is it to do that?

We should see how it all interacts. The health service targets are one sliver of a broad system that, if managed appropriately, could enhance wellbeing and lead to decreased demand and better outcomes in the national performance framework.

So those should all be crunched into one.

They should be seen as part of one system. To be perfectly honest, I do not know what the mechanism is for changing the national performance framework. Again, we have focused on health and on the idea that what can be measured is what counts. In the national performance framework, outcomes are measured every year or every three years.

12:00  

It is clear that you are advocating a greater focus on the early years, as you did in your previous role as chief medical officer. The new CMO has a different focus. We have been speaking a lot about care for the elderly, chronic illnesses and the realistic medicine agenda, whereas you are advocating a life-course approach. How might that help us address some of the challenges that we face? You note that Scotland has the lowest life expectancy of 16 western European countries and that that has only become the case since the 1960s. What might that life-course approach look like and how could it help us address some of the unintended consequences of the targets?

The evidence around adverse childhood experiences comes predominantly from a very large, prolonged American study, a study carried out in New Zealand, some work done in England and so on. For children who experience four or more very clearly defined adverse events, such as physical violence, emotional neglect, or parental absence, either through parental imprisonment or parental mental health problems—postnatal depression, for example, is a very significant adverse childhood experience—the evidence shows that when they grow up, they are eight times more likely to become alcoholics or other substance misusers, eight times more likely to be arrested for violence, significantly more likely never to work, significantly more likely to require healthcare and so on.

The English study showed that if someone had none of the nine defined adverse events in early life, they had a 35 per cent chance of having a chronic illness by age 60; if they had four or more, it was a 70 per cent chance. The American study has calculated that one year’s worth of child neglect in the US brings with it a lifetime cost to the American economy of $124 billion in terms of demand for support and care, failure to pay taxes, because those individuals never work, and so on. Pro rata, the Scottish equivalent is that one year’s worth of child neglect in Scotland may bring with it a lifetime cost of £1.8 billion. If we get early years right, children do better at school, they are less likely to fail when they move into the workplace and they are less likely to go to jail. Their life course begins to move in a different direction.

A report that was published a few weeks ago pointed out that the greatest number of deaths from drug and alcohol abuse in Scotland were in 40-year-olds. Ten or 15 years ago, the highest number of deaths from drug and alcohol abuse was in 20-year-olds. What we are seeing is a cohort effect. People born in the 1960s or around that era are moving through the life course and acquiring all sorts of problems. The way to begin to fix it is to change the life course at the beginning. Yes, we have to do things for the others—we have to support them and provide services for them—but we had better start getting it right in the early years if we want to have a flourishing population.

If we know that those mortality effects relate greatly to young people or that those young people are now carrying conditions throughout life, what can we do to make sure that we address that? All the targets that we have been discussing seem far removed from that life-course approach.

The work that I have done over the past 10 or 15 years has been to demonstrate the biological consequences of adversity in early life. It always seemed to me that if one just expressed an opinion that adversity in early life led to all sorts of problems later on, folk might recognise that, but if one could show that there are biological changes that lead to problems, nobody would be able to argue with that. We have shown that through studies carried out in Glasgow that involved measuring neurological function and so on. Fundamentally, in children who experience adversity in early life, brain development leads to reduced ability to learn, reduced ability to suppress inappropriate behaviour and increased emotional lability. We have kids at school who are more anxious, aggressive and fearful, less able to suppress those tendencies and less able to learn. We have shown biologically different brain patterns in affluent and deprived Scots. We have measured psychological function and so on.

Can we change that in later life? This is relatively new science, but the evidence is emerging that certain things can be done to reverse some of those brain changes. One of the most important—you see this in the third sector, which is particularly successful at it—is mentoring and supporting individuals who are living chaotic lives.

I will give you an example of a jaw-dropping outcome. I recently gave a lecture to English chief constables at one of their continuing professional development days. Afterwards, a chief constable of a county in England said to me that his force was doing a randomised controlled trial of criminal justice. People who were arrested in his county went through a screening programme. For serious offenders such as murderers, there was no question about it: they were charged and they went through court. However, medium and low-risk offenders were randomly allocated to being charged and going to court or to not being charged and therefore not acquiring a criminal record, and having a support package of mentoring and so on. He said that the follow-up after two years showed that the re-offending rate of those who went to court was 65 per cent—for those who got the support package it was less than 10 per cent.

There are all sorts of different ways of doing this. If we follow those folk through the life course and support them in ways that keep them involved and engaged in society, we will begin to deal with that bulge of low life expectancy.

We recently heard from ex-prisoners in an informal session. One of them, who had been in prison several times—the convener will know who I am talking about—said that those in prison had changed markedly over the years. He said that prison felt more like a mental health ward now. One of your suggestions is reporting the incidence of prevalence of mental health problems by the Scottish index of multiple deprivation. Why would that be useful when it comes to identifying the impact of other interventions?

We can look at things such as domestic violence. Given all the focus that is on education just now, it is interesting that the American study shows that the biggest predictor of educational failure is witnessing domestic violence in the home. Adverse childhood events are not exclusively associated with low socioeconomic status, but they tend to be more common in areas of low socioeconomic status. That is largely because of worries about money and worries about alcohol consumption.

There is a cyclical effect, which I have referred to as the cycle of alienation. I talk to young people in prison. If, for example, I ask an 18-year-old in Polmont who is about to get out what he is going to do when he gets out, he might say, “I will never get a job. I have got a criminal record.” If I ask, “So what are you going to do?”, he will say, “I will sit at home, watch telly and drink.” That is literally what I have been told, but what such people do not factor into the equation is that their girlfriend will have a baby and that baby will then be born into a chaotic household. That is where you begin to break that intergenerational cycle. It is hugely important for us to focus on that life course, and to note that the focus begins with adversity in families. If we focus on them we will see that bulge of dysfunctionality moving out of the system.

Good morning, professor. Your section on adverse childhood experiences was music to my ears, as I worked in the voluntary sector for 15 years, eight years of which was for an organisation that delivered trauma recovery for children of all ages. I was delighted to see that and delighted to see your push towards a more trauma-informed approach. The National Society for the Prevention of Cruelty to Children report “The right to recover: therapeutic services for children and young people following sexual abuse” identified that 15 out of 17 local authorities that they examined did not have any trauma recovery services for the under-fives and a further 11 of those 17 had nothing for primary school-aged children either. In your recommendations, you suggest that we should set up a protocol for the management of such cases. That is as close as you come to calling for the widespread introduction of trauma recovery services. Why did you pull your punches on that?

Because that was not what I was asked to do. I would anticipate—and I earnestly hope—that some group is set up to consider the collection of data on adverse experiences and the management of it. If we start off by identifying the problem, I would love to be involved in further discussions on it.

I have been looking at this issue. One of the most interesting things in this area is the Barnahus system in Scandinavia. The problem is that for a three-year-old who has experienced abuse—either sexual abuse, which can happen in nursery schools, or physical abuse—the current system reinforces the trauma, as a result of legal requirements. The accused has the right to be there. The child could be having their evidence filmed, but video has often been an instrument of the abuse. The trauma is reinforced by the way that we manage it, so we have to start looking at alternatives. The Scandinavian system, as is often the case, has a far more sensitive and rational way of collecting evidence that allows abusers to be dealt with.

However, it was not my job to look at that. I was not asked to come up with the solutions; I was there to say, “Our targets and indicators system is probably not fit for purpose.”

I get that. I understand that it would have felt like mission creep to start laying out recommendations that might have been more linked to your work with the early years collaborative. I support what you have just said, though, because I absolutely believe that we still have a cultural reality in which what gets measured gets done. If we measure childhood trauma and lack of trauma recovery, perhaps that will pump-prime local authorities, health boards and everything else to build those services around the children.

I would like to take you back to the national performance framework, which looks at dental health, child and adolescent mental health services, waiting times and babies of healthy body weight. In the report, you go on to mention the getting it right for every child approach. You say:

“It is not clear how this system identifies ACEs and it would be helpful to see if there is a standard approach to identifying and managing neglect in babies.”

When it comes to those processes and outcomes, do you think that there is a disconnect between education and health?

No. I probably talk to more teachers than doctors.

I know—in fact, the last time I saw you, you were in front of my higher class.

I get more sense out of teachers than I get out of doctors. [Laughter.]

There is an understanding of the close link, but there is no real understanding of how to manage it. I recently spoke to a headteacher who had just been given £500,000 for his school to spend on whatever he liked. His comment to me was, “I don’t really need this—I’d far rather it was spent on giving the kids a decent breakfast before they came to school.” That is part of it.

12:15  

People have different ideas. We are a small enough country for people to be able to get together and say, “What is the link here?” The link is absolutely cast-iron: adversity before someone goes to school leads to failure when they get to school. If we are serious about having a flourishing, inclusive economy, we have to get that link built more strongly. Well-meaning policies such as GIRFEC have arrived, but it is time someone came up with a system to create success at school and pulled all of that together.

I agree.

In paragraph 72(a), on page 18 of the report, you recommend:

“Analysis of school attainment rates should routinely consider the effect of adverse circumstances arising from socioeconomic deprivation on attainment.”

School attainment data is a very narrow measure. What other factors do you think should be taken into consideration?

What are the things that influence the attainment rate? We have already mentioned factors such as adversity and exposure to violence. One of the most complex issues here is the notion of mentoring. All of us have someone in their family who was the first to go to university. We probably all started off coming from a poor background. I keep coming across stories of mentoring. For example, I bumped into a former medical colleague who was volunteering as a mentor, and the boy he was mentoring, who lived in Possilpark, had just got a place in medical school. The boy was so poor that he had to walk the 45 minutes to school and back every day because he could not afford the bus fare. There are guys from Lenzie and Bearsden who come from the best schools in Scotland who do not get into medical school. We need to have more of a focus on supporting people who might not feel that they have any place at university and convincing them that they do.

There are a number of projects out there on developing the young workforce. There is a programme in Newlands in Glasgow that takes troubled children and trains them very effectively to go to university or to succeed in some other way. There are ways of achieving success that we should collect data on. We should try to have a more consistent approach, because if we have a piecemeal approach, everything just gets fragmented.

Good afternoon. This is a fascinating topic, especially the link between education and health. With that link and early intervention in mind, why are we not linking health targets with educational targets? Should we be taking a more cross-portfolio approach?

I am really interested in understanding the idea of lack of access to opportunity at a very early age. With the 30 hours of free childcare, do we have an opportunity to make a more positive intervention? If some kids are likely to be 40 per cent behind by the time they get to primary school, why are we focusing on primary school?

That comes back to the idea of the life-course approach. Basically, the life course begins as soon as the pregnancy test is positive. When the United Kingdom chief medical officers considered recommendations on alcohol consumption during pregnancy a few years ago, I was the only one who said, “I want the recommendation to be that no alcohol should be consumed during pregnancy.” The others said, “One or two drinks might be all right.” Drinking alcohol during pregnancy has an impact on brain development.

That is the starting point. We need to look at the whole life course in that way. We should not start at the age of five. In fact, the adverse childhood events study calculated cognitive performance at age two and age 10 by socioeconomic status. At the age of two, there was a group on the 90th centile—very high performers—from affluent and deprived backgrounds. By the age of 10, the affluent children had maintained their cognitive functioning, whereas the deprived ones had deteriorated. The evidence is that there are things that we need to do to support those kids throughout their childhood to enable them to achieve the best possible educational outcome.

You are absolutely right when you talk about the need for a holistic approach to pull everything together. At the moment, we have different groups working in different silos to do similar things. Ultimately, we are not going to get a harmonious result or one that we can apply indicators to effectively.

I want us to co-produce—with teachers, children’s carers, third sector organisations and so on—a programme for leading children to the best possible intellectual place over the first 10 years of life, because if we get them to that point, they will do quite well thereafter. At the moment, we do not have any way of doing that, which is why I said that we should have a set of indicators for that, but it is not up to me to say what they should be—it is up to the whole system to design them.

If we extrapolate from that, could we realistically state that educational intervention has such a huge impact on health outcomes later in life that we should be focusing on education much more?

I spent five years as a consultant surgeon at Glasgow royal infirmary, and it was that experience that prompted me to go into public health, because I kept having patients come to me—as a surgeon—who were there to see me because they drank too much and had a gastrointestinal haemorrhage or something like that. I would say to them, “If you don’t stop drinking, you’re going to die,” and the response would be something along the lines of, “Why should I care? Life’s really crap, and I don’t care. The drink’s the only thing that makes life worth while.” People get to that point in life at which they have no sense of purpose, no sense of meaning and no sense of self-efficacy in life, and that comes about largely because they have had a difficult childhood that has sent them on that road to a cycle of alienation.

A kid who experiences adverse events is more emotionally labile or less able to suppress his feelings. He is badly behaved, so he gets excluded from school because he is disrupting education. I think that that policy is nuts. When I asked an education department whether it could provide me with data on who was excluded from school, it could not. It did not know who was being excluded or how often they were being excluded.

Because such kids are excluded from school, they get it into their heads that they are stupid, they end up drinking bottles of cheap vodka—maybe it will no longer be so cheap—they get into fights and they go to jail. That is often the life course that adversity sets them on, unless they get picked up very early on and get mentored and supported. It is not in my nature to talk about the issue in purely economic terms, but that is a huge waste of human capital. Those are the kids who should be the doctors and the lawyers—no; I will leave the lawyers out of it. [Laughter.] They should be the doctors, the engineers, the inventors, the artists and the musicians; instead, they are ending up in Polmont.

I could talk about this all day, but I will give somebody else—

I am happy to talk about it all day.

I want to pick up on a couple of the issues that you have raised. In a number of those areas, whether in early life or elsewhere, the people who would have picked up on what was happening would have been youth workers, child development workers and third sector organisations that were employed or funded by local government. How can we address the very serious issues that you raise when local government services are disappearing through our fingers? I know from your previous work that you worked closely with local government, so you will know this stuff inside out. Given what is going on at the moment, are we not in danger of exacerbating the problem?

I am in the process of working with five or six local authorities and their associated health boards. We are thinking about applying a different pattern of service to people who live in difficult circumstances and measuring it. I am in the process of pulling that work together. Just yesterday, I interviewed for four PhD students who would help me to assess the impact of such an approach. There is no doubt that we need to work differently with the public sector and third sector organisations that confront this kind of problem. My hope is that that will give us the evidence that we need.

I think that youth workers might be intervening too late; I think that the work needs to start—

It is child development workers, nursery staff and outreach workers that we need.

Yes—we need nursery staff and health visitors. We need things such as the family nurse partnership. One of the most inspiring things that I have ever witnessed was the result of work that family nurses had done with six pregnant 16-year-olds. I met one of those young girls and watched her with her baby. The attachment between her and the baby was absolutely secure. The father appeared, and he was similarly attached. The girl then said, “Right, I have to go now—there’s a taxi waiting to take me back to school.” She was sitting five highers and she wanted to be a lawyer. I said to the family nurse, “If you hadn’t been there, what would she be doing now?” She said, “She’d be wheeling the pram down to the shopping centre and drinking with her mates.” That kind of intervention is expensive, but it is gold dust. As I said earlier, one year’s worth of child neglect could have a lifetime cost of £1.8 billion.

But such services do not run on fresh air.

They do not.

It has been a very interesting discussion, but I am going to change the topic slightly and go back to the targets. You recommended keeping most of the targets, but one that you suggested should perhaps be dropped is the 18-week guarantee, because that possibly alters clinical decision making. Can you say a bit more about that?

Yes. Let us say that someone presents with a complex problem such as complex abdominal pain. They may have an orthopaedic issue or whatever. For a start, it can take a good few weeks to run down the diagnosis, and it might be that, as the diagnosis is being narrowed down with different tests and so on, different options for treatment appear. The patient may be offered a treatment and they may ask to go away and think about it. If the clock is ticking, that puts pressure on both the clinician, who is trying to come up with the right management strategy, and the patient, who may want to take time to think about it. You could come up with all sorts of strategies such as the clock stopping whenever the patient decides they want to think about the proposed treatment and so on, but that would not build good clinician-patient relationships. You want to build a relationship in which the clinician is trusted and feels that he is supporting the patient.

I would not want to go back to the days when, as a consultant surgeon, I used to manage my own waiting list. Like all the other surgeons in the Glasgow royal infirmary, I had a waiting list and, every week, I would take patients off it for the next week’s surgery. The more serious cases came off and the ones waiting for varicose veins surgery, hernia repair or whatever might wait for two years. All of that was swept away because of a big investment in waiting list initiatives. I never practised privately, but my colleagues who did were driving big, flashy cars on the back of the waiting list initiatives. They made a lot of money out of them.

Patients should not have to wait, but imposing a target that might interfere with the clinical decision making and the doctor-patient relationship is not a good thing to do, especially when the target is not legally enforceable.

12:30  

You said that it might affect patient choice as well. Patients need time and decision support tools to make an informed choice about their treatment.

Yes.

If the 18-week guarantee is cutting across such issues, how can we decide on a better target that would lead to the outcomes that we are looking for?

Once the decision is made, there is the 10-week target, which is there as a backstop. I am talking about the process between referral and deciding what is clinically indicated and what the patient wants to accept, which can take longer than eight weeks even with all things working smoothly.

Complex problems should not be rushed at. The clinician needs to stop, think and discuss with the patient what the options might be. I am seeking decision support tools. Things such as the internet are making patients much more aware of their options, which is a good thing. In the old days, I would see a patient and say that they needed such-and-such an operation, and they would say, “Aye, okay,” and go away. Things have improved a lot. The word “empowered” is overused, but patients should feel more in control of the big decisions.

I want to look at what impact our target-based approach to health is having on the work that is done in our health services. This week, it has been reported that, across NHS Lothian’s accident and emergency units, there has been underreporting of waiting times. Is the massaging of figures or underreporting becoming common throughout the health service?

I have no factual insights into that, so anything that I say should not be taken as gospel. It would not surprise me, however, because what gets measured is what counts. People who work in the health service genuinely want to do a good job for their patients, and putting them in a position where they might have to be dishonest is not a good thing.

That is why I am suggesting that you look at the whole system. If a lot of people are waiting in an A and E department, is that because there are not sufficient beds? Is it because there are too many inappropriate folk pitching up who have problems that could be more effectively managed elsewhere? We need to understand the situation and not put the blame on hard-pressed A and E staff. That is why I am suggesting co-production. Involve people in designing what the processes and indicators should be, and you will find that they go much further than what a bunch of officials would do, because they want to do the right thing.

I am absolutely stunned by the results of the patient safety programme, whereby the front-line staff got the bit between their teeth and eradicated whole swaths of infections. When I worked in intensive care units, 90 per cent of people who had been ventilated for more than a week had ventilator-acquired pneumonia. Nowadays, in some hospitals, it is years since they have seen ventilator-acquired pneumonia, because the staff changed the way that they worked. Involve them and you will get outcomes far better than you ever anticipated.

How can we move to that outcomes-focused NHS? There are lots of pilots—we hear about them all the time. There is lots of good work in certain areas, but that does not get rolled out and there does not seem to be any learning from it. You talk about systems thinking, but how can we make sure that professionals take professional responsibility, and how would you go about measuring that?

When we ran the early years collaborative, every five or six months we would get 800 people from every local authority and every health board in Scotland who were involved in early years care into a room, where they would sit down and share ideas. It is like athletics without the drugs.

You have got my attention now.

Perhaps it would be more appropriate to talk about the UK cycling team.

That is better.

You are losing both the athletes and the cyclists.

There have been lots of marginal gains. We tested things and got a 2 or 3 per cent improvement in performance. We counted 1,500 things that were tried by the earliest collaboratives, and maybe 60 of them actually produced a benefit. Where all 60 of them were done consistently and the data was collected, there was a step up in performance. An 18 per cent reduction in the stillbirth rate over a matter of a few years is unheard of.

It is about bringing people together and making it plain that we want to hear what they are doing. We want to hear what works and, crucially, we want to hear what they have tried that does not work. There is no shame in failure except in not telling people that you have failed. It is about saying, “We tried this and it didn’t work, so don’t waste your time,” and gradually building improvement in that way. A colleague up in St Andrew’s house, Professor Jason Leitch, is a guy who can do that. He certainly frightens me.

We have covered a lot of what I was thinking about. Last week, Dr Mackintosh talked about the original paternalism of healthcare and the idea that, if you can count it, it counts. You have talked about that as well. He said that a more professional or moral approach is what we need, not forgetting that targets inform us about where we need to go.

I was directly involved in the Scottish patient safety programme as a clinical educator nurse at NHS Dumfries and Galloway, and we took a multidisciplinary team approach because that is how we got all the views. I am interested to hear your thoughts about whether we should move to a less target-driven culture and take a more professional or moral approach, as Dr Mackintosh outlined.

We need a less target-driven approach but a stronger indicator-driven approach. Targets delineate the end of a journey—“Okay, we have made the target. We can stop trying,”—but indicators tell us our direction of travel. A 15 per cent reduction in infant mortality is a good thing, but we should keep going, and indicators are about understanding the way in which we want to go. In the earliest collaboratives, ensuring that 90 per cent of children attained all their developmental milestones at the 30 months health visitor assessment was something that the front-line staff identified as an indicator on the way to improving intellectual performance.

We need indicators, but indicators need to be feasible. They need to be pragmatic, they need to be co-produced and we need to be able to say, “Okay, we’ve done that now. What’s the next thing?” At the moment, some targets seem to be cast in stone and there is no thought that we would move away from them. We should be aiming high, and indicators tell us that we are shooting for the stars, although we do not want a target that prevents people from trying. In bringing people together, it is critical to have not only those on the front line but the bosses there. The heads of health boards must show those on the front line by their presence that the meetings are important.

When Gerry Marr was the chief executive of NHS Tayside, the front-line staff were really impressed that he came on ward rounds. The chief executive of the health board was there on ward rounds to show that hand washing and so on was important. He was taking an interest in what they were doing. Having leadership from the top while having front-line staff there to create the change is the way to do it.

With the co-production that you are talking about and all these masses of programmes and integration joint boards, there is so much happening. Will we see a tipping point eventually? Those at the front line have to engage in constant hard work, as does everyone else, but surely there must be light at the end of the tunnel.

The integration of health and social care is really important. We have talked about integration with education and that kind of stuff, which is important, but we are creating new organisations. Organisations tend to have their boundaries and cross-boundary working, and the more you fragment the system, the less able you are to get a coherent strategy. That is why the report starts by talking about how we will achieve a flourishing population in Scotland. Let us start from there and see how we design a system that takes us all there.

I have never been a member of any political party, nor would I ever want to be. There are things in this that go right across the political spectrum—social justice, excellence in outcomes, economic development and so on. It is about creating a society that we all feel proud of. If we put that ideal at the forefront, how do we design the indicators to show how we get there? If you want me to go back and do phase 2 of this, I could design something, but the system must be co-designed by the people who have to deliver it.

What is the next stage of the process?

You would have to ask colleagues up the hill.

Who are those folk up the hill? Tell us who they are. I have never met them.

I was asked to do this by Mr John Connaghan, who was the director of performance and is now no longer up the hill. He is now the chief operating officer of the health service in Ireland.

Is that because his performance was good or because it was not so good?

I think you would regard it as good, because he is still going to be in the European Union—but let us not go there.

My fear is that the system will get taken away and, in the traditional way, designed by civil servants, whereas it needs to be designed by the people who are actually working within it. A year has gone by and I am just getting out there and doing it. I got money from various sources. An American charity heard about what I am doing and said that it would like to support the work because it wanted to do the same in the US. It told me to ask it for some money, so I asked it for £500,000 and it got back to me and said that I had not asked it for nearly enough.

A group of local authorities are expressing an interest and are trying to integrate things differently.

Is that work being done by you on your own?

Yes.

The committee needs to know what the next stage in the process is.

It would be very helpful for me to know that, too.

That is probably a good place to finish. Thank you very much. As always, it has been good to have you before the committee. It always provokes an interesting conversation and there is much for us to think about.

Thanks a lot.

12:43 Meeting continued in private until 12:52.