Public Accounts Committee
Membership and Powers

The Public Accounts Committee is a Standing Committee established in accordance with Standing Orders under Section 60(3) of the Northern Ireland Act 1998. It is the statutory function of the Public Accounts Committee to consider the accounts and reports of the Comptroller and Auditor General laid before the Assembly.

The Public Accounts Committee is appointed under Assembly Standing Order No. 51 of the Standing Orders for the Northern Ireland Assembly. It has the power to send for persons, papers and records and to report from time to time. Neither the Chairperson nor Deputy Chairperson of the Committee shall be a member of the same political party as the Minister of Finance and Personnel or of any junior minister appointed to the Department of Finance and Personnel.

The Committee has 11 members including a Chairperson and Deputy Chairperson and a quorum of 5.

The membership of the Committee since 9 May 2007 has been as follows:

Mr John O’Dowd (Chairperson)
Mr Roy Beggs (Deputy Chairperson)
Mr Willie Clarke
Mr Jonathan Craig
Mr John Dallat
Mr Simon Hamilton
Mr David Hilditch
Mr Trevor Lunn
Mr Patsy McGlone
Mr Mitchel McLaughlin
Ms Dawn Purvis

List of abbreviations used in the Report

List of Abbreviations used in the Report

C&AG Comptroller and Auditor General
ERMS Electronic Referrals Management System
GP General Practitioner
ICATS Integrated Clinical Assessment and Treatment Services
NHS National Health Service

Executive Summary

Understanding outpatient activity

1. Every year around £259 million is spent providing outpatient services in hospital and community clinics in Northern Ireland. Until recently, the trend in the number of patients waiting for a first outpatient appointment had been steadily upwards. The Committee acknowledges the efforts of the Department in meeting its target in March 2007 that no one was waiting more than 26 weeks for a consultation. However, the Committee stresses that in doing so, clinical standards or priorities should not be compromised.

2. As a temporary expedient in achieving the target, the Department used private/independent sector capacity to ease the pressure on health service resources. This cost £6.3 million. The Committee accepts that, in the circumstances, this was a reasonable approach, however, it is imperative that the Health Service develops sufficient capacity to keep outpatient waiting lists down in the long term.

3. The Committee welcomes the steps the Department has taken to improve outpatient provision by redesigning services to reflect the needs of patients. If managed carefully, the innovative practice of locating initial consultations in community settings through Integrated Clinical Assessment and Treatment Services (ICATS) should improve patients’ access to outpatient care.

4. The Committee found it surprising that about half of all outpatient activity is not recorded in the Department’s patient database. Its management information systems only record attendances at consultant led clinics. However, a census carried out by the Department showed that other healthcare professionals run clinics for around 1.7 million outpatients every year. Because of this, data collection does not provide a comprehensive picture of the efficiency and effectiveness of outpatient activity.

Improving attendance at outpatient clinics

5. An extrapolation of the census figures for cancelled clinics and patients failing to turn up for appointments, shows that in a typical year over 300,000 outpatients will not be seen at clinics. Northern Ireland has traditionally had the highest clinic non-attendance rate among its health service counterparts in the United Kingdom. This element of unpredictability costs the Health Service around £12 million a year makes managing clinics difficult and can lead to a poor service and longer waiting times.

6. It is important that Trusts should examine the causes of non-attendance rates for their clinics and take action to reduce these. The Committee found little evidence that this has been done. The Committee is concerned by the Department’s reluctance to encourage the use of targets as a way of focussing the attention and action of Trusts on the problem of non- attendance, and cancelled clinics. The use of such targets is common practice among Trusts in Great Britain.

7. A specific feature of non-attendance is that it can vary significantly between Trusts and specialty. As a case in point, the Committee is concerned by the Department’s inability to explain why the Mater Hospital Trust has a particularly poor record of clinic attendance across a range of specialties. Moreover, the Committee notes that the mental health sector suffers most from non-attendance and is disappointed by the Department’s lack of commitment to monitoring performance in this area against target reductions and timescales.

8. With regard to the area of mental health in general, the Department told the Committee that it saw the shortage of staff within the sector and the demanding issue of attracting more people into the area as a crucial factor in addressing a wider range of strategic issues which would include non-attendance by outpatients. The Committee is concerned that this staff imbalance may be indicative of poor strategic manpower planning on the part of the Department and Trusts.

9. While non-attendance can result from inefficient administration and communication with patients by Trusts, the Committee recognises that the failure of patients themselves to take responsibility for attending appointments can play a major part in the problem.

10. The Committee welcomes the establishment of an Outpatient Improvement Manager Network across Trusts as a means of identifying and spreading good practice. This forum should provide a platform for bringing together ideas and views on how to take forward issues like outpatient non-attendance. The Committee believes this could be a model for dealing with similar operational problems in the wider public sector and recommends its use where sharing good practice is important.

11. Partial booking of outpatient clinics involves Trusts telephoning patients six weeks or so before an appointment is due to agree on a suitable time. This makes getting an appointment more convenient for patients and should also help to minimise the incidence of occasions when patients do not turn up. The Committee is concerned that it took the Department until September 2006 to introduce partial booking, particularly when Northern Ireland has the highest non-attendance rate in the United Kingdom (see paragraph 5 above). This practice has been operative in England since 2000, in Wales since 2001 and in Scotland since 2004.

Improving the efficiency of outpatient clinics

12. The level of cancellations, at 2.3 per cent of all outpatient appointments, indicates that clinics are, for the most part, organised effectively. However, it is important that the focus on minimising cancellations is maintained as this is an integral element in ensuring that patient choice is maximised.

13. The issue of how the interface between the private practice work of consultants could conflict with their outpatient commitments is one that continues to exercise the Committee. The Department said, in evidence, that the implementation of job plans and associated disciplinary procedures for consultants would safeguard against consultants failing to fulfil their commitments to the Health Service. The Committee also notes the introduction of improved management information systems for monitoring consultant activity. However, the Committee remains to be convinced that these initiatives will provide the necessary assurance that the risk of private practice being given priority over outpatient clinics will be adequately controlled.

14. The Committee is concerned that the advantages of pooling patients within clinics rather than referring them to a specific consultant may not be fully realised within outpatient services. The operation of single handed clinics can be particularly problematical. Where pooling arrangements do not exist, if such a clinic is cancelled, potentially useful capacity elsewhere may not be utilised.

Summary of Recommendations

Understanding Outpatient Activity

1. The Committee notes the efforts of the Department in shortening waiting times for outpatient appointments. However, there must be a concern that these efforts should not adversely affect the care given to outpatients, particularly, if there is pressure on consultants to spend less time with patients or treat them in different order to clinical priority to meet tight time targets. The Committee looks to the Department to advise managers in Trusts and hospitals of the need for them to work in close cooperation with consultants to ensure that in all cases outpatients receive care which is appropriate to their needs (see paragraph 5).

2. The Committee recommends that it is imperative that the focus is shifted from spending on short term waiting list initiatives such as the use of the independent/private sector towards ensuring that the design and capacity of outpatient services are sufficiently developed to keep waiting times down on a sustainable basis (see paragraph 7).

3. The Committee welcomes the steps the Department is taking to improve referrals and it expects to see the use of ICATS extended to all specialisms where it offers the potential for improvement (see paragraph 11).

4. The Committee recommends that the Department ensures that satisfactory arrangements are maintained for the collection of accurate data on outpatient activity (see paragraph 14).

5. The Committee recommends that the Department should identify the data requirements for managing all outpatient services and ensure that systems are in place to address these (see paragraph17).

Improving Attendance at Outpatient Clinics

6. In order to stimulate action in Northern Ireland, the Committee recommends that Trusts should adopt challenging but achievable reduction targets tailored to the levels of non-attendance experienced by their outpatient clinics (see paragraph 22).

7. In the drive for improved outpatient attendance rates the Committee recommends that the development of more sophisticated methods to understand the roots and demographics of non-attendance should be a priority. One way of obtaining information on this would be to undertake surveys of patients who do not show up for appointments. The Committee also expects the Department to closely monitor the position at the Mater hospital in view of its particularly poor attendance rates (see paragraph 25).

8. The Committee urges patients to take greater responsibility for their part in running the Health Service. If an appointment is missed it is their taxes that are being wasted. At a time when many Trusts are facing financial difficulties, it is important that patients understand this and try to keep their outpatient appointments. The Department may need to consider further measures to deal with persistent non-attendance (see paragraph 27).

9. The Committee expects the Department to ensure that there is a maximum take up of the depression awareness scheme by GPs (see paragraph 30).

10. Given the incidence of non-attendance by outpatients with mental health problems, the Committee believes it is crucial that greater priority be given to this group of patients. The Committee recommends that as a matter of urgency, the Department takes steps to clarify the reasons for the high rate of non-attendance among mental health patients. Moreover, the Department needs to demonstrate its capacity for overseeing the proper management of mental health outpatient services by setting a target for reducing the current level of non-attendance and monitoring performance against this target (see paragraph 32).

11. The Committee recommends that the Department examines closely ways of increasing the capacity of health service provision for services to mentally ill patients in order to overcome the imbalance of appropriately skilled staff (see paragraph 34).

12. The Committee considers this arrangement to be a potential model which could be applied by the wider public sector as a way of addressing similar issues and ensuring that successful approaches to common problems can be effectively disseminated. The Committee believes this should be a model for dealing with similar operational problems in the wider public sector and recommends its use where sharing good practice is important (see paragraph 36).

13. The Committee urges the Department to ensure that it keeps abreast of new developments regarding the handling and timing of outpatient clinics. This can be done by networking with other health departments in Great Britain, through its contacts with the Republic of Ireland and further afield (see paragraph 38).

14. The introduction of partial booking is welcome but long overdue. The Committee recognises that more time is needed for the new system to realise its potential benefits for outpatients. The Committee shares the Department’s hope that it will lead to an improvement. The Committee recommends that the Department keeps the operation of partial booking under review and evaluates the extent to which it is having the cumulative effect of falling waiting times, fewer patients not attending and reduced overbooking (see paragraph 40).

15. The Committee expects the Department and Trusts to be able to demonstrate that they are taking account of patient preferences about the timing of clinic appointments and that existing patterns of delivery are reviewed to ensure that they represent the most efficient and effective use of resources (see paragraph 42).

Improving the Efficiency of Outpatient Clinics

16. The Committee welcomes the fact that the Department is making strides in putting in place management information systems which allow it to track the performance of consultants and their outpatient activities. It is clearly desirable that existing problems and developing trends can be quickly identified. The Committee would like a clear account from the Department setting out precisely how the information collected on consultants’ workload is monitored and verified to ensure that private practice does not lead to the cancellation of clinics or any other abuse (see paragraph 49).

17. The Committee would like detailed information on the extent to which disciplinary procedures have been used against consultants in each of the past five years and how many of these cases related to accountability for outpatient clinics (see paragraph 51).

18. The Committee considers that pooling can increase confidence among patients that appointments will be kept and urges the Department to actively promote its use throughout the range of outpatient specialties (see paragraph 53).

Introduction

1. The Public Accounts Committee met on 28 June 2007 to consider the Comptroller and Auditor General’s report on “Outpatients: Missed Appointments and Cancelled Clinics” (HC 404, Session 2006-07). The witnesses were:

Dr Andrew McCormick, Accounting Officer, Department of Health, Social Services and Public Safety.
Dr Michael McBride, Chief Medical Officer.
Mr Dean Sullivan, Director of Planning and Performance Management, Department of Health, Social Services and Public Safety.
Mr John Dowdall CB, Comptroller and Auditor General.
Mr David Thompson, Treasury Officer of Accounts, Department of Finance and Personnel.

The Committee also took written evidence from Dr Mc Cormick (Appendix 3).

2. Every year, around £259 million is spent on providing outpatient services in Northern Ireland. The management of these services is an important issue for the Department of Health, Social Services and Public Safety to address, particularly in the context of lengthy waiting times. Patient non-attendance at clinics and the cancellation of clinics by Trusts are costly and add pressure to waiting list management. Both problems can also have a negative impact on patient health.

3. In taking evidence, the Committee focussed on a number of issues raised in the Comptroller and Auditor General’s (C&AG) report. These were:

the adequacy of management information on outpatient clinics;
the effectiveness of the management of outpatient clinics; and
the lack of action taken to minimise outpatient non-attendance.

Understanding Outpatient Activity

Outpatient waiting lists

4. Waiting for an outpatient appointment covers the time a patient waits from seeing a general practitioner until they are seen at an outpatient clinic by a consultant or other healthcare professional. The Committee noted that the waiting list situation had been deteriorating over the past ten years and wondered why there had been no effective departmental response. However, in more recent times, the Department has made progress in reducing waiting lists and waiting times for outpatient clinics led by consultants and its published statistics for March 2007 show that the number of outpatients waiting six months or more for a consultation had fallen from 74,000 in December 2006 to zero. This met the target that no outpatient should wait longer than 26 weeks for a consultation and, while this is still a long way behind the waiting time performance of the National Health Service (NHS) in England, the Department indicated that it was on a par with performance in Scotland and Wales. The Department told the Committee that it owed patients an improvement in the delivery of outpatient services and “held its hands up” that waiting times had been unacceptable in the past.

Recommendation 1

5. The Committee notes the efforts of the Department in shortening waiting times for outpatient appointments. However, there must be a concern that these efforts should not adversely affect the care given to outpatients, particularly, if there is pressure on consultants to spend less time with patients or treat them in different order to clinical priority to meet tight time targets. The Committee looks to the Department to advise managers in Trusts and hospitals of the need for them to work in close cooperation with consultants to ensure that in all cases outpatients receive care which is appropriate to their needs.

6. Outpatient waiting lists entail costs in terms of additional burdens on social care, the welfare system and the Health Service itself as a consequence of the potential additional expense of treating more advanced medical conditions. Above all, longer waiting times have a real impact on the patient’s quality of life. In order to drive down the waiting list backlog, the Department told the Committee it used the independent sector to carry out 43,000 consultations during 2006-07 at a cost of £6.3 million. The Committee recognises that it can be expedient to deal with shortages of capacity in outpatient provision by making use in the short term of the independent sector. However, the Committee acknowledges that using the independent sector as a sticking plaster in this way is potentially demoralising for the Health Service which does the Department’s reputation as a strategic organisation little good.

Recommendation 2

7. The Committee recommends that it is imperative that the focus is shifted from spending on short term waiting list initiatives such as the use of the independent/private sector towards ensuring that the design and capacity of outpatient services are sufficiently developed to keep waiting times down on a sustainable basis.

Outpatient referrals

8. Managing demand for outpatient services relies heavily on the gatekeeper role of the general practitioner (GP). A consultant relies on the judgement and experience of GPs to help decide how quickly to bring an outpatient into a clinic. However, GPs’ referral practices vary widely and this could mean that a proportion of referrals to outpatient clinics may be inappropriate.

9. The Department indicated that as part of its strategy to reform and redesign outpatient services it is taking steps to shape demand expressed through GP referrals. It told the Committee that it was progressively rolling out the introduction of Integrated Clinical Assessment and Treatment Services (ICATS) whereby patients do not necessarily proceed directly from GP to referral. This marks an intermediary stage where a decision is taken on the most appropriate course of action for the individual either by a GP who has a special interest in the area of medical care or by whatever medical professional is running the clinic.

10. Orthopaedics is the pilot for this initiative and has been running since November 2006. Regionally this service sees 1,200 patients a month and the Department expects that 14,000 of the 30,000 referrals made by primary care practitioners will be resolved through ICATS without patients needing to see a hospital consultant. Phase one also includes Urology and Ophthalmology, while Ear, Nose and Throat, Dermatology and Cardiology have been identified as specialties for Phase two. Integral to the initiative is the establishment of an Electronic Referrals Management System (ERMS) which will provide the Department with the ability to oversee the detail of every referral made by a primary care practitioner to a hospital.

Recommendation 3

11. The Committee welcomes the steps the Department is taking to improve referrals and it expects to see the use of ICATS extended to all specialisms where it offers the potential for improvement.

Management information

12. The C&AG’s report indicates that the Department considers its management information on outpatient activity to be of “…the highest standard and among the most advanced in the United Kingdom”. However, while the data available provides a good overview of waiting times at consultant led outpatient clinics, it provides little insight into the efficiency and effectiveness of outpatient activity overall. By its own admission, the Department carried out a census during the C&AG’s review because official statistics did not give an accurate picture of the level of cancelled clinics and the rate of non-attendance by patients.

13. When the Committee questioned the fact that the official statistics showed Down Lisburn Trust with zero non-attendance rates for Cardiology and Accident and Emergency, the Department explained that in the case of Cardiology the data actually related to a small private clinic which operated on the Trust’s estate. As patients were paying for consultations non-attendance was not an issue. For Accident and Emergency, the Department apologised to the Committee that the zero figure for non-attendance was incorrect. The Accounting Officer in his letter dated 27 July 2007 (Appendix 3) stated “that the Trust had incorrectly included fracture patients attending Accident and Emergency for the first time as first outpatient attendances. Departmental guidance requires that such attendances should be recorded as Accident and Emergency attendances in the A&E specialty.” The Trust also incorrectly recorded the number of patients in the Accident and Emergency specialty who did not attend their review appointment. These instances have raised concern within the Committee both about how accurately Trusts are measuring their performance and how effectively the Department is coding this information.

Recommendation 4

14. The Committee recommends that the Department ensures that satisfactory arrangements are maintained for the collection of accurate data on outpatient activity.

15. Despite the progress in reducing waiting times for consultant led clinics, the Committee is disturbed to find that there are substantial numbers of patients (1.7 million) referred to other healthcare professionals who are currently not captured in the official waiting times statistics and a risk that many of them might suffer undue delays in the process. The Committee noted the Department’s acceptance that it was currently leaving out half the information from its official statistics. The data set on outpatient activity produced annually by the Department is in line with that produced by health authorities in the rest of the United Kingdom. The Department said that this was appropriate because there was a requirement to contrast, compare and benchmark performance between the regions in the United Kingdom. However, the Department’s management information systems have not kept pace with new developments in outpatient services and, therefore, do not give a comprehensive view of activity.

16. While there is some utility in the figures produced by the Department, it recognises that these come with a “health warning” attached to the absence of data about clinics run by other healthcare professionals. The Committee was assured that progress is being made in rectifying these deficiencies and that the Department intends to apply the 26 week waiting time target to non- consultant led clinics as well. Monitoring the numbers and length of times involved waiting in these clinics will enable local managers to identify potential “black holes” and allow them to develop practical solutions. Without good management information it is difficult to manage outpatient services well and demonstrate that resources are being used effectively.

Recommendation 5

17. The Committee recommends that the Department should identify the data requirements for managing all outpatient services and ensure that systems are in place to address these.

Improving Attendance at Outpatient Clinics

The scale of non-attendance at outpatient clinics

18. The Committee notes with some concern that almost 400,000 patients for a variety of reasons fail to turn up for their appointments on an annual basis. This is an astonishing statistic. The Department explained that this overstates actual activity lost due to non-attendance because, in practice, Trusts frequently overbook clinics to compensate for patients who fail to attend. The census carried out by the Department showed that the cancellation of clinics by Trusts and the failure of patients to attend appointments actually results in lost activity of over 300,000 patients not seen on an annual basis representing an opportunity cost of around £12 million. While overbooking is used to manage the flow in outpatient clinics, the Department said that it was not to be encouraged as it can create problems for patients and staff, with longer waits at clinics where the non-attendance rate is lower than expected.

19. Among its health service counterparts in the United Kingdom, Northern Ireland has traditionally had the highest clinic non-attendance rate. However, the Department pointed out that at 11.7 per cent in 2005-06, it is within a range of 10 to 12 per cent which covers the rates in the other United Kingdom countries. Following the evidence session, the Accounting Officer provided the Committee with updated statistics for 2006-07 which show that the rate for non-attendance was marginally lower at 11.4 per cent. The Department accepted that the reduction could not be regarded as a success but that slow progress was being made.

20. The failure of almost 12 per cent of outpatients to attend their appointments is wasteful of hospital resources and inevitably impacts on the waiting times of other patients. It is disappointing that the Department’s recent data indicates that to date measures seem to have had little or no effect on the numbers of outpatients not attending for an appointment. The Department has to ensure that it embraces the increased public expectation for responsive outpatient services built around patients’ needs. A significant element in securing the achievement of this goal should be reduced wastage from cancelled clinics and missed appointments and most importantly, outpatient services which are long on quality and short on waits.

21. The Department told the Committee that it does not intend to introduce target setting between itself and Trusts for the reduction of non-attendance rates. Its focus will remain on the strategic target of patient waiting times. However, reducing non-attendance rates remains a key objective for outpatient services and the Department told us that it expects partial booking to help drive non-attendance down. The Committee believes that target setting is a basic precondition to the effective management of this process and the basis for accountability for achieving such an outcome. The Committee notes that targets related to the reduction of outpatient non-attendance levels are already “common” practice among Trusts in Great Britain.

Recommendation 6

22. In order to stimulate action in Northern Ireland, the Committee recommends that Trusts should adopt challenging but achievable reduction targets tailored to the levels of non-attendance experienced by their outpatient clinics.

Variation in non-attendance rates

23. Non-attendance is a widespread problem which does not lend itself to easy answers. Figure 5 of the C&AG’s report shows that there can be extreme variations in rates of non-attendance between hospitals and specialties. One incredible feature of the data is that the Mater Hospital Trust, which covers a catchment area of high social deprivation in Belfast, features in four of the ten specialties with the highest non-attendance levels. The Committee noted the Department’s acknowledgement that the figures were a cause for concern. In particular, it was astonishing to discover that almost 20 per cent of patients with heart problems failed to turn up for appointments at this Trust. Following the evidence session, the Accounting Officer provided the Committee with updated data which showed that, while things had improved in some of these areas, one had actually got worse. The Committee was staggered to learn that, after contacting senior management at the hospital, the Department could still provide no detail on the reasons for the poor performance of the Trust. Ironically, the same Trust was also included in the list of top ten performers with a lowest non-attendance rate in Trauma and Orthopaedic surgery. This would suggest that evidence for the influence of demographic data on non-attendance is inconclusive but requires detailed investigation.

24. Patient non-attendance is a source of dissatisfaction for staff and patients. It is also a drain on the scarce resources of staff time and capital equipment. The Committee welcomes the Department’s recognition of the importance of following up the reasons for patient non-attendance. If outpatient services are to be as patient focussed as possible, Trust managers need to have an informed view of the reasons for non-attendance.

Recommendation 7

25. In the drive for improved outpatient attendance rates the Committee recommends that the development of more sophisticated methods to understand the roots and demographics of non-attendance should be a priority. One way of obtaining information on this would be to undertake surveys of patients who do not show up for appointments. The Committee also expects the Department to closely monitor the position at the Mater hospital in view of its particularly poor attendance rates.

Patients and non-attendance

26. The non-attendance rate in hospital outpatient clinics is a widespread problem and complicates appointment scheduling. Moreover, it is a cause of inefficiency due to the lost staff time which could be spent providing services to other patients and wasted capital equipment. The Committee understands the causes for non-attendance can be many and has seen that it can vary between hospitals and clinics. This is partly due to inadequate administrative processes on the part of hospitals, however, the Committee recognises that patient factors, such as forgetfulness or apathy, can also be important.

Recommendation 8

27. The Committee urges patients to take greater responsibility for their part in running the Health Service. If an appointment is missed it is their taxes that are being wasted. At a time when many Trusts are facing financial difficulties, it is important that patients understand this and try to keep their outpatient appointments. The Department may need to consider further measures to deal with persistent non-attendance.

Non-attendance in mental health outpatient clinics

28. Appendix four of the C&AG’s report shows that different specialties/illnesses have different rates of non-attendance. In particular, the Committee drew the Department’s attention to the fact that the highest rate of non-attendance was among patients with appointments for clinics dealing with mental illnesses. Indeed the Department indicated to the Committee that the worst three performers identified in the C&AG’s report were clinics for mental health and were at Alexander Gardens Day Hospital, Whiteabbey Hospital and Gransha Hospital.

29. In terms of the past problems of attendance experienced within the mental health sector, the Department agreed with the Committee that it must work on ways to improve this. The Committee was told that the non-attendance of mental health outpatients would be considered within the wider range of issues covered by the Bamford Review. The Department also explained to the Committee that, to provide these vulnerable patients with greater support at primary care level, an intervention to improve depression awareness training for GPs was being rolled out.

Recommendation 9

30. The Committee expects the Department to ensure that there is a maximum take up of the depression awareness scheme by GPs.

31. Mental health patients are a vulnerable group who have very varied needs. The Accounting Officer stated in his letter of 27 July 2007 (Appendix 3) that “clearly it is not acceptable that some of the most vulnerable people in our society can be allowed to slip through the net by failing to attend appointments which could be crucial in the management or treatment of their conditions”. The Committee is disappointed that the Department failed to give any commitment about the setting of time limits and targets for reducing the 20 per cent non-attendance among mentally ill patients. The Committee considers that in the area of mental health there is a special onus on the Department, rather than patients, to take responsibility. It welcomes the subsequent assurance from the Accounting Officer that tackling mental health problems is one of his highest priorities.

Recommendation 10

32. Given the incidence of non-attendance by outpatients with mental health problems, the Committee believes it is crucial that greater priority be given to this group of patients. The Committee recommends that as a matter of urgency, the Department takes steps to clarify the reasons for the high rate of non-attendance among mental health patients. Moreover, the Department needs to demonstrate its capacity for overseeing the proper management of mental health outpatient services by setting a target for reducing the current level of non-attendance and monitoring performance against this target.

33. Part of the problem, as the Department saw it, was a capacity problem connected with the number of people who are prepared to enter into the specialty. It seemed to the Committee that this was likely to be the result of a lack of foresight in planning for the number and type of staff required.

Recommendation 11

34. The Committee recommends that the Department examines closely ways of increasing the capacity of health service provision for services to mentally ill patients in order to overcome the imbalance of appropriately skilled staff.

Dissemination of Best Practice

35. With almost 50 different outpatient departments spread across the Trusts, there should be considerable scope to share and promote good practice in dealing with non-attendance. The operational management of outpatient services lies with the clinical directorates within Trusts. This has the advantage of encouraging a sense of ownership of services among staff and of facilitating innovations in service. On the negative side this can lead to directorates becoming insular both with their own Trust and in their relationships with other Trusts. The Department told the Committee that, in the past, it had relied on the informal sharing of information and benchmarking among Trusts. However, in the absence of a central presence within Trusts championing outpatient services there was a danger that best practice may not have been spread as effectively as it might. Therefore, the Committee welcomes the recent establishment of an Outpatient Improvement Manager Network across Trusts. This Network meets on a fortnightly basis with the Department to share best practice and discuss challenges such as cancelled clinics and missed appointments.

Recommendation 12

36. The Committee considers this arrangement to be a potential model which could be applied by the wider public sector as a way of addressing similar issues and ensuring that successful approaches to common problems can be effectively disseminated. The Committee believes this should be a model for dealing with similar operational problems in the wider public sector and recommends its use where sharing good practice is important.

37. The Committee asked the Accounting Officer about models used for managing outpatient clinics elsewhere, including Europe. In particular, the Committee was aware of an example in England called “choice appointments” where new referrals and patients requiring follow up appointments are given an appointment on the same day that they ring to request it. The Committee was told that the Department had no knowledge of this example but agreed it was the kind of research it must be aware of.

Recommendation 13

38. The Committee urges the Department to ensure that it keeps abreast of new developments regarding the handling and timing of outpatient clinics. This can be done by networking with other health departments in Great Britain, through its contacts with the Republic of Ireland and further afield.

The introduction of partial booking

39. The Department told the Committee that it considers the biggest cause of non-attendance to be people forgetting or missing appointments because they are made so far in advance. In order to deal with this problem it introduced a new partial booking system in September 2006. This system had already been in operation in England since 2000, Wales from 2001 and Scotland from 2004. The Committee noted that it has not been universally accepted. Under partial booking, appointments are negotiated via phone-call with patients who have been scheduled to be given appointments. For instance, if for whatever reason a patient on a waiting list decided to go private, the Department would hope that the process would give the patient ample opportunity to indicate that he/she no longer needed an appointment and could be removed from the waiting list. The Department expects this approach to booking appointments will result in improved communication with patients and in turn reduce the number of patients who fail to attend for appointments. Acknowledging that communications needed to be improved, the Department told the Committee that communication was an area where it “wanted to turn the corner and move forward to bring about a patient centred system that maximises good communication with patients”. The Department also told the Committee that as it completed restructuring it was necessary to ensure that services are joined up properly.

Recommendation 14

40. The introduction of partial booking is welcome but long overdue. The Committee recognises that more time is needed for the new system to realise its potential benefits for outpatients. The Committee shares the Department’s hope that it will lead to an improvement. The Committee recommends that the Department keeps the operation of partial booking under review and evaluates the extent to which it is having the cumulative effect of falling waiting times, fewer patients not attending and reduced overbooking.

Timing of clinics

41. The Committee asked if the Department had considered organising clinics outside the normal hours of 9.00am and 5.00pm as a way of helping to reduce the likelihood of non-attendance. The Department told the Committee that, traditionally, few clinics had been held outside this time period. However, during the initiative to achieve the 26 week waiting time target, much of the extra work was undertaken in the evenings and weekends. In moving to further reduce the waiting time target to 13 weeks, the Department considered there was likely to be a continuing need to hold clinics outside the standard hours. The Department had no information on whether the timing of clinics was a cause of non- attendance but considered it a less likely reason than simply not being given a choice of appointment.

Recommendation 15

42. The Committee expects the Department and Trusts to be able to demonstrate that they are taking account of patient preferences about the timing of clinic appointments and that existing patterns of delivery are reviewed to ensure that they represent the most efficient and effective use of resources.

Improving the Efficiency of Outpatient Clinics

Cancellation of appointments by Trusts

43. The C&AG’s report shows that around 60,000 outpatients have their appointments cancelled by Trusts. This is disruptive to patients and suggests poor planning. The Committee expressed concern that in its experience some cancellations can be due to poor administrative procedures and coordination in the appointment process. The Department commented that in its view this was not a major problem but accepted that this was a matter for local management to get right. It hoped that the introduction of a new Electronic Referrals Management System (ERMS) would improve any problems in this area.

44. A more significant element in the cancellation of clinics is the role of consultants. The Department referred to an earlier report by the Northern Ireland Audit Office, “Private Practice in the Health Service” (May 2006), which highlighted the lack of clarity around the relationship between consultants’ private and public work and the potential lack of accountability. The Department told the Committee that under the terms of a new contract, introduced in 2004, consultants have a job plan setting out their work commitments as agreed with the employing Trust. The Accounting Officer assured the Committee that where outpatient commitments in this plan were not honoured by consultants this was largely due to sick leave and clinics cancelled would be re-booked. He explained that in the past, the reasons for cancelled clinics had included unplanned leave by consultants. However, he told the Committee that the system was tightened up in 2003 to ensure that six weeks’ notice had to be given for annual leave and that there was no evidence of any pattern of unplanned leave leading to the cancellation of clinics.

45. The Department also told the Committee that action was taken to try and halt the rising trend in clinic cancellations during the period covered by the C&AG’s report but this proved to be ineffective. However, it was encouraged by figures for 2006-07 which show that there had been a small fall in cancellations and hoped that this would lead to a downward trend. The Department pointed out to the Committee that outpatient activity lost through cancellations amounts to 2.3 per cent of all appointments and, as such, considered it hard to reach a lower figure.

46. While the level of cancelled outpatient clinics is 2.3 per cent, further improvement will contribute to meeting waiting time targets. The Committee, therefore, urges the Department to ensure that, with the introduction of partial booking, outpatient clinics are organised as productively as possible. Partial booking is about redesigning outpatient services more around the needs of patients. Providing greater choice for patients will only be a smokescreen if clinics are continually cancelled once patients have chosen their date. Patients want certainty, not a system that promises a date and then lets them down.

Clinic cancellation and private practice

47. Over 8,000 clinics are cancelled by Trusts on a yearly basis. The Committee accepts that there can be good reasons in some circumstances for this happening, for instance, sick leave among consultants. However, the Committee is concerned that there is a perception that the private practice commitments of consultants may have some impact on whether clinics actually take place. While there is no doubt that the majority of consultants operate to the highest professional standards, it must also be recognised that there can be a potential conflict between these two elements of consultants’ work.

48. The Committee questioned the Department on the potential for the cancellation of clinics to result from consultants undertaking private consultations which impinged on their health service work. The Department told the Committee that that the new contract forbade this and that the private activities of consultants were written into their job plans. If consultants failed to fulfil their commitments to the Health Service they would be in breach of contract and liable to be disciplined. However, the Committee believes there is a need for greater assurance that Trusts are able to hold consultants properly to account concerning their private practice work. It is essential that the systems monitoring the working patterns of consultants are robust enough to ensure that that their valuable contracted time is being used effectively within the Health Service.

Recommendation 16

49. The Committee welcomes the fact that the Department is making strides in putting in place management information systems which allow it to track the performance of consultants and their outpatient activities. It is clearly desirable that existing problems and developing trends can be quickly identified. The Committee would like a clear account from the Department setting out precisely how the information collected on consultants’ workload is monitored and verified to ensure that private practice does not lead to the cancellation of clinics or any other abuse.

50. The Department assured the Committee that, if job plans were to be habitually distorted by the actions of any consultants, there were disciplinary procedures in place which could be brought to bear by Trust management.

Recommendation 17

51. The Committee would like detailed information on the extent to which disciplinary procedures have been used against consultants in each of the past five years and how many of these cases related to accountability for outpatient clinics.

52. When questioned on the pooling of patients as a way of limiting the effects of cancelled clinics, the Department told the Committee that pooling happens within outpatient clinics where possible and is on the increase. It also confirmed that the impact of cancellations in single handed clinics shows that they are part of the problem.

Recommendation 18

53. The Committee considers that pooling can increase confidence among patients that appointments will be kept and urges the Department to actively promote its use throughout the range of outpatient specialties.

Appendix 1 Minutes of Proceedings of the Committee Relating to the Report

Thursday, 28 June 2007
Senate Chamber, Parliament Buildings

Present: Mr John O’Dowd (Chairperson)
Mr Roy Beggs (Deputy Chairperson)
Mr Jonathan Craig
Mr John Dallat
Mr Simon Hamilton
Mr David Hilditch
Mr Trevor Lunn
Mr Patsy McGlone
Mr Mitchel McLaughlin
Ms Dawn Purvis

In Attendance: Mrs Cathie White (Assembly Clerk)
Mrs Gillian Lewis (Assistant Assembly Clerk)
Mrs Pauline Hunter (Clerical Supervisor)
Mr John Lunny (Clerical Officer)

Apologies: Mr Willie Clarke

The meeting opened at 2.00pm in public session.

3. Evidence on the NIAO Report ‘Outpatients: Missed Appointments and Cancelled Clinics’

The Committee took oral evidence on the NIAO report ‘Outpatients: Missed Appointments and Cancelled Clinics’ from Dr Andrew McCormick, Accounting Officer, Department of Health, Social Services and Public Safety (DHSSPS), Dr Michael McBride, Chief Medical Officer, DHSSPS, and Mr Dean Sullivan, Director of Planning and Performance Management, DHSSPS. The witnesses answered a number of questions put by the Committee.

The Chairperson raised the issue that it was the convention that no comment should be made by the Accounting Officer and Departmental Officials regarding NIAO reports in advance of a PAC hearing.

Mr Thomson, TOA, agreed to write to all Accounting Officers reminding them of the convention.

[EXTRACT]

Thursday, 6 September 2007
Room 144, Parliament Buildings

Present: Mr John O’Dowd (Chairperson)
Mr Roy Beggs (Deputy Chairperson)
Mr Jonathan Craig
Mr John Dallat
Mr Simon Hamilton
Mr David Hilditch
Mr Trevor Lunn
Mr Mitchel McLaughlin
Ms Dawn Purvis

In Attendance: Mrs Debbie Pritchard (Principal Clerk)
Mrs Cathie White (Assembly Clerk)
Mrs Gillian Lewis (Assistant Assembly Clerk)
Mr John Lunny (Clerical Officer)

Apologies: Mr Willie Clarke
Mr Patsy McGlone

The meeting opened at 2.05pm in public session.

2.25pm The meeting went into closed session.

7. Consideration of Draft Committee Report on Outpatients: Missed Appointments and Cancelled Clinics

Members considered the draft report paragraph by paragraph. The witnesses attending were Mr John Dowdall, C&AG and Mr Barry Edgar, Assistant Auditor General.

The Committee considered the main body of the report.

Paragraphs 1 – 3 read and agreed.

Paragraph 4 read, amended and agreed.

Paragraph 5 read and agreed.

Paragraph 6 read, amended and agreed.

Paragraphs 7 – 12 read and agreed.

3.21pm Mr Dallat left the meeting.

Paragraphs 13 – 15 read and agreed.

Paragraph 16 read, amended and agreed.

Paragraph 17 read and agreed.

Paragraph 18 read, amended and agreed.

Paragraph 19 – 22 read and agreed.

Paragraph 23 read, amended and agreed.

Paragraph 24 read and agreed.

Paragraph 25 read, amended and agreed.

Paragraphs 26 read and agreed.

Paragraph 27 read, amended and agreed.

Paragraphs 28 - 30 read and agreed.

3.43pm Mr Hamilton left the meeting.

Paragraph 31 read, amended and agreed.

Paragraphs 32 – 35 read and agreed.

3.47pm Mr Hamilton rejoined the meeting.

Paragraphs 36 – 39 read and agreed.

Paragraph 40 read, amended and agreed.

Paragraphs 41 – 45 read and agreed.

Paragraph 46 read, amended and agreed.

Paragraph 47 – 53 read and agreed.

The Committee considered the Executive Summary of the report.

3.57pm Mr Hilditch left the meeting.

Paragraph 1 read and agreed.

Paragraph 2 read and agreed.

Paragraphs 3 – 5 read and agreed.

Paragraph 6 read, amended and agreed.

Paragraphs 7 – 8 read and agreed.

4.02pm Mr Hilditch rejoined the meeting.

Paragraphs 9 - 14 read and agreed.

Agreed: Members ordered the report to be printed.

Agreed: Members agreed that the Clerk’s letters to Dr Andrew McCormick requesting additional written information and Dr McCormick’s replies would be included in the Committee’s report, together with Outpatient Activity Data for Northern Ireland 2006/2007 and 2005/2006; the remaining papers will be laid in the Assembly library.

Agreed: Members agreed to embargo the report until 10.00am on Thursday, 27 September 2007, when the report would be officially released at a press conference.

Agreed: Members agreed that in future when substantial information is received the Clerk will inform the Committee that the documents will be available for members to view in the Committee office.

[EXTRACT]

Appendix 2 Minutes of Evidence

Thursday, 28 June 2007

Members present for all or part of the proceedings:
Mr John O’Dowd (Chairperson)
Mr Roy Beggs (Deputy Chairperson)
Mr Jonathan Craig
Mr John Dallat
Mr Simon Hamilton
Mr David Hilditch
Mr Trevor Lunn
Mr Patsy McGlone
Mr Mitchel McLaughlin
Ms Dawn Purvis

Also in attendance:
Mr John Dowdall CB, Comptroller and Auditor General
Mr David Thomson, Treasury Officer of Accounts

Witnesses:

Dr Michael McBride
Dr Andrew McCormick
Mr Dean Sullivan

Department of Health, Social Services and Public Safety

The Chairperson (Mr O’Dowd): Before we begin formal proceedings, I ask Members and visitors to switch off all mobile phones. Please do not turn them to silent, as the proceedings are being recorded and, even on silent mode, mobile phones interfere with the recording.
There is only one apology, and that is from Mr William Clarke; everyone else is here.
The next item on the agenda is the Comptroller and Auditor General’s report on ‘Outpatients: Missed Appointments and Cancelled Clinics’. We welcome Dr Andrew McCormick, Accounting Officer of the Department of Health, Social Services and Public Safety. Dr McCormick, please introduce your colleagues to the Committee.
Dr Andrew McCormick (Department of Health, Social Services and Public Safety): With me are the Chief Medical Officer, Dr Michael McBride, and Mr Dean Sullivan, who is currently the director of the service delivery unit of the Department of Health, Social Services and Public Safety (DHSSPS), but who, previously, was in charge of the secondary care directorate.
The Chairperson: Today’s proceedings will begin with my putting questions to you; we will then go around my Committee colleagues. We will have a question-and-answer session. I will begin the questioning.
Paragraph 2.7 of the Auditor General’s report highlights a worrying gap in management information for outpatient services; your recent census shows that half of outpatient activity is not officially recorded. That is a serious matter, and I would like you to explain how the Departments apply a whole-system approach to outpatient services and ensure efficient service delivery, when the total population being dealt with is not known or recorded.
Dr McCormick: We record a range of information. The key point is that the statistics that we produce, on which most of the report is based, are on a consistent basis with those in the rest of the UK. Therefore the korner series, as it is called, of statistics are for consultant-led clinics. We have emerging information databases that we are developing and are working on at the moment to cover community-based clinics.
The Minister of Health, Social Services and Public Safety is about to announce targets to reduce waiting times for clinics that are led by allied health professionals (AHPs) and others. That announcement is imminent and will bring those targets into line with the rest of the outpatient targets.
We have achieved the target for outpatient waiting times for consultant-led clinics. The number of patients waiting to be seen at those clinics had been very high. That number was reduced from 180,000 in March 2006 to 102,000 in March 2007. That included seeing 70,000 people who had been waiting for more than six months. We achieved the six-month target in March 2007. The intention now is to have a waiting-time target of 26 weeks for all outpatients, which will then be reduced to 13 weeks.
I agree with you that it is important not to leave out half of the information. We are working on that by setting new targets. In the next few days, the Minister will be making an announcement setting a target for AHP-led clinics and those led by other professionals, so that all outpatients are getting attention and access as soon as possible. That is a multi-disciplinary system. It is important that all the teams work together and that patients get what they need as quickly as possible.
The Chairperson: Are you bringing in a system that will record the number of clinics and appointments in those other sectors, and that will give you accurate figures across the board?
Dr McCormick: We need that information to monitor the targets. One of the most important things that we have done in the past couple of years is take a big step in performance management. Success in that depends, fundamentally, on good information. On Monday, I saw a demonstration of a portal showing how we can have up-to-date weekly information for accident and emergency clinics on a real-time basis. The portal is for trust management, mainly, to use and draw on the fundamental information base of a hospital and the community, to monitor what is going on, and to ensure that we meet those targets and deliver improvement in services. Given that waiting times have not been acceptable, we owe people an improvement in the service. We hold our hands up to that. However, progress is being made, and we are seeking to secure that across the full range of services.
The Chairperson: The figure quoted in the report estimates that approximately £12 million a year is wasted as a result of people not attending clinics and clinics being cancelled. Why was that situation allowed to continue for so long? Why did the Department not tackle the issue sooner?
Dr McCormick: As you say, the problem has been around for a long time, and we have sought ways in which to address it. The biggest cause of non-attendance is that people forget or miss appointments because they are made so far in advance. Recently, we adopted a new procedure called partial booking. That means that if the waiting time is six months, for example, instead of getting an appointment out of the blue — a letter in the post asking a patient to turn up at a certain time — the patient will get a phone call to agree an appointment time six weeks before the appointment is due. The patient is consciously involved in making the appointment and therefore much less likely to forget. It is also less likely for the appointment time to be unsuitable. Introducing that procedure has been one of our biggest steps. It is primarily to improve the service to patients, and we expect it to have the effect of reducing non-attendances. People will be more aware of their appointments, and there is less chance of people’s circumstances changing or for them to forget if the waiting time is reduced.
The Chairperson: Following on from that, regarding partial booking and schemes that have been introduced in an attempt to improve the system, the figure on page 31, Appendix 4, breaks down in categories the highest rates of non-attendance in various clinics, for example audio and visual impairment clinics.
The highest rates of did not attends (DNA) come from the group that includes some of the most vulnerable people in society — those who suffer from a mental health illness. Is the Department working directly with mental health advocacy groups or with people who have mental health problems to improve attendance? Those who suffer from a mental health illness do not and cannot regulate their own lives, so we have to assist them as best we can. Is the Department working with that group?
Dr McCormick: The Department will be developing a major strategy on mental health, as recommended in the Bamford Review, and part of that will involve consultation with the groups that you mentioned. We must ensure that those who suffer from mental health illnesses receive adequate support from their families and community, and from the mental health professionals. As you say, when one considers the nature of those people’s illnesses, it should come as no surprise that they are least likely to attend clinic appointments. That is why their DNA rates are so high.
It is important that as the Department’s response to the Bamford Review is developed, and as mental health initiatives are taken across the whole service — especially in the community —the focus of mental health service delivery is shifted. For too long, that service has been delivered through a hospital-based system, but that must be changed so that people are supported and helped in a community context or in their own environment. It is important that the reasons for a patient’s non-attendance are followed up, and we must ensure that they attend subsequent appointments.
More than anything, people with mental illness need the attention and intervention of professionals. The Department cannot accept the situation in which people with mental health illnesses are considered to be less likely to attend appointments. We must work on ways to improve that, as the Chairperson has said.
The Chairperson: Does the Department have a timescale and a target for reducing DNA rates? If so, please explain what it is, because the mental health sector of the Health Service is under severe pressure. It is imperative that people in that sector attend appointments and that emergency cases are dealt with. We are constantly hearing stories of people threatening to take their own lives and being unable to access services.
Dr McCormick: It is work in progress. The Department has no specific timetables or targets to set now. Some of those will depend on the Department’s response to the Bamford Review and on the resources that are still to be determined as part of the comprehensive spending review. Targets are a major part of what we are working on, but there is nothing specific afoot that I can talk about now.
The Chairperson: Therefore the Department has not set itself targets or timelines. The Bamford Review comprises many individual reports, but the problem is glaringly obvious: there is a 20% non-attendance rate at clinics by some of the most vulnerable people in society. The Department should not need any more details or the full conclusions of the 11 Bamford reports. The problem is there for all to see. Can the Department not say that it will reduce the DNA rate to 10% and set out how it will achieve that?
Dr McCormick: The focus of attention has not been on mental health DNA rates; it has been on a wider range of demanding strategic issues such as the workforce and the number of people who are prepared to enter into such specialties. Developing a strategy to get enough people to provide the help is a crucial part of tackling the problem. It would not be sufficient for the Department to base its response solely on the DNA rate: that is an important manifestation of the problem, but the Department is trying to get a strategy that will tackle the problem root and branch. I am sorry that I do not have a more substantive answer on that point.
The Chairperson: I hate to labour the point, but when will the Committee see the strategy — will it be in one, two or three years’ time?
Dr McCormick: The strategy will be part of the Department’s response to the Bamford Review, and it will not be possible to finalise it until the comprehensive spending review is completed. The Department hopes to have a strategy in place as soon as possible after December 2007, because it is one of the Minister’s highest priorities.
The Chairperson: Thank you. That ends my questions for now. Jonathan Craig will begin questions from members.
Mr Craig: Dr McCormick said that the Department achieved the target of the six-month maximum waiting time in March 2007. That is all well and good, but how does that compare with other parts of the United Kingdom? He also referred to the number of people who do not turn up for referrals. Have the incredibly long times that some people have had to wait for appointments contributed to that phenomenon?
Dr McCormick: I accept the Member’s second point; long waiting times have been a major part of the problem. The Department is still well behind the level of performance in waiting times achieved in England. Our performance is broadly comparable to that of Scotland and Wales in that our figures are in a similar ballpark area. Departments in Scotland and Wales set a similar range of targets to those set by DHSSPS.
In England, the system is moving towards an 18-week referral timetable that will embrace outpatient, diagnostic and inpatient services. That is a very ambitious target, but it is the right thing to do from the patient’s point of view. We would love to get there; the Department is working to progress from a very poor performance to a better one. In the longer term, we aspire to the English level of performance, which is going from good to great.
Like Northern Ireland, the six-month target has been achieved in Scotland, and an 18-week target has been set for March 2008. Wales is considering setting a similar comprehensive target to that in England; to date, Wales has achieved a target of eight months. Northern Ireland is on a par with, or perhaps slightly ahead of, Wales, although I would not boast about that. We are concentrating on trying to make an improvement for Northern Ireland’s population. That has been the Department’s dominant priority over the past couple of years.
Mr Craig: In future, the Department will aim for better targets. The other aspect of the report that concerned me has already been mentioned by the Chairperson. There appear to be no figures for outpatients receiving non-consultant-led services. In the back of my mind, I wonder whether the Department has been offloading work from consultant-led services to non-consultant-led services. In some cases, that is a natural progression. However, if the Department is not recording non-consultant-led outpatient services, are they perhaps being offloaded to another sector? Do you have any figures on that?
Dr McCormick: The Department’s approach is to ensure that patients receive the attention that is most suitable for their needs and circumstances. That is not offloading work; it is improving services. The Department intends to proceed with the extension of integrated clinical assessment and treatments services (ICATS), whereby patients do not necessarily proceed directly from GP referral to consultant. If such a progression is the right thing for the patient, that will happen.
Through ICATS, there will be an intermediary stage where a decision is taken on the most appropriate course of action for the individual. For example, should a patient proceed to diagnostic testing or go straight into a treatment regime? That is decided, through ICATS, by a GP who has a special interest in the subject or by whoever is running the clinic. Where it is appropriate for patients to go straight to a consultant, they will be placed on the consultant’s waiting list. The ICATS initiative will reduce waiting times and waiting lists, and patients will get a better service and receive responses that are more appropriate to their needs. That is part of the reform and redesign that we are trying to achieve.
Information and monitoring systems will be in place as the Department seeks to develop and apply targets for non-consultant-led clinics. Some information is already available through the census that was undertaken as part of the NIAO report. That has provided some information about the performance of non-consultant-led clinics. However, as the Department sets and monitors those targets, there will be regular, up-to-date and systematic information on clinics led by allied health professionals, for example.
Mr Craig: I do not criticise the Department for moving patients from one sector to another. I am slightly concerned that, if the Department is moving work from a monitored sector to one that is not monitored, it may simply be moving the problem elsewhere. The new statistics that will be recorded in the future will reveal that.
Paragraph 1.2 of the report refers to the reduction in waiting times. How much of that improvement was due to the independent private sector? How much did it contribute to the improvement, and were significant costs incurred?
Dr McCormick: Yes, the independent private sector was a significant factor in the improvement. Mr Sullivan will provide the Committee with the detailed facts on the additional expenditure and the numbers that are involved.
The Health Minister had given us clear direction on achieving targets in order to provide a more prompt service to the public. The use of the independent sector was a matter of securing capacity — not long-term capacity, but securing a steady position — in order to continue to deliver low waiting times and fully eliminate problems. However, there was a serious backlog, and after we examined the facts and figures, we decided that the only way to draw on additional capacity was to procure it through the independent sector.
Mr Dean Sullivan: During 2006-07, in the course of achieving the targets set by the Minister for a six-month maximum outpatient waiting time, the total number of outpatients who were waiting fell from approximately 180,000 to just over 100,000 — representing a reduction of just under 80,000. During the same period, the number of patients who were waiting for more than six months for an outpatient appointment fell from 74,000 to zero.
More than half of those reductions were secured by using the existing capacity of the trusts, but we bought approximately 43,000 outpatient assessments from the independent sector in 2006-07, at a cost of £6·3 million. As Dr McCormick said, that was necessary because we had a significant backlog to address in a relatively short period of time. Although the Health Service was able to gear itself up to make a substantial dent in that backlog, it would not have been realistic — or possible in some specialties, such as plastics or orthopaedics — for it to have addressed that backlog alone in the time that was available.
Mr Craig: A significant amount of investment went into reducing the backlog. However, you met the targets. Are you absolutely content that that money was well spent? Were there any reforms in the existing system that could have brought about the same level of change?
Dr McCormick: A consistent approach was always taken to putting internal teams to the test. Those teams were under considerable pressure, and they rose to the challenge in a range of ways to make dramatic progress in a short space of time. However, when the team had pushed those efforts to the limit and found that there was no other way forward, we judged that buying independent outpatient assessments was the right thing to do, bearing in mind the best interests of the patients, who are best placed to decide whether such investment is worthwhile. We sought to ensure that the additional cost was kept to a minimum, but that investment was an important part of the intervention.
Mr McLaughlin: It is good to see you, Andrew. We have worked together before in different capacities.
The outcome of the initiative was that the set targets were met. I have questions on two resulting impacts of that. First, did a pattern of aftercare difficulties arise? Presumably, the independent team were something of a flying squad that came in, carried out the procedures, left, and then the Health Service picked up the thread. Has there been a pattern of difficulties in aftercare for patients who were treated in that way?
My second question concerns a longer-term strategic concern. Is the Health Service encouraged or discouraged from dealing with the gaps in capacity that continue to exist?
Dr McCormick: The figures that Mr Sullivan provided related to outpatient referrals. Therefore that was not a question of treatment. In parallel, over the same period, we have been using some independent-sector flying squads, to use your term, to deal with some backlogs. That is for inpatient treatment, rather than for the outpatient element with which we are mainly dealing today.
In order to meet the inpatient targets, we must ensure that we plan capacity properly. Part of the job of managing and planning for the entire health and social care service is to ensure the best possible match between the different types of need, and to ensure sufficient capacity.
We have learned a lot from this exercise about where, both on the inpatient side and in outpatient referrals, the capacity gaps are — Mr Sullivan has already mentioned one or two of those — and the exercise will inform the workforce planning and service development needs as we go forward. We do not plan to rely on the independent sector for the long to medium term.
Mr McLaughlin: Figure 2 and paragraph 2.5 of the Audit Office report provide a fairly comprehensive picture of the level of cancelled clinics and missed appointments. What has been learned about the main reasons for cancelled and missed appointments? How are those lessons being applied to target problem areas?
Dr McCormick: The table in figure 2, which was produced with the Audit Office’s consent as part of the study, is very enlightening because it helps us to understand the extent to which cancellations and non-attendance led to lost activity.
The figure for the number of cancelled clinics is relatively small. It is smaller than the figure in the published statistics because the census of outpatient activity revealed that, on the system from which the statistics are drawn, quite a few clinics were recorded as cancelled that had been subject to only a minor change. Minor rearrangements could trigger the cancellation indicator on the computer system so that, even if the clinic were reinstated the next day, it would still show up as cancelled. The table in figure 2 shows that the total number of cancelled clinics was projected to be 5,328 for the acute sector and 8,232 overall. That shows that the proportion of cancelled clinics is quite small.
The reason for cancellations is, we understand, mainly to do with factors such as sick leave, which by definition cannot be predicted —
Mr McLaughlin: Sorry, it is mainly due to what?
Dr McCormick: Mainly, the reason is that the consultant fell ill and could not carry out the clinic. In the past, the reasons for cancellation included annual leave and study leave as well as sick leave. In the light of previous investigations, we have tightened up the system since 2002 to ensure that, for planned events such as annual leave and study leave, notice must be given six weeks in advance. That means that fewer clinics are now cancelled for those reasons
There will, however, always be a residual number of situations in which, at the last minute, the people responsible for providing the clinic are not available because of force of circumstances. That is especially true in the context of a dispersed service in which some clinics have a single consultant. That is part of the circumstance that we are working in. The total cancellation rate of 2·3% that is shown in the table is not a very large number. Inevitably, there will always be some cancellations.
The main reasons for non-attendance are that the patient forgets the appointment, the patient’s symptoms or circumstances change or there is a change of need. The research that is mentioned in the report shows that people in deprived areas have a greater tendency not to attend. The point that the Chairperson made about poor mental health being a known cause of non-attendance has also been well researched.
The table in figure 2 helps us to understand that the headline figures for non-attendance that appear in the published statistics overstate the problem with regard to the actual loss of activity. The column showing the number of patients not seen is the measure of activity that is lost to the system as a consequence of non-attendance. Given that there is a pattern of overbooking, the actual activity lost in the census week was only 7·4%, whereas the figure for non-attendance was 13·9%.
Even if the headline figure for non-attendance was high, the figure for loss of activity was lower because the clinics had been overbooked. That is all part of trying to manage the process to ensure that there is as much real activity as possible and that as many patients as possible are seen.
Mr McLaughlin: Does overbooking continue to happen?
Dr McCormick: It is a double-edged sword. It is not to be widely encouraged because it produces administrative activity and, more importantly, could result in too many patients turning up for appointments. Overbooking is part of current practice, as the census shows, and it works insofar as it reduces the loss of activity. However, we must be very careful about adopting that practice, and it is not used as much as it used to be.
Mr McLaughlin: Has a threshold of permissible overbooking been established?
Dr McCormick: We must allow that decision to be made locally, because the circumstances and context of service delivery are quite diverse. There is no one-size-fits-all approach. We have to allow the clinical teams to judge what they can reasonably do, because outpatient referrals cover such a wide range of different activities.
Mr McLaughlin: We may have to return to that issue.
Figure 2 and paragraph 2.5 of the Audit Office report indicate that the cancellation of acute clinics for surgical and medical patients could well affect those patients with urgent needs. What checks and balances exist within trusts to ensure that those patients with urgent needs retain priority status?
Dr McCormick: Assessing the urgency of patients’ needs is always a matter of clinical judgement, and that has to be handled locally. It is up to the individual trust and hospital administration to oversee the flow and management of the system in such a way to ensure an appropriate and speedy response to urgent cases. It must also ensure that the response has the least possible effect on elective and planned care. We must find that balance. That task must be carried out locally, and skilled and effective management throughout the various organisations is essential to handle that responsibility effectively.
Mr McLaughlin: What does experience of that local approach tell the Department about its effectiveness? Are there variations in the judgements that are being made? Have there been complaints, and, if so, have the complaints been concentrated in certain areas?
Dr McCormick: We do not have a vast amount of detail on that. The clinical judgements are best made locally, and I would not want the Department to interfere with clinical judgement.
As regards the broader systems issues, the focus and attention has been on securing an improvement in access times and ensuring that that is accompanied by good and effective management of urgent care. The Department is also developing and imposing strong performance management targets for urgent care. There are clear targets for accident and emergency and the different specialties that affect the response to urgent need. The Department is responsible for strategic management. It is then up to the individual organisations to respond and ensure that they deliver — the detail of how they deliver are a matter for them.
Mr McLaughlin: Paragraph 2.8 of the report refers to the establishment of arrangements for monitoring the performance of a range of non-consultant-led outpatient clinics for 2007-08. Why not monitor all the clinics? The census provides a fairly comprehensive picture of outpatient activity. Why not request information from trusts on all clinics for the Department’s future planning arrangements?
Dr McCormick: The plan is to set a target that embraces the full range of outpatient clinics, and it is intended to be comprehensive.
Mr McLaughlin: The words “a range of” imply that it is a percentage sample.
Mr Sullivan: The Minister intends to set targets for the full range of services provided by allied health professionals. Slightly later in the year, following a return from boards and trusts that is due at the end of July, he also intends to set targets for access to a range of elective care services provided in the mental-health field by other types of professionals. A small number of clinics may fall outside those two areas, but I expect that there will not be many. If there are any, we will consider and include them in due course.
Regarding Mr Craig’s point, we are working to ensure that there are no black holes in which patients are waiting too long. In the past two to three years, when the Department has shone a light on certain areas and monitored them weekly or fortnightly, the improvement secured has been amazing. We intend to continue that. It is reasonable for the public to expect that services provided by the Department are accessible.
Mr McLaughlin: Will the Department be taking that approach until 2008-09?
Mr Sullivan: The Department is considering that on a continuing basis. We need to review the responses from boards and trusts on the mental-health proposals. However, we are confident that, considering existing targets, associated monitoring arrangements for consultant-led services, and the arrangements that will be in place for allied health professionals’ services and mental-health services, the majority of the clinic services provided by trusts will be included in the monitoring and performance management arrangements. If some clinics have not been identified yet, we will consider including them.
Mr Beggs: Good afternoon, Andrew. Figures 4 and paragraph 2.16 of the report show a wide variation in DNA figures across individual outpatient departments. Why are some so bad? Which are the worst three hospitals?
Dr McCormick: The worst three are Alexandra Gardens Day Hospital, Whiteabbey Hospital psychiatric nursing unit (PNU), and Gransha Hospital. Those, and several others at the top end of the spectrum are in the mental-health area. I refer to the point that was made earlier: the highest rates of DNA are in the area of mental health.
Mr Beggs: Figure 5 and paragraph 2.17 show that there are extreme variations in DNA rates between hospitals and specialties. Specifically, the report states that Down Lisburn Trust has a zero DNA rate in its cardiology and emergency units. That trust appears to have cracked the problem. Has no one failed to attend those clinics?
Dr McCormick: I need to explain those figures. That cardiology clinic is private. It is small clinic that is held by a retired cardiologist on the premises of Lagan Valley Hospital. The procedure is to record all clinics that are conducted on health and social care premises. The non-attendance rate is zero because the patients are paying.
I am glad that Mr Beggs asked about the accident and emergency unit in Down Lisburn Trust. I must confess that the figure given is incorrect. We checked it, and I must apologise that the figure has crept in. The problem was that first referrals to accident and emergency clinics were not being recorded as they should have been. Therefore there are some DNA cases in that unit. Mr Sullivan has the details if Mr Beggs would like them, but we will need to write to the Committee to provide the explanation for what happened. That figure is not correct, and I apologise that it slipped through.
Mr Beggs: It is unfortunate that that has happened, and it would be useful if you would update the Committee. What steps are being taken to ensure that those hospitals that are not performing well, or are performing badly, are learning from the experience of the best hospitals? I imagine that specialties across hospitals experience similar issues. If so, why is there such variation between DNA rates in specialities? What steps are being taken to learn the lessons from those who are excelling and pass them on to specialties that are not achieving reasonable targets?
Dr McCormick: That is exactly the approach that we have sought to take in driving improvement and reform throughout the service. It involves having clear targets and making sure that management teams are aware of those targets. However, it is not just a matter of cracking the whip — that is not an effective way to drive improvements. The approach has been to share good practice and to ensure that where there is success, that success is explained: for example, explaining why good achievements have been secured, especially on the main objective of reducing waiting times, and what the techniques have been.
We have ensured that we have supported, and worked together within, the system. Many of the successes and areas of progress have come from within — from the initiative and imagination of clinicians and nurses, etc, as they work in their own areas. We promote and celebrate success to ensure that it is made known from one part to another. Lessons can be learned from one specialty to another and from one site to another.
Mr Beggs: Figure 5 and paragraph 2.17 show that, at the other end of the scale, the Mater Hospital Trust features in four of the 10 specialities with the highest DNA rates. However, the report also shows that the Mater Hospital Trust had one of the lowest DNA rates for trauma and orthopaedic surgery. There appears to be a specific problem if a trust has four specialties in the top 10. What is the cause of that problem? Is it a management issue or a reflection of the difficulties in the local community as a more deprived area? There is a major difficulty. What issues have been identified?
Mr Sullivan: Across three of the four specialties that were highlighted in the Northern Ireland Audit Office report, provisional information available for 2006-07 shows that the Mater Hospital Trust has improved its DNA rates in each of those areas. The one area where rates have not improved is cardiology, where the DNA rate has gone up by 1% from 17·6% in 2005-06 that was mentioned. Therefore there has been an improvement.
The issue comes back to the focus that the Department has had, and continues to have, on driving down outpatient waiting times. There is a huge incentive for trusts to minimise DNAs. There is a finite amount of support that they receive, centrally, from the Department on the delivery of the targets. Beyond that, it is down to the trusts. It is not in the interest of any trust to have large numbers of patients not attending, and there is a significant financial and operational motivation to address that.
Mr Beggs: You said that the latest figures show an improvement. Does the Mater Hospital Trust still figure significantly in the top 10 worst DNA rates?
Mr Sullivan: Some of the specialties from the Mater Hospital Trust would still be outliers.
Mr Beggs: Have any specific issues — with Mater Hospital Trust management, community background or whatever — identified the problem and how it will be addressed? The rates are incredible: in most cases, 20% of patients across the four different departments do not turn up for appointments.
Dr McCormick: We need to look into that further, as we have no details available on that just now. I will come back to the Committee with the details, as it is a cause for concern.
Mr Beggs: How does the Department intend to achieve the potential efficiency gains, estimated in paragraph 2.23 of the report to be £11·6 million, that could result from decreases in missed appointments and cancelled clinics? What measures will be in place to validate the accuracy of the data on expected savings? Paragraph 2.23 shows that there are big variations in the estimated cost between Northern Ireland and the Scottish Executive. How will we be sure that we can have data that will stand up?
Dr McCormick: We are targeting very significant efficiency gains across the full range of services, both now and in the years ahead, that would dwarf the amount referred to in paragraph 2.23. We delivered £113 million of efficiency gains. Those gains are cash released from one aspect of service that have been redeployed into front-line services in the past year, 2006-07. The Department has plans to deliver a further £142 million in the current year. Under the terms of the comprehensive spending review, the Department has an obligation to produce a total of £340 million of efficiency gains, and that is the perspective we are working on.
If we can, we will secure some of those efficiency savings by taking action on DNA rates. We hope that the initiatives that we are taking on partial booking, improving the service and reducing waiting times will have a good effect. There are limits to the specific interventions that can be made, given that the reasons for non-attendance can be very personal and can concern individual behaviour, making them quite hard to get at.
Wales and Scotland have set a non-attendance rate target of 5%, but that is proving difficult to achieve. We want to secure significant efficiency gains across the board, and we are obliged to do that to ensure that as many resources as possible are used as effectively as possible. However, that is hard to do.
In working out the detail on the comparative figures and when projecting the opportunity cost figures, we drew on the work that was done in Scotland. We produced estimates of average costs. Outpatient services cover a wide range of activities, and to get a precise handle on the specific cost of each different appointment list — each apple and pear, so to speak — would be a major task.
There is a plan to move towards a tariff-based regime as a way of driving out cost. The point of that is to avoid getting into the detailed management of the individual elements of cost. In a tariff-based regime, a hospital will receive a fixed amount, depending on the volume of activity. The effect of that will be to make hospitals think very hard about costs and to find any way that they can to cut them. That would put hospitals in the very strong position of having to cut costs in order to meet a budgetary obligation.
It is not a perfect system, and there are limits on what it can be used for. At the same time, hospital trusts knowing that they will get a fixed amount for each procedure in inpatients and for each appointment in outpatients is a major reform. That will make them think about what they can do to improve many of their services.
Mr Beggs: A huge amount of money has been invested in the local Health Service, and it is vital that that produces results. There are concerns that the best possible outputs are not being realised; I wish you success in your endeavours.
Mr Dallat: Looking at the report, the first thing that hits me is the statistics in figure 3, which shows that the problem has been worsening over the past 10 years. Surely someone must have been screaming from the rooftops about the deteriorating situation and the horrendous cost to the public purse of missed appointments.
Can we be sure that cancelled appointments were largely outside the control of the consultants who were involved and not necessarily cancelled by them? I pay tribute to the majority of consultants, who are overworked and underpaid. If there were a choice between the clinic and a slot in the operating theatre — and I emphasise “operating theatre” rather than the other kind — consultants would, I am sure, take the second choice.
Dr McCormick: The trend shown in figure 3 is a bad one, but the most recent provisional information that we have, about which we will write to the Committee, shows that there is a downturn in the figures. During the financial year April 2005 to March 2006, 14,794 appointments were cancelled. That figure has decreased to just over 14,000 during the period April 2006 to March 2007. There has been a slight improvement in the number of clinics that were cancelled. The main reason for cancellation is when a consultant is ill or unavailable on the day of the clinic. Those are the reasons for the majority of cancelled clinics.
Action was taken in the period covered by the Comptroller and Auditor General’s report to address that issue, but as the graph included in the report shows, that action was ineffective. We recognise that cancellations will always happen for various reasons, but we want to keep them to a minimum. We are encouraged by the most recent figures and hope that they will lead to a downward trend.
The reasons for cancellations were examined in more detail in order to establish the extent to which they led to lost activity. That was one of the reasons for taking the census of outpatient clinic activity, which revealed that a substantial proportion of the statistics overstate the problem. As the report outlines, the problem is overstated because of the way in which the statistics are recorded. Any small change in a clinic’s arrangements will trigger a record of a cancellation. The more detailed census information shows that lost activity amounts to 2·3%, which is still a loss, but it is harder to reach a lower figure.
Mr Dallat: I appreciate the difficulty in collecting data. We all know that consultants do not like politicians noseying into their affairs — all of us could provide examples of that happening. Can we be sure that there were no last-minute opportunities for consultants to go skiing in the Alps, duck shooting in Lough Neagh, or fishing in Mayo?
Dr McCormick: Consultants are contractually obliged to give notice of leave. The examples that you mentioned could lead to disciplinary action or restriction of pay progression. Consultants are contractually required to give six weeks’ notice of planned annual leave or study leave. Management would intervene in an instance such as that which you outlined, and any repetition would lead to disciplinary action. We have no evidence that that is happening. It is clear that the main reason for cancellations is illness.
Mr Dallat: We can be sure, then, that, in future, such occurrences will be closely monitored and that there will be penalties.
I refer again to paragraph 2.9 of the report. Has there been any assessment of the worsening medical condition of those people who have had to rearrange a cancelled appointment? God knows, I am talking about those who survive, because we know that some people do not survive.
Dr McCormick: There is no specific research or evidence on that matter. The Department’s response to that problem is mainly to bear down as strongly as possible on waiting times in general; to ensure that patients can access services as quickly as possible; and to ensure that cancellations are rearranged quickly so that the patient can be seen as quickly as possible so that we can fulfil our duty of care to the patient, which is our prime responsibility.
Mr Dallat: The information contained in paragraph 2.9 of the report leads me to ask whether it is possible to pool patients so that when a consultant is genuinely indisposed, the patient is not inconvenienced by the cancellation of an appointment.
Dr McCormick: Pooling of patients happens where possible; that is exactly how a group of consultants in a larger clinic should deal with patients. The number of clinics that pool patients is on the increase. However, the evidence of our examination of the impact of cancellations in single-handed clinics shows that they are part of that problem. Cancellations by clinics staffed by one individual are more prevalent here, where service delivery is dispersed to a greater degree than elsewhere.
Mr Dallat: I am sure that you have examined models from other places. My attention has been drawn to a particular model in an East Sussex hospital — called “choice appointments” — where the number of cancellations has dropped to 1%. Is any research being done to determine whether that kind of model can be implemented in Northern Ireland?
Dr McCormick: I am not aware of that example, but that is the kind of research of which we must be aware. The Department needs to be aware of the other models that exist; examine them and consider how they could be applied; establish whether it is possible to apply a lesson that has been learned from a situation such as that; and make sense of it in the Northern Ireland context.
Sometimes, certain models do not translate for various reasons. However, the Department must explore ideas to improve practice and consider in detail how a model will work. Effective management is part of what is needed — particularly during the current major reorganisation — to ensure that focus is kept on that kind of issue.
Mr Sullivan: Concerns have been raised by members about the impact of cancelled clinics on patients. Perhaps the concern is that when a clinic is cancelled, a patient is bumped to the bottom of the queue and made to wait for several months for a new appointment. The Department’s monitoring arrangements ensure not only that outpatient targets are achieved by the end of the year, but also that the prevailing outpatient waiting time standard, which is currently six months, is achieved on a monthly basis thereafter.
Therefore in the event that a clinic is cancelled by a trust, for reasons such as those that Dr McCormick has described, the only way in which the trust would be able to hold the six-month standard for that month is to ensure that those patients are seen before the end of the month. If patients’ appointments were cancelled during the second week of July, for example, the trust must ensure that those patients who would otherwise breach the 26-week standard are rebooked into another clinic before the end of July. There is therefore no risk of patients drifting off into the sunset while they wait for another clinic. There is huge pressure on the trusts to avoid cancelling a clinic in the first place and, in the event that one is cancelled, to ensure that patients are rebooked into another clinic.
Mr Dallat: It is comforting to know that patients will not drift into the sunset and will be seen at a clinic.
Mr Lunn: My first question is simple: at 11·6%, Northern Ireland’s DNA rate is the highest in the United Kingdom. Why does Northern Ireland have the worst rate?
Dr McCormick: That rate is not much different from rates elsewhere. It is comparable to, and within the range of, 10% to 12%, which covers all other rates. It is hard to pick out a significant reason for the difference when the difference is quite small. Northern Ireland is lagging a bit behind England, where progress on waiting times has been more rapid. It is easy to criticise England’s financial performance, but I would love the English activity performance to be achieved here. That performance has delivered very short waiting times, and I expect that that is one major reason for the slightly better attendance rate there.
Mr Lunn: You know the figures better than I do. The reason that I asked the question in such a simple way is that I would have thought that there would be a bigger demand for medical services in Northern Ireland than anywhere else in the UK. There is probably a higher demand here than in many other places around the world. So many people demand to see doctors and consultants, yet why do so many of them not turn up? I cannot understand that.
Dr McCormick: The level of activity in Northern Ireland is proportionate to the need. The higher levels of demand and the socio-economic factors that give rise to the need for healthcare show up in the level of activity. The figures that have just been discussed are percentages. Northern Ireland’s figure is the same percentage of a bigger figure in proportion to the population. That is part of the nature of the issue.
Mr Lunn: On the same tack as Mr Beggs’s question a few moments ago: 17·6% of patients with heart problems who are asked to attend the Mater Hospital do not turn up. I would have thought that they would make it a priority to turn up. The figure for the Down Lisburn Trust is 0%, as you have explained. With some of the other specialties, I can understand that people might even get better without seeing their consultants, which tells us something.
Dr McCormick: It is hard to explain. The most likely reason is the length of waiting time: a large proportion of patients who do not keep their appointments may have had a change in circumstances. There will always be an underlying percentage of missed appointments due to an unsuitable date or patient forgetfulness. One study recorded that 55% of patients said that their reason for non-attendance was that they had forgotten about the appointment. It is a difficult area.
Mr Lunn: I know it is early days, but has there been a significant reduction in the level of cancellations and non-attendance since the introduction of the partial booking system?
Dr McCormick: There is no systematic link between the introduction of partial booking, which, as you say, has just been introduced and is being extended across the board, and a change in the level of non-attendance. The Department hopes, and expects, that the partial-booking system will lead to an improvement in the rate of appointments that are kept. Partial booking was established to get a better system for hospitals and patients in order to make things work more smoothly. I hope there will be an improvement.
The rate of non-attendance has been steadily and slowly decreasing over several years. The most recent figures have not been published. As soon as the figures for the year ending March 2007 are fully validated, the Department will send them to the Committee.
Mr Lunn: John Dallat asked a about model in East Sussex. Have you looked at DNA rates around Europe, and do you have any thoughts on why models in other countries would be better than ours? Is there a better model out there?
Dr McCormick: I have not looked at other models in great detail. The difference in the nature of the systems means that it is hard to make valid comparisons. The Department is proud that our system is free at the point of delivery, which makes a significant difference to the relationship between the population and the Health Service. It is hard to make valid comparisons, but the Department is keen to secure information, research and insight from different contexts to see whether there are lessons that apply to us and that can be learnt.
Mr Lunn: What provisions are in place to assess the ability of patients to attend appointments? When an appointment is made under the partial-booking system, is a patient spoken to ensure that appropriate arrangements for their attendance can be made?
Dr McCormick: I will ask Mr Sullivan to say a bit more about that, but the main point is that an appointment is not only a matter of a card appearing in the post. At the time of referral, a patient is told what waiting time to expect, and six weeks before the appointment, the patient is telephoned.
Mr Sullivan: Usually, if someone who is referred for an outpatient appointment faces a particular communication issue, that is flagged up by the GP at the time of referral. Therefore there is an awareness of a patient’s particular needs. As Dr McCormick said, once the hospital receives the referral, it immediately writes to the patient, giving the maximum waiting time as x weeks. The patient is also informed that six weeks before that time, the hospital will write asking him or her to contact it to agree an appointment. If a patient does not respond to the first letter, a further letter is sent, reminding him or her to contact the hospital.
What happens thereafter depends on the particular circumstances of the patient. If the hospital felt it appropriate, it would contact the patient’s GP to ascertain whether something strange had happened, for example, a change to the patient’s contact details.
Now, however, we are in a very different place. As Dr McCormick said, there have been long waiting times, especially for some outpatient services. Long waiting times lead to a greater risk of patients’ details being out of date or their circumstances having changed. We are now dealing with a fresh batch of referrals and can say that no one is waiting for an outpatient appointment who has not been referred in the past six months. Our hope is that the people who have been referred still want and need outpatient assessments. It can be reasonably expected that their details will be up to date.
Mr Lunn: The partial booking system sounds terrific. However, I notice that consultants are not so sure. Why is that?
Dr McCormick: Consultants in Wales had some reservations. The Department’s general approach is to work with clinical teams so that the system is not imposed from the outside but that the practice and detail of running clinics is a matter for engagement and leadership from the clinicians. We hope that, together, we will be able to talk through problems or difficulties to find a resolution rather than running into the sand.
Mr Lunn: If consultants have arranged to go duck shooting in Fermanagh, it would perhaps be more difficult for them to cancel a clinic.
Ms Purvis: I want to focus on cancelled clinics, in particular paragraph 2.11 of the NIAO report, which refers to the staffing problems that can lead to the cancellation of clinics. Are you aware of any such problems, including shortages of staff with specialty skills, that have led to cancellations?
Dr McCormick: Not in general terms. Trusts attempt to secure the best match between the population’s need for provisional clinics and the consultants and other professionals who provide those clinics. Staff shortages in some specialties require the Department to consider long-term workforce planning to ensure that there is a flow of trainees into those specialties. However, that is not a major factor in clinic cancellations, which are normally triggered by short-term factors.
Ms Purvis: Can you tell us where those shortages exist?
Dr McCormick: In specialties. Dr McBride can expand on that.
Dr McBride: The Chairperson mentioned manpower issues in mental-health services, and we are certainly aware of those, particularly in psychiatric services. Manpower issues will be addressed in the context of the Bamford Review.
It should be remembered that some of the approaches that have been adopted to reduce waiting times, such as those that have been used in anaesthetic specialties, are not particularly relevant to outpatient procedures but are especially relevant to inpatient and day procedures. Those are two examples of areas where we are aware that the medical workforce needs to be increased and, correspondingly, the nursing and allied healthcare professional workforces.
Ms Purvis: John Dallat mentioned unplanned leave as a possible reason for the cancellation of clinics. You said that consultants are now required to give notice of leave. What other planning and management practices are in place to ensure that such problems with unplanned leave are ironed out?
Dr McCormick: Trust managements are required to enforce the clear terms of consultants’ contracts. Individual consultants accept those contractual terms by signing the consultant’s contract. That is a matter that can be, and, we believe, is, effectively applied.
There is no evidence of a pattern of unplanned leave being taken. If there were, it would eventually be a serious matter.
Ms Purvis: That is comforting. Paragraph 2.16 of the report recommends benchmarking so that best practice can be spread among the hospitals. Is benchmarking now in place, and, if it is, why did you not insist on it some time ago when the increases in cancellation rates were noticeable?
Dr McCormick: We have accepted that benchmarking is part of the way ahead. We use evidence and benchmarking from other parts of the UK to ensure that our attention to outpatients’ appointments is as effective as possible.
Mr Sullivan: In the past, the Department has relied on the informal sharing of information and benchmarking among trusts. More recently, an outpatient improvement manager network has been established, with managers in each of the five trusts. Those managers work together, and every fortnight they meet the lead director for outpatient services in the Department’s service delivery unit. In those meetings, they share best practice and discuss issues and challenges in order to achieve the targets and implement reforms in a range of areas. Those challenges include ensuring that patients turn up for appointments and that cancelled clinics are kept to a minimum. The Department has systematised and made formal what was previously informal.
Ms Purvis: Are targets for DNAs set across all specialties?
Mr Sullivan: No, they are not.
Ms Purvis: Are there plans to set those targets?
Dr McCormick: The targets that the Department tightly monitors weekly are for services that have long waiting times. That system is making a significant difference to the way in whic

Public Accounts Committee Membership and Powers

Report

Appendix 1:

Appendix 2:

Appendix 3:

Appendix 4:

Appendix 5:

List of Abbreviations used in the Report

Executive Summary

Understanding outpatient activity

Improving attendance at outpatient clinics

Improving the efficiency of outpatient clinics

Summary of Recommendations

Understanding Outpatient Activity

Improving Attendance at Outpatient Clinics

Improving the Efficiency of Outpatient Clinics

Introduction

Understanding Outpatient Activity

Outpatient waiting lists

Recommendation 1

Recommendation 2

Outpatient referrals

Recommendation 3

11. The Committee welcomes the steps the Department is taking to improve referrals and it expects to see the use of ICATS extended to all specialisms where it offers the potential for improvement.

Management information

Recommendation 4

14. The Committee recommends that the Department ensures that satisfactory arrangements are maintained for the collection of accurate data on outpatient activity.

Recommendation 5

17. The Committee recommends that the Department should identify the data requirements for managing all outpatient services and ensure that systems are in place to address these.

Improving Attendance at Outpatient Clinics

The scale of non-attendance at outpatient clinics

Recommendation 6

22. In order to stimulate action in Northern Ireland, the Committee recommends that Trusts should adopt challenging but achievable reduction targets tailored to the levels of non-attendance experienced by their outpatient clinics.

Variation in non-attendance rates

Recommendation 7

Patients and non-attendance

Recommendation 8

Non-attendance in mental health outpatient clinics

Recommendation 9

30. The Committee expects the Department to ensure that there is a maximum take up of the depression awareness scheme by GPs.

Recommendation 10

Recommendation 11

34. The Committee recommends that the Department examines closely ways of increasing the capacity of health service provision for services to mentally ill patients in order to overcome the imbalance of appropriately skilled staff.

Dissemination of Best Practice

Recommendation 12

Recommendation 13

38. The Committee urges the Department to ensure that it keeps abreast of new developments regarding the handling and timing of outpatient clinics. This can be done by networking with other health departments in Great Britain, through its contacts with the Republic of Ireland and further afield.

The introduction of partial booking

Recommendation 14

Timing of clinics

Recommendation 15

Improving the Efficiency of Outpatient Clinics

Cancellation of appointments by Trusts

Clinic cancellation and private practice

Recommendation 16

Recommendation 17

51. The Committee would like detailed information on the extent to which disciplinary procedures have been used against consultants in each of the past five years and how many of these cases related to accountability for outpatient clinics.

Recommendation 18

53. The Committee considers that pooling can increase confidence among patients that appointments will be kept and urges the Department to actively promote its use throughout the range of outpatient specialties.

Appendix 1

Minutes of Proceedings of the Committee Relating to the Report

3. Evidence on the NIAO Report ‘Outpatients: Missed Appointments and Cancelled Clinics’

7. Consideration of Draft Committee Report on Outpatients: Missed Appointments and Cancelled Clinics

Appendix 2

Minutes of Evidence

Public Accounts Committee
Membership and Powers