Scotland’s NHS workforce: The current picture

Major challenges lie ahead for the NHS in Scotland. As I reported last year, there are growing pressures on NHS boards which are struggling to juggle service delivery and progress major reform, at the same time as managing considerable financial challenges.

cover_nhs_workforceNearly 160,000 people work in Scotland’s NHS, which provides vital services for millions of us every year. Their hard work and commitment, sometimes in life-or-death circumstances, is always to be admired. However, the NHS faces challenges if the workforce is to meet the growing demands of our ageing population and adapt to new ways of working.

We know that our audit work on health and social care in Scotland has a role to play in the wider debate about what’s needed to transform these services and make them sustainable for the future.

Building on our recent findings, we’ve begun a new two-part audit to evaluate how the Scottish Government and NHS boards are tackling the issues, through workforce planning and national and local initiatives. The first report focuses on overall workforce planning and workforce pressures in hospitals and will be published in summer 2017. The second is due out in 2018/19 and will explore primary care and GP workforce issues.

In advance of our first report, this briefing provides some key information on the shape of the current NHS workforce and sets out some of the issues that we’re delving into during the course of our audit.

About the author

MM6A8690croppedCaroline Gardner is the Auditor General, and Accountable Officer for Audit Scotland. She started her term in July 2012, and has 30 years’ experience in audit, governance and financial management. Follow her on twitter @AuditorGenScot

The story behind Self-directed Support

About £8 billion was spent on providing social care last year, and as the public spending watchdog, we’re really interested in what that funding is achieving for the people who deliver and use these vital services. We’ve done a lot of audit work in this area already, and we’ve reported that these services face tough challenges, like coping with rising demand alongside financial pressures.

Under the policy of Self-directed Support (SDS), people accessing social care services are able to choose where, when and how they receive care. This was a major change to the way services were delivered and, when the legislation first kicked in, Audit Scotland reported on how ready the Scottish Government and local authorities were to implement the new way of working.

Just over two years on, we want to see how well things are going. I’m part of the team carrying out Audit Scotland’s latest review of self-directed support, on behalf of the Auditor General and the Accounts Commission.

At this crucial early stage of the new approach, it’s very important for us to understand what’s being delivered for the people who need support. So we’ve launched a survey asking users, their carers, friends and family to share their stories of using SDS in 2016 and 2017.

We want to hear about your journey, from approaching the authorities for help, to having your support needs assessed, to making choices about how you’re supported and agreeing a care plan.

Did you feel your needs were understood by the assessor? Were you given a range of options? How is your support managed now? Were you ultimately satisfied with the outcome?

Your experiences will be invaluable to us in understanding how the changes to social care are affecting people. It’ll help us shine a light on what’s working well, and what still needs to be improved, as we pull together our key findings and judgements.

You can share as much or as little detail as you like, and if you’d rather talk to us in person about an issue you’ve highlighted in the survey, we’d love to hear from you – just include your contact details.

We’ll run the survey until the 27th February, so please share the questionnaire with other users and carers, so we can gather as many stories as possible.

Thank you for your support.

About the author


Zoe McGuire, Auditor, joined Audit Scotland in January 2014. She has been involved in auditing community partnerships at national and local level, as well as Best Value audits of East Dunbartonshire Council and Moray Council. She is part of the team carrying out the 2017 audit of Self-directed Support.

Event reflections: How can we transform health and social care?

I recently took part in a Holyrood event focused on the messages and recommendations in Audit Scotland’s Changing models of health and social care report. We partnered with Holyrood on the event, and I set the scene with a presentation on our recent health and social care work –including a screening of our new animation – to highlight some of the challenges facing these services, and what still needs to be done to get them to a place where they can cope with the demands of our growing, ageing population.

01_title-slideThe guest speakers at the event – from bodies such as NHS boards, health and social care partnerships and the ALLIANCE – gave some really useful insight into different approaches and new models of care being developed in local areas. We featured these examples as case studies alongside our report.

One speaker, Professor Lewis Ritchie, talked about transforming out-of-hours care and the importance of people. Representatives from ISD Scotland and NHS Greater Glasgow and Clyde: Public Health illustrated how good data can support and improve decision-making, to help transform services. The presentations were extremely varied and interesting, with engaging speakers who were clearly passionate about what they do.

It was a small event with around 30 delegates. I was initially concerned that we’d struggle to stimulate enough questions and discussion during the panel sessions, but I needn’t have worried. The venue’s cosy and informal nature seemed to make people more relaxed and open, and we actually ended up running out of time in each session as people had so much to say!

The big take home message for me was that while this is one of the most challenging times ever experienced by public bodies, there are a lot of dedicated staff determined to get it right and make the needed changes to how care is delivered. These ‘local champions’ are the ones that can identify what’s needed on the ground. They are the ones who come up with innovative ways of working, overcome many barriers and convince managers that the old way of doing things isn’t an option any more.

We’ve recommended that evaluation of new models needs to improve to inform the evidence base of what works. I was heartened to see at the event that this was something that presenters and their colleagues had been working hard to do.

08_line-up-of-our-reportsThere was also lot of admiration in the room for Audit Scotland, which was really encouraging.

We know that the challenges facing health and social care can be a sensitive subject, and we’re always acutely aware of how our work will be received, and the impact we can have on the public’s awareness of the issues we highlight. That’s why it was great to hear delegates say that they valued our clear, factual and independent reports, which stimulated useful debate and helped to influence change. They also commented that we weren’t afraid to tackle difficult subjects and tell it like it is.

This is brilliant feedback for us to build on, particularly as we have a number of future audits planned in different areas of health and social care, including a look at the NHS workforce. We’ll post updates on our online hub as these are developed in more detail. In the meantime, we’d welcome comments or feedback from anyone interested in this area of our work.

About the author

mm6a5513Jillian Matthew is an audit manager and joined Audit Scotland in 2003. She has worked on numerous audits with a health and social care focus, including Audit Scotland’s annual review of the NHS in Scotland, an overview of mental health services, and reviews of NHS waiting lists, cardiology and orthopaedic services.


Early learning and childcare: What you told us

Over the summer, Audit Scotland ran a survey to try to capture the views of parents and carers about their experiences of early learning and childcare in Scotland. This was a key part of our preparations for a new audit of these services, to give an independent assessment of how the system is working and what outcomes are being delivered for people who access this support.

It was the first time that Audit Scotland had directly reached out families who use these services, so we weren’t sure what kind of response to expect. We were really pleased with the result, as dozens of individuals and organisations helped to spread the word about the survey and over 300 people completed the questionnaire.

Icon_A_B_AS-04We learned a lot from the engagement, and collected some really useful material, including individual stories. Our early analysis of the responses shows a range of recurring views, including the positive impact that early learning and childcare can have on a child’s development and wellbeing.

However, concerns were raised on issues such as the cost of services, a lack of choice, and limited flexibility, particularly for working or studying parents.

It’s important to highlight that reform of early learning and childcare is continuing: in her September announcement on the 2016/17 Programme for Government, the First Minister set out a commitment to double the amount of free care available to all three and four-year-olds, and two-year-olds who will benefit most, by the end of the Scottish Parliament’s fifth session.

This means that our audit will be a timely and relevant contribution to the future development of early learning and childcare services. The views contributed by parents and carers have helped us to lay the groundwork for our audit and shape what questions we want to answer. There are a number of insights that we’ll investigate further and test out during the course of our fieldwork. We’ve set out more detail about our work – which we’ll carry out on behalf of the Auditor General and the Accounts Commission – in a new flyer.

One thing that’s certain is that we want to continue engaging with parents and carers, and we’re looking forward to building on the great response we’ve had so far.

We’ll continue to post updates about when we’ll publish our audit report as our work develops in the coming year – watch this space for news.

About the author

MM6A5569Rebecca Smallwood is an auditor and joined Audit Scotland in 2008. She has worked on a number of audits with a health and social care focus, including community health partnerships, emergency departments and reshaping care for older people.

Scrutinising Scotland’s infrastructure investment

The Scottish public sector invests around £5 billion each year on new infrastructure. Projects such as schools, social housing and hospitals are essential for delivering high quality, effective public services and for improving the wellbeing of people in Scotland. Investment in areas such as roads and superfast broadband can also help contribute to sustainable economic development by easing the transport of goods to market and by opening existing markets to a wider audience.

Because of all this, auditing capital investment is a key part of Audit Scotland’s work. Not only is it a significant area of public expenditure, with individual projects often costing hundreds of millions of pounds, but they also attract high public, political and media interest.

Over the summer we published two reports looking at different aspects of infrastructure investment.

The first report, Maintaining Scotland’s roads: A follow-up report published on behalf of the Accounts Commission and the Auditor General, confirmed the continuing difficulties in maintaining the condition of Scotland’s roads in the face of declining budgets and conflicting priorities. We made the point that progress with introducing a shared services approach to roads maintenance has been disappointingly slow. We also stressed that while investment in new infrastructure brought benefits, it was important that an appropriate balance was struck between new investment and the maintenance of existing infrastructure.

Shortly afterwards, we published a progress update on Superfast broadband for Scotland. We looked at the progress made on delivering superfast broadband through the public sector’s contracts with BT, and how the Scottish Government was developing plans to extend coverage and achieve its vision of world-class digital infrastructure. We found that while good progress is being made towards extending access to the fibre network, connecting rural and remote areas to the network remains a challenge. There is still work to do if the Scottish Government is to achieve its vision of high speed internet access available anywhere, and on any device, by 2020.

The broadband update was a new style of report for us, presented in a landscape format and with the emphasis on graphics rather than text to get our main findings over. We’re currently thinking about how to adapt the format for other reports, so it would be useful to hear people’s views on what they thought of the presentation of the broadband report.

We’re due to brief the Public Audit and Post-Legislative Scrutiny Committee at the Scottish Parliament on both reports on Thursday, 24th of November. This will give the members the opportunity to ask questions about the reports and for them to consider how best to continue their scrutiny of the subject areas. It’s clear from the reaction to both reports that broadband speeds and road condition are issues people in Scotland really care about, so the Committee session promises to be a lively one.

And it doesn’t just stop there. We’re proposing infrastructure audits on subjects as diverse as the Scottish Government’s CAP Futures IT project, the £1.3 billion Forth Replacement Crossing and City Deals as part of our 2017/18 performance audit programme, available here.

dscn0292Graeme Greenhill is a Senior Manager at Audit Scotland, with responsibility for the investment audit portfolio.


Measuring community engagement

I recently joined Audit Scotland on secondment from West Lothian Council, to help the organisation explore its approach to community engagement. As you might know from Audit Scotland’s recent efforts to reach out to parents and carers and to young people, engaging better with the people who use public services is a big priority for the organisation going forward.

I used to be a community planner, so I know what it’s like to be on the other side of an audit and I’m using that perspective to explore Audit Scotland’s approach to auditing community planning, engaging with citizens, and how it measures public bodies who claim to be good at this.

I’m really passionate about communities and individuals being involved in the planning, design and delivery of public services. That’s why I’ve been really pleased to be involved in the revision of the National Standards for Community Engagement, launched recently in Kelty Community Centre. People (as well as managers) who use services are best placed to be able to help co-design the services they need and the revised national standards will provide much needed consistency and good practice to support this.

I’m really glad to be working with Audit Scotland to develop new robust ways to measure community engagement and assess how well public bodies are rising to the challenges set in the Community Empowerment (Scotland) Act 2015.  The revised standards will no doubt be useful in taking that work forward, and we hope to be able to publish some information on benchmarking activities that we’re holding with a range of public sector bodies in the near future.

On November 17th, I’ll be chairing a roundtable event at Audit Scotland with representatives from the Scottish Health Council, the Consultation Institute, the Scottish Rural Parliament, Community Ownership Support Services, SCDC, PAS and the ALLIANCE. Together we’ll be exploring what good community engagement delivers, how we assess it and what tools we need to do it. I’m really looking forward to having these interesting discussions and sharing the learning that comes from the event. If you’re interested to hear more about Audit Scotland’s work in this area, be sure to keep an eye on the website for updates.

About the author

Lorraine Gillies image
Lorraine Gillies is on a 23 month secondment to Audit Scotland from West Lothian Council. A former community planner, she has a keen interest in the field of citizen engagement. She is chair of the housing and disability charity Housing Options Scotland.

Auditing Scotland’s further and higher education sectors: The story so far…

Scotland’s universities and colleges deliver a wide range of benefits to individuals and communities, and so most of us will have an interest in how they are performing, particularly in this time of significant change and uncertainty for the country’s public finances.

On Thursday, the Scottish Parliament’s Public Audit and Post-legislative Scrutiny Committee hears from Auditor General Caroline Gardner and Audit Scotland teams – myself included – on reports we’ve recently published on the higher education and college sectors. Members will also hear from the Auditor General on challenges facing Edinburgh College, and Glasgow Colleges’ Regional Board.

cover800x1132I was part of the team taking Audit Scotland’s first look at the entire higher education sector, which attracts a growing number of students and is internationally renowned. More than 50,000 students from outside the UK came to Scotland to study in 2014/15, and almost all Scottish universities deliver higher education abroad, either by running overseas campuses, through partnerships with other universities, or through distance learning.

In 2014/15, the Scottish Government provided over £1.7bn in funding, made up of direct funding to universities and financial support to individual students, such as paying tuition fees and funding student loans. Our report raises important issues about the use of public funding, and the challenges facing both universities and the Scottish Government if the sector is to stay successful, and if the Scottish Government’s policy ambitions are to be achieved.

For example, one of our key findings is that it’s becoming increasingly difficult for Scottish students to get a university place in Scotland. There’s a need for greater understanding of trends in applications, offer rates, and acceptances to assess what impact Scottish Government policies are having on access to university for Scottish and EU students. This is one of several recommendations we make in our report, touching on areas such as student support, widening access and the role of the Scottish Funding Council (SFC)

The review of higher education was followed by Audit Scotland’s annual look at the performance of Scotland’s colleges. This piece of work was managed by my colleague Stuart Nugent. You can listenas_cover_colleges to Stuart discuss the key findings of that report here. Though colleges and universities are very different bodies in a number of ways, both sectors face challenges. In the case of colleges, substantial reforms have transformed the way that they operate and deliver services.

Our latest review of the college sector found that it is financially stable and achieving learning targets, whilst still adjusting to the big changes it’s experienced in recent years. However, several issues remain outstanding if the full effects of government reforms are to be understood and addressed by the sector.

Like universities, the college sector is experiencing changes within its student population – though for different reasons – such as growing numbers of under-25s in full-time education and reductions in women and over-25s. Our report states that the Scottish Government, the SFC and colleges need to work together to improve their understanding of demand for courses across the country, and create long-term plans for how they will commit finances and staff to meet future need.

Both of these reports have generated a lot of ongoing debate about the future challenges facing the respective sectors, and how to manage them. The Scottish Government and SFC have responded to both reports ahead of Thursday’s meeting and once we present our findings to the Public Audit and Post-Legislative Scrutiny Committee, members will then decide what action they would like to take to continue their scrutiny of the sectors.

For our part, the audit teams will continue to explore ways to engage with stakeholders on our recommendations and share the knowledge we’ve gained through our work. For example, I’ve been travelling round the country since July, presenting our findings at universities and sector events and it’s been really interesting to hear the range of views on what approach should be taken to deal with the challenges ahead.

We’ll use this feedback to consider how we can focus our future audit work on education, and will post updates on our website as that starts to take shape.

About the author

kwsmallKirsty Whyte managed our audit of higher education in Scottish universities. She has worked at Audit Scotland for over 12 years undertaking performance audits on a wide range of topics across the whole of the public sector, including school education, the use of locum doctors in the NHS, and efforts to reduce reoffending.

How can we create a world-class approach to public finances?

The Scottish Parliament may have been in recess since my last blog, but you wouldn’t know it from all of the activity that’s been underway at Holyrood over the summer. It’s been a pleasure to be involved in some of this work, including contributing to the business planning days for different parliamentary committees and joining colleagues in the new budget review group, taking a fundamental look at how this important process should develop.

There has also been plenty of work under way at Audit Scotland over the summer. Colleagues have been busy signing off the financial audits of dozens of central and local government bodies, and I’ve reported on a number of different policy areas, including higher education, colleges, and broadband, to name just a few.

And today, I report on the Scottish Government Consolidated Accounts for 2015/16. I’ve set out the Scottish Government’s budget, how it works and how it’s reported, as well as my findings on the Government’s financial and performance management.

The Consolidated Accounts are an integral part of the Scottish Government’s accountability to the Parliament and of course, the public. They cover about 90 per cent of the spending approved by the Parliament, and show what the Scottish Government has spent against the overall Scottish Budget.

This is the second year that I’ve produced a report to accompany the accounts. The new financial powers flowing from the Scotland Acts 2012 and 2016 mean it’s increasingly important that the Parliament and the public have comprehensive, transparent and timely information about public finances. For example, one of the key changes in this year’s consolidated accounts is that they reflect the revenue collected through Scotland’s new devolved taxes – Land and Buildings Transactions Tax and Scottish Landfill Tax – for the first time.

The Scottish Government has made some progress since my last report in improving the transparency of public finances. However, there is still no set of consolidated accounts for the whole of the Scottish public sector – something I have reported on previously. These would give a fuller picture and understanding of public spending and the longer-term implications for public finances. This is especially important considering the uncertainty created by the EU referendum result and the continuing pressures on the public purse, alongside the impact of the new financial powers.

I’ve also highlighted some significant issues and risks to the Scottish Government budget, including management and control of European Funding; an important income stream for the Government.

I look forward to taking the report to the Parliament’s Public Audit Committee later this year, and supporting MSPs to discuss and scrutinise some of the issues highlighted in my report.

As I’ve mentioned before , managing the new financial powers brings both opportunities and risks to Scotland’s public finances and with this in mind, Audit Scotland has pulled together a paper looking at some of the key issues. This paper is accompanied by a high level overview of the new powers, how the funds flow through the system and which organisations are involved. I’ll also be reporting again next spring on how well these powers have been prepared for and managed.

There are undoubtedly hard decisions ahead but I believe we’ve got a rare opportunity to create a world class approach to public finances. Let’s not waste it.

About the author

MM6A8690croppedCaroline Gardner is the Auditor General, and Accountable Officer for Audit Scotland. She started her term in July 2012, and has 30 years’ experience in audit, governance and financial management. Follow her on twitter @AuditorGenScot

Supporting economic growth: A complex picture

A strong, sustainable economy is important for a successful Scotland, and the performance of our economy has been subject to a great deal of debate and scrutiny in recent months.

In July, Audit Scotland published a review of the roles of Scottish Enterprise (SE) and Highlands and Islands Enterprise (HIE), which spend around £398 million a year delivering the Scottish Government’s economic priorities, as outlined in Scotland’s Economic Strategy.

This strategy was the starting point of our audit work, as this determines SE and HIE’s plans and activities. Although it sets out the Scottish Government’s high level priorities and overall approach to supporting economic growth, we found that the detail on how specific policies and initiatives would be implemented is missing.

The strategy states that the Scottish Government’s National Performance Framework (NPF) will measure progress, but this cannot be used to measure the contributions of policies and initiatives to delivering outcomes. We’ve therefore recommended that the Scottish Government strengthens its approach to developing, delivering and monitoring the economic strategy. This is particularly important due to the complex nature of supporting economic growth and the uncertainty surrounding public finances for the foreseeable future, as a result of new financial powers flowing from the Scotland Acts 2012 and 2016, and the outcome of the recent EU referendum.

report_cover_595pxTurning to the economic development agencies, SE and HIE provide a range of financial and non-financial support to businesses and other customers and we found that overall, they are performing well. Often their investments in projects will be significant and high risk. Our audit sought to raise awareness of how much is spent and where, and what’s achieved as a result. To help inform our conclusions we pulled together case studies which looked at specific types of support, such as SE’s work to help rejuvenate the Dundee Waterfront and HIE’s investment in the Harris Tweed industry.

Both agencies regularly meet or exceed their individual performance measures, despite a 12 per cent reduction in their spending since 2008/09, and they undertake a range of evaluation work to help demonstrate the impact their support has. There are also good examples of partnership working to achieve positive outcomes, such as creating jobs and increasing business turnover.

Where things could improve is in the way that SE and HIE often offer similar support, which means that there’s scope to deliver some activities more efficiently. We recommended agreeing common performance measures, aligned to the NPF, to allow the agencies’ contribution to Scottish Government outcomes to be identified and clearly tracked.

The Scottish Government announced a comprehensive review of enterprise and skills services in May this year, which should offer the opportunity to address our findings and we’ll consider the outcomes of this review and what it may mean for any future audit work in this area.

The responses to the report have been very interesting; we’ve discussed our key messages with a number of stakeholders, including the Scottish Parliament’s Economy, Jobs and Fair Work, and Rural Economy and Connectivity, Committees, and tomorrow (Thursday, 29 September) we present our findings to Holyrood’s Public Audit Committee.

And there’s more to come, as we’re exhibiting the report and other information about our work in this area at the Scottish Business Exhibition in Novemberforward to meeting business people face-to-face to chat through our findings. If you’re there on the day, please say hello!

About the author

mm6a5992Mark Pentland is a performance auditor and joined Audit Scotland in 2013. Since then, he’s worked on a number of different audits, most recently contributing to Supporting Scotland’s economic growth: The role of the Scottish Government and its economic development agencies.

Social work audit raises tough questions for us all

Until I worked on this audit my perceptions of social work came from the media: overworked professionals in a very challenging environment, constantly trying to do the right thing and having to make decisions which would likely have a serious impact on people’s lives.

And, unless you have had recent personal experience, I suspect many people think that when there is a need, the state will step in to provide help.

During this work the team learnt that the challenges we are confronting as a society are huge. The number of elderly people is increasing, there will be fewer people of working age, and more children and adults living chaotic lives or longer lives with complex needs.

While we are living longer, the number of years we spend in good health is not increasing, and in order to live independent, fulfilling lives, many of us will need help for longer. So we all have a responsibility to make lifestyle choices which will keep us healthy.

One thing that surprised us was how much we rely on unpaid carers to provide support. One in six adults in Scotland and almost 1 in 25 children under 16 are caring for someone. And the amount that saves the public purse is estimated at  nearly 11 billion a year.

The audit threw up a lot of philosophical issues for me.

Legislation gives certain groups rights but how do we balance them with other’s needs, such as the difference between a 64 year old and a 65 year old with the same needs? Or children who lose benefits and opportunities once they become adults?

How do we pay for the care we need? How much is it the responsibility of the individual or their families and how much should society pay from a finite and reducing public purse?

During this audit the team had a privileged opportunity to meet with those working in social services at all levels in six council areas. We were surprised to find that, in spite of the size of the challenge, social workers  were positive about their work and confident that they can help people change their lives for the better.

It was interesting to see how different the principal issues confronting different councils were; for example, providing care for people living in rural and isolated communities in Eilean Siar or coping with wide scale deprivation, and the consequences of drug and alcohol abuse in Glasgow.

But the overall thing I have taken away from the audit is that we as society have to make some really difficult decisions about how we define need, how we want to support those in need of help – and how we will pay for it.

liz-ribchesterAbout the author

Liz Ribchester joined Audit Scotland’s Performance Audit and Best Value group as a Senior Auditor in 2004. She was a member of the Social work in Scotland audit team.