3rd Report, 2013 (Session 4): Report on the management of patients on NHS waiting lists

SP Paper 315

PA/S4/13/R3

3rd Report, 2013 (Session 4)

Report on the management of patients on NHS waiting lists

CONTENTS

Remit and membership

SUMMARY OF CONCLUSIONS AND RECOMMENDATIONS
INTRODUCTION
KEY ISSUES

Use of social unavailability codes
Work underway to improve the use of codes
Health board scrutiny of the use of social unavailability codes
Issues highlighted in 2010 Audit Scotland report
The rise and fall in the use of unavailability codes
The basis for the rise and fall in the use of codes
Conclusions on the rise and fall in the use of codes
Monitoring of the increasing number of patients recorded as unavailable
Level of focus on the increase in the use of unavailability codes
The role of ISD Scotland

ANNEXE A: EXTRACT FROM THE MINUTES OF THE PUBLIC AUDIT COMMITTEE

ANNEXE B: ORAL EVIDENCE AND ASSOCIATED WRITTEN EVIDENCE

Remit and membership

Remit:

The remit of the Public Audit Committee is to consider and report on—

(a) any accounts laid before the Parliament;

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

(c) any other document laid before the Parliament, or referred to it by the Parliamentary Bureau or by the Auditor General for Scotland, concerning financial control, accounting and auditing in relation to public expenditure.

(Standing Orders of the Scottish Parliament, Rule 6.7)

Membership:

Colin Beattie
Bob Doris
Willie Coffey
James Dornan
Iain Gray (Convener)
Mark Griffin
Colin Keir
Mary Scanlon (Deputy Convener)
Tavish Scott

Committee Clerking Team:

Senior Assistant Clerk
Roz Thomson

Assistant Clerk
Jason Nairn

Committee Assistant
Parminder Kaur

Report on the management of patients on NHS waiting lists

The Committee reports to the Parliament as follows—

SUMMARY OF CONCLUSIONS AND RECOMMENDATIONS

Introduction

1. The Committee acknowledges that: the Scottish Government and health boards accept the recommendations in the Auditor General for Scotland’s report Management of patients on NHS waiting lists in full; and that work is already underway to seek to rectify issues raised in internal auditor reports and in relation to recommendations in the AGS report.

2. Given the importance of the effective management of patients on waiting lists, the Committee considers that this matter justifies continued scrutiny from Audit Scotland on the progress towards improving the audit trail of information on the use of unavailability codes. The Committee seeks an update report from the AGS by the end of 2013 in order to receive an independent perspective on the progress made by the Scottish Government and health boards.

3. The Committee considers the evidence on national performance of the NHS to be useful context in considering the AGS’s report. (paragraphs 1-17)

Use of social unavailability codes

Limitations in IT systems prevented sufficiently detailed information being recorded

4. In order to provide reassurance that social unavailability codes are being applied appropriately, and consistently, by health boards across Scotland, the Committee recommends that the Scottish Government should set out the core ‘audit’ data that all health board IT systems must be able to record. (paragraphs 22-17)

Approach to inputting of data

5. The Committee seeks an assurance from the Scottish Government that the current guidance to health boards on the patient management system will be amended given the various recommendations made in the AGS report on recording social unavailability. The Committee recommends that the format and detail of the guidance should be reviewed at that stage with a view to:

  • making it a less complex, more accessible document; and
  • producing quick reference guidance to supplement it wherever useful. (paragraphs 25-29)

Application of guidance

6. The Committee welcomes any health board seeking to demonstrate flexibility to go beyond minimum requirements contained within Scottish Government guidance on the application of waiting time codes, but would seek the Scottish Government’s view on how it will monitor the application of codes in this way by individual health boards. The Committee would also welcome the Scottish Government’s views as to whether health boards should be required to notify the Scottish Government when they seek to go beyond requirements within such guidance. (paragraphs 30-32)

Inappropriate use of codes where there were capacity issues

7. The Committee draws a distinction between the deliberate inappropriate use of social unavailability codes and instances of the inadvertent misapplication of codes. The Committee is aware of the firm action taken in response to the deliberate inappropriate use of codes at NHS Lothian and would hope that this has acted as an effective deterrent. (paragraphs 33-34)

Bullying

8. The establishment by the Scottish Government of the central National Confidential Alert Line for NHS staff is to be welcomed on the basis that this anonymous approach should help ensure that staff feel they can communicate more freely on sensitive matters such as bullying.

9. The Committee notes that the Alert Line will initially be in place for a year. The Committee requests information from the Scottish Government on how its success will be assessed. Such assessment could inform future consideration of whether to keep the line open in the longer term. In addition, given the nature of the experiences the line should encourage people to share, the Committee requests details from the Scottish Government as to how well resourced and publicised amongst NHS staff the line will be.

10. The Committee would expect health boards to complement this new initiative with on-going support for their staff that promotes a culture of openness. (paragraphs 35-41)

Work underway to improve the use of codes

Outpatients

11. The Committee requests clarification from the Scottish Government as to whether it is the intention for outpatients to receive written confirmation when a patient advised unavailability code is applied, and in any of the other circumstances outlined in the 2012 guidance where inpatients receive a letter. (paragraphs 45-46)

Patients with additional support needs

12. The Committee invites the Scottish Government, in reviewing the guidance to boards, to look specifically at ways in which the application of the patient management system is adaptable to the support needs of patients. This could include requiring boards to be able to demonstrate that the manner in which patients are contacted and the nature of the ‘reasonable offer’ made to the patient includes reasonable adjustments to accommodate their needs. (paragraphs 47-49)

Health board scrutiny of the use of social unavailability codes

13. The Committee considers that the standard of information provided to boards of health boards should be sufficient to allow non-executive directors to provide an effective challenge function. The Committee asks the Scottish Government to ensure that:

  • internal auditing by health boards takes place, including sampling of patient records on a monthly basis (by staff that are independent of the areas where the patient records are generated), to validate that the use of social unavailability codes is appropriate;
  • all boards of health boards look at this monthly information on the level of the use of social unavailability codes, broken down by hospital and also by specialty. This should be considered alongside information on capacity pressures in these services to reassure boards that there are no patterns of codes being used excessively to relieve ‘pressure points’ in service delivery. (paragraphs 50-58)

Issues highlighted in 2010 Audit Scotland report

14. The Committee reminds Audit Scotland that it has the ability to raise issues highlighted in its 12 month follow-up reports with the Public Audit Committee. (paragraphs 59-62)

The basis for the rise and fall in the use of social unavailability codes

15. The Committee considers that health boards should have sufficient information to demonstrate that codes are being used for appropriate reasons. Due to the lack of data in the audit trail on the use of codes, the Committee is not in a position to draw firm conclusions on the extent to which codes have been applied as a result of capacity pressures in the NHS, or the extent to which reducing waiting time targets may have impacted upon the use of codes (as outlined in the AGS report). This highlights the importance of ensuring accurate data is available in future to validate the positions of health boards and the Scottish Government on the performance of the NHS. (paragraphs 67-87)

Level of focus on the increase in the use of unavailability codes

16. The Committee further recommends that ISD Scotland should require that the information produced under paragraph 13 above is provided to it by all boards, in a standard format that allows it to collate these figures into national performance monitoring reports.

17. These reports should be able to identify where capacity pressures are occurring alongside a high incidence of unavailability codes in the same specialties, or in particular health boards, across Scotland. Reports should also detail overall use of social unavailability codes by boards, broken down by the new categories of reasons for social unavailability.

18. Emerging trends from these reports can then be discussed at meetings between chief executives of health boards and also at meetings between chief executives and Scottish Government officials. (paragraphs 90-107)

The role of ISD Scotland

19. The Committee considers that ISD Scotland should ensure that potentially significant concerns, such as the levels of retrospective changes in patient records made by NHS boards, are highlighted to the Scottish Government as standard procedure.

20. The Committee recommends that the discussions between the Scottish Government and ISD Scotland that are proposed in the AGS report should cover the extent to which the Scottish Government expects ISD Scotland to:

  • highlight any concerning information, including trends, to the Scottish Government; and
  • seek evidence based responses from health boards on any future anomalies identified. (paragraphs 108-118)

INTRODUCTION

1. The Auditor General for Scotland’s report Management of patients on NHS waiting lists1‘the AGS report’] aimed to identify whether NHS Lothian’s manipulation of waiting lists in 2011 was an isolated incident or whether it was an indication of widespread problems across the NHS.

2. Unavailability codes were introduced by the Scottish Government as part of the New Ways policy for the management of patients on waiting lists in 2008. This replaced a system where patients who were unavailable for an appointment or treatment due to medical or social reasons could lose their guarantee of a maximum waiting time.2

3. Social unavailability codes are intended to be used where patients cannot attend appointments. In addition, they have been used to reflect patient choice, where patients choose to wait longer for alternative appointments with their preferred clinician or at their preferred hospital.3 NHS Lothian misused social unavailability codes to manipulate performance against patient waiting time targets.

AGS Report: NHS Lothian’s misuse of codes meant that some patients were unknowingly waiting longer than they should have been. An investigation revealed a culture of managers putting too much pressure on staff to find ways around the system to avoid failing to meet targets.4  

Changes to patient records were made just before reporting to management was due on any patients not being seen or treated within waiting time targets. As periods of unavailability are not included in patients’ reported waiting times, this meant that many patients not being treated within waiting time targets were not reported and NHS Lothian falsely reported it was meeting the targets in nationally published reports.5 

4. The Committee agrees with the view of the AGS that accurate reporting of performance against waiting time targets is crucial in ensuring public trust in the operation of the NHS.6 It is also extremely important that the NHS is capable of maintaining accurate patient records that match the actual quality of individual patient experiences.

5. The Committee is pleased to note that Audit Scotland found no evidence of widespread manipulation of waiting lists.

Auditor General for Scotland: this has been the most data-rich, data-intensive exercise that we have done.7  

As we have said in the reports and as I have said today, we have not found any evidence of manipulation at all. The wording on the aim of the work is very clear. It was about looking for an indication of:

“widespread problems across the NHS.”

The evidence suggests that there were widespread problems with the use of the unavailability code. Our challenge and the reason why we reported in the way that we did is that the information systems and the information that is recorded do not enable us to clarify what caused codes to be used wrongly or explain the wider pattern in the use of unavailability codes across NHS boards.8  

6. The extensive use of codes created some marked differences between the performance figures reported by boards against waiting time targets and the actual wait times including periods of unavailability.

AGS report: In the quarter ending June 2011, 23 per cent of inpatients across Scotland had an actual wait (including periods of unavailability and clock resets) of over nine weeks9, compared to three per cent with a reported wait of over nine weeks. This varied by board (Exhibit 9). The biggest percentage difference between reported and actual waits was in NHS Forth Valley (35 per cent); and the biggest difference in the number of patients was in NHS Greater Glasgow and Clyde (5,000 patients).10  

7. The AGS report also found that there was a marked increase in the use of social unavailability codes over time, increasing from 11 per cent in 2008 to just over 30 per cent at the end of June 2011.11 The report also concludes that, around the time concerns were raised about NHS Lothian, the use of social unavailability codes began to reduce across Scotland and the percentage of patients waiting longer than the 12 week waiting time target started to rise.12 The Scottish Government contests this conclusion as it considers that the decrease in the use of codes began at the end of 2010, approximately a year before the issues at NHS Lothian were uncovered13 (see paragraphs 63 to 87 below).

8. At this juncture it is worth noting that it is not for the Public Audit Committee to take a view on Scottish Government policy, rather it is charged with assessing whether appropriate measures are in place for the effective and financially efficient delivery of policy. Scrutinising what constitutes the appropriate use of targets in health policy is a matter for the Health and Sport Committee. The AGS’s findings on the focus on meeting waiting times targets and its impact on scrutiny of the increased use of codes are considered in paragraphs 50 to 51.

9. The AGS report makes recommendations for better scrutiny by, and communication between, health boards, Information Services Division Scotland (ISD Scotland) and the Scottish Government to ensure early identification of any trends that could suggest the concerted misapplication of codes.

10. The Committee took evidence from these bodies on the AGS’s findings. The Committee acknowledges that: the Scottish Government and health boards accept the AGS’s recommendations in full;14 and that work is already underway to seek to rectify issues raised in internal auditor reports15 and in relation to recommendations in the AGS report.16

11. Given the importance of the effective management of patients on waiting lists, the Committee considers that this matter justifies continued scrutiny from Audit Scotland on the progress towards improving the audit trail of information on the use of unavailability codes. The Committee seeks an update report from the AGS by the end of 2013 in order to receive an independent perspective on the progress made by the Scottish Government and health boards.

12. The evidence received pointed towards a number of explanations for the overall increase and subsequent decrease in the use of codes. Due to the lack of data on why social unavailability codes have been used in most health boards, the basis for the overall trend in the use of codes has been open to wide interpretation following the publication of the AGS report. The Committee has sought in this report to propose constructive recommendations that supplement those within the AGS report which will help to move this situation forward; ensuring future trends can be explained.

13. The Committee thanks Audit Scotland for the forensic work that contributed to the AGS’s findings and thanks all those who gave oral and written evidence to the Committee (detailed in Annexe B).

14. As the Committee heard from three health board chief executives, the evidence in this report has a particular emphasis on these boards. However the Committee wishes to make clear that the recommendations made in this report reflects the evidence in the AGS report which highlights examples from health boards across Scotland.

15. Witnesses from health boards, including NHS Greater Glasgow and Clyde17, provided valuable context within which the AGS’s findings should be considered, including the performance delivered by the NHS in recent years set against the challenges of shorter waiting time targets to meet and more patients to treat. The reductions in waiting times targets since 2003 are reflected in Exhibit 2 of the AGS report, reproduced below.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 16. The Scottish Government highlighted in evidence that, even including all periods of medical and social unavailability for patients, overall the NHS is achieving waiting times targets.

Scottish Government: Even including periods of unavailability within the reported figures shows that patients now wait no longer than 32 days on a median basis (see annex18). The inter country comparisons by OECD and the Office of National Statistics (ONS) confirms Scotland’s leading UK and European position.19  

17. The Committee considers the evidence on national performance of the NHS to be useful context in considering the AGS’s findings. The waiting time data collected by ISD Scotland and reported to the Scottish Government is considered further in paragraphs 108 to 118 below.

KEY ISSUES

Use of social unavailability codes

18. Social unavailability codes, when applied appropriately, are a positive thing as they provide flexibility for patients. Therefore the Committee’s starting point in considering the use of these codes is that it is legitimate to do so as long as: they are applied consistently and appropriately across all health boards; and the reason for their use is recorded with sufficient detail to allow their correct application to be verified.

19. The AGS report reflects very varied practices across health boards in relation to the use of social unavailability codes. In analysing records, Audit Scotland found widespread use of codes and frequently could not establish the basis for their use or found they had been applied inappropriately.20

Audit Scotland: …in those 3 million transactions, there were a lot of unusual patterns…there are a lot of examples of very unusual things that we could not explain. For example, in NHS Grampian there were 300 patients with four or more periods of unavailability during the wait. That is quite unusual, but we could not explain it… we follow quite a lot of trails and then come to a dead end because there is no information to allow us to clarify absolutely why something has happened.21  

20. It should be central to health board patient record systems that individual patient experiences can be tracked to ensure patients remain within the system and are treated in a timely fashion. Whilst acknowledging it represents a small number of the transactions randomly sampled by Audit Scotland, it is still concerning that Audit Scotland found hundreds of examples where patients remained on lists for long periods of time.22

21. Audit Scotland highlighted a number of themes in relation to a lack of data being recorded or the misapplication of codes. These are highlighted below.

Limitations in IT systems prevented sufficiently detailed information being recorded

22. The AGS report found that some IT systems lacked sufficient capacity to include all details of contact with the patient’s GP and also with the patient, such as confirmation of whether the patient actively agreed to be recorded as socially unavailable.23 Six different systems are used, some of which wipe any saved information when a patient finishes being treated or is removed from the waiting list for other reasons.

23. For example, Audit Scotland was not able to carry out any analysis on electronic waiting systems within NHS Greater Glasgow and Clyde due to a lack of information on its iSoft or Meditech systems. A lack of functionality in systems, such as the ability to use drop down lists, may have been conducive to certain health boards using their own local categories as reasons for social unavailability. This has contributed to a variation in the basis for codes being applied across health boards.24

24. In order to provide reassurance that social unavailability codes are being applied appropriately, and consistently, by health boards across Scotland, the Committee recommends that the Scottish Government should set out the core ‘audit’ data that all health board IT systems must be able to record.25

Approach to inputting of data

25. Most electronic patient records have a space where staff can add at least limited notes to record information, for example about why a code has been applied or details of a conversation with a patient or their GP about availability. Where IT systems have the necessary functionality, certain approaches to the inputting of data were also identified as an issue. This included large numbers of patient records being updated at the same time, as opposed to updating records close to the time of patient contact.26 There was also evidence of lengthy or multiple periods of social unavailability being recorded, or some patients having periods of unavailability with no end date.

AGS report: NHS Highland had patients with periods of social unavailability with no end date. This means patients could have remained unavailable indefinitely if they were not reviewed.27

26. There was also an instance in NHS Lanarkshire of patients not appearing on a waiting list at all.

AGS report: In NHS Lanarkshire, some patients who should have been covered by waiting time targets were not on the electronic waiting list and their waiting times were not being formally reported locally or to ISD Scotland during 2011 and early 2012. NHS Lanarkshire estimates that this could have affected around eight new patients referred each month over a period of 12 months. These patients were mainly patients with learning disabilities who needed dental treatment under general anaesthetic. As their waiting time was not being formally recorded or reported, they could well have been waiting longer than the guarantee.28 

27. A reason cited in evidence to the Committee as a barrier to accurate consistent inputting in line with best practice was the complexity of the New Ways policy and associated guidance.29 The New Ways guidance was 99 pages long and was required to be used by a large number of NHS staff accessing and managing waiting lists.30 Exhibit 3 from the AGS report provides a flow chart of the patient journey based on the guidance.31 The NHSScotland Waiting Time guidance, issued in August 2012, replaced the New Ways guidance.

28. Useful supplementary documents such as FAQs are being produced to complement the guidance in some health boards.32 This provides staff contacting patients and using the IT systems with a practical and quickly accessible means of following the guidance.

29. The Committee seeks an assurance from the Scottish Government that the current guidance will be amended given the various recommendations made in the AGS report on recording social unavailability. The Committee recommends that the format and detail of the guidance should be reviewed at that stage with a view to:

  • making it a less complex, more accessible document; and
  • producing quick reference guidance to supplement it wherever useful.

Application of guidance

30. The New Ways guidance stated that if a patient turns down two reasonable offers, they should be referred back to their GP.33 The updated guidance (NHSScotland Waiting Time Guidance) issued in August 2012 provides more flexibility stating that ‘at least two offers should be made’. The Committee heard evidence that some health boards, whilst using the New Ways guidance, coded patients who should have been referred back to their GP as socially unavailable to keep them on the waiting list. NHS Greater Glasgow and Clyde allowed three reasonable offers to be turned down before re-referring the patient.

NHS Greater Glasgow and Clyde: It was a conscious decision—certainly in NHS Greater Glasgow and Clyde and, I believe, a number of boards across Scotland—not to disadvantage those patients in recognition of their choice but to keep them on the waiting list so that they could then be treated. However, under the technical rules, we in NHS Greater Glasgow and Clyde could have discharged a significant proportion of our patients who were coded socially unavailable back to their GP.34

31. This example demonstrates that some health boards adopt their own practices which offer additional choice beyond that specified within Scottish Government guidance. The Committee appreciates that the motivation behind keeping patients on the list is to treat them as promptly as possible and not to disadvantage patients for expressing preferences, and that the guidance has been updated to allow more flexibility to allow for patient choice.

32. The Committee welcomes any health board seeking to demonstrate flexibility to go beyond minimum requirements contained within Scottish Government guidance on application of waiting time codes, but would seek the Scottish Government’s view on how it will monitor the application of codes in this way by individual health boards. The Committee would also welcome the Scottish Government’s views as to whether health boards should be required to notify the Scottish Government when they seek to go beyond requirements within such guidance.

Inappropriate use of codes where there were capacity issues

33. The internal audit report for NHS Tayside found that codes had been applied inappropriately in specialties with capacity pressures to prevent patients from being recorded as in breach of the waiting time limits.35

AGS report: The internal audit report [for NHS Tayside said ‘for 17 per cent of the 367 transactions tested, unavailability appeared to have been systematically applied to prevent patients being reported as not meeting their treatment guarantee date...’ this included making patients unavailable retrospectively without contacting the patient and making patients unavailable on the grounds that the patient was informed by the consultant that the patient guarantee was not achievable.…according to staff descriptions of processes then in place, staff reviewed weekly waiting times information reports, which identified patients at risk of not meeting their guarantee date and systematically applied unavailability to avoid a breach position. For the majority of these transactions, according to staff descriptions, there was no factual basis for the unavailability.36 

34. The Committee draws a distinction between the deliberate inappropriate use of social unavailability codes and instances of the inadvertent misapplication of codes. The Committee is aware of the firm action taken in response to the deliberate inappropriate use of codes at NHS Lothian and would hope that this has acted as an effective deterrent.

Bullying

35. NHS Tayside also gave evidence on the extensive work it had undertaken to investigate allegations made to the internal auditor that there may have been a culture of bullying in parts of the board, where staff may have been pressured to use codes inappropriately.37 As a result of an internal investigation no evidence of a bullying culture was found.38

36. When asked about a British Medical Association briefing stating that an ‘aggressive management style is not isolated to Lothian’,39 NHS Forth Valley and NHS Greater Glasgow and Clyde refuted this suggestion. The health boards cited consultations with staff, the key messages from these being that their workplace could be a pressured environment involving free and frank discussions but that staff took pride in their work and did not have instances of bullying to report.40

37. The Committee does not want to make any detailed comments on bullying as the AGS report did not find any evidence of deliberate manipulation of records as a result of staff being bullied or coerced to undertake such practices. On this basis the Committee did not take evidence from NHS frontline staff on this matter.

38. The Committee is encouraged by the evidence taken, but appreciates that highlighting any evidence of a bullying culture to management can be daunting and so all instances of bullying are unlikely to be highlighted to senior staff. The Committee also appreciates that it is extremely challenging for health boards faced with notable work pressures to maintain a working environment across a board area that is consultative with staff and responsive to accusations of bullying.

39. The establishment by the Scottish Government of the central National Confidential Alert Line for NHS staff is to be welcomed on the basis that this anonymous approach should help ensure that staff feel they can communicate more freely on sensitive matters such as bullying.

40. The Committee notes that the Alert Line will initially be in place for a year. The Committee requests information from the Scottish Government on how its success will be assessed. Such assessment could inform future consideration of whether to keep the line open in the longer term. In addition, given the nature of the experiences the line should encourage people to share, the Committee requests details from the Scottish Government as to how well resourced and publicised amongst NHS staff the line will be.

41. The Committee would expect health boards to complement this new initiative with on-going support for their staff that promotes a culture of openness.

Work underway to improve the use of codes

42. Following the emergence of details of the falsifying and manipulation of patient records at NHS Lothian, the Scottish Government commissioned the internal auditors of all health boards to report on, amongst other things, the use of social unavailability codes in those areas. Following publication of internal audit reports, the Cabinet Secretary for Health and Wellbeing made a statement which detailed a number of pieces of work to improve the performance of health boards. This included:

  • the implementation of individual action plans by health boards by the end of March 2013, with a requirement to report progress to the Cabinet Secretary in April 2013;
  • a requirement on health boards to produce follow-up audits to ensure improvements have bedded in;
  • the introduction of the Trakcare IT system across health boards including drop down lists options to allow consistent recording of reasons for unavailability;
  • in place of ‘social unavailability’ inpatients will now be informed by letter of their status under the new coding of ‘patient advised unavailability’ and will be invited to raise any questions of clarification they may have; and
  • introduction of a Scottish Government action plan on waiting times focusing on recording systems, procedures, training, reporting and governance – aimed at improving the consistency of recording and the quality of waiting times information.41

43. Health boards detailed in evidence some of the work they are undertaking, either as a result of the action plans or improvements identified of their own volition. This included improved training for staff, such as the introduction of electronic training modules.42 43 44

44. Given the importance of removing discrepancies in the audit trail in order to be assured that patient experiences match the information published on NHS performance, the Committee welcomes all of the work that has already been instigated by the Scottish Government and health boards in this area. In addition to the work currently underway, the Committee has identified two further changes to the waiting time system that could improve the consistency of the application of unavailability codes.

Outpatients

45. The AGS report highlights that there is no requirement for outpatients to receive a letter to inform them that they are being categorised under an unavailability code, or in any of the other circumstances outlined in the 2012 guidance where inpatients receive a letter.45 The Committee acknowledges that there may be practical reasons, possibly to do with the shorter waiting time target for outpatients compared to inpatients, which could impact on health boards’ ability to provide the same level of information and support to outpatients.46

46. The Committee requests clarification from the Scottish Government as to whether it is the intention for outpatients to receive written confirmation when a patient advised unavailability code is applied, and in any of the other circumstances outlined in the 2012 guidance where inpatients receive a letter.

Patients with additional support needs

47. In March 2010, the then AGS, Robert Black, published findings on the progress of the implementation of the New Ways guidance in a report entitled Managing NHS waiting lists. One of the key messages of that report was on the need to ‘ensure that communication with patients takes account of any need for additional support and tailor information to meet these needs’.47 The 2013 AGS report looked again at the extent to which the support needs of patients are taken into account by boards.

AGS report: We examined whether NHS boards have improved their systems for recording patients’ additional needs, such as a disability or requiring a translator.48

We found little evidence to suggest that NHS boards are taking account of patients’ individual circumstances, such as access to transport, mobility or additional support needs…the guidance on what constitutes a reasonable offer did not take into account any additional support needs a patient may have had.49 

48. Every patient should be provided with an equal opportunity to understand and take informed decisions in relation to their treatment. The Committee is pleased to note that the NHSScotland Waiting Time guidance, issued in August 2012 by the Scottish Government, includes a requirement for health boards to take account of patients' additional needs.

49. The Committee invites the Scottish Government, in reviewing the guidance to boards, to look specifically at ways in which the application of the patient management system is adaptable to the support needs of patients. This could include requiring boards to be able to demonstrate that the manner in which patients are contacted and the nature of the ‘reasonable offer’ made to the patient includes reasonable adjustments to accommodate their needs.

Health board scrutiny of the use of social unavailability codes

50. The Committee heard some evidence that suggested that the standard of information recorded by some boards in previous years was minimal because there was no requirement to report that level of information to the Scottish Government.50

51. It would appear from the numerous examples above (paragraphs 22 to 34) that accurately recording information on the reasons for using social unavailability codes has not been sufficiently prioritised by most health boards (with notable exceptions such as NHS Forth Valley). The lack of ability to verify that codes were being used in accordance with guidance should have been a focus for health boards, regardless of whether they had to report up the line to the Scottish Government.

52. The AGS report found that ‘it is important that non-executive directors have access to the full range of information available to allow them to provide effective challenge’.51

53. Without sufficient good quality information in patient records, health board executives have not been in a position to assuredly provide accurate figures on the use of codes and of performance against waiting targets to its non-executive directors. This compromises the ability of these directors to perform an effective challenge function to ensure patients are being treated in a timely and appropriate fashion.

54. Furthermore, boards of health boards dealing with incomplete information were not in a position to provide figures that accurately reflected performance against waiting time targets to the Scottish Government. This has impacted, to a degree, on the accuracy of the overall picture of NHS performance presented by the Scottish Government.

55. Implementing the recommendations outlined in this section of the report, together with the work already underway in recognition of this issue at health board and Scottish Government level, should provide an improved and consistent standard of information to non-executive directors of boards. This should aid these directors in performing an effective internal challenge function and help them report accurate information to the Scottish Government.

56. An example of good work already underway was provided in evidence by NHS Greater Glasgow and Clyde.

NHS Greater Glasgow and Clyde:…we are reinforcing the rules. From 1 April, we have plans to implement a full audit process under which every month a number of records in the board area will be validated, independently from the directorate teams. In addition, the directorates will be asked to scrutinise and audit another cohort of patients. We will therefore have a transparent monthly audit report that describes the situation.52 

57. The Committee considers that there is scope for this type of work to be rolled out across health boards.

58. The Committee considers that the standard of information provided to boards of health boards should be sufficient to allow non-executive directors to provide an effective challenge function. The Committee asks the Scottish Government to ensure that:

  • internal auditing by health boards takes place, including sampling of patient records on a monthly basis (by staff that are independent of the areas where the patient records are generated), to validate that the use of social unavailability codes is appropriate;53
  • all boards of health boards look at this monthly information on the level of the use of social unavailability codes, broken down by hospital and also by specialty. This should be considered alongside information on capacity pressures in these services to reassure boards that there are no patterns of codes being used excessively to relieve ‘pressure points’ in service delivery.

Issues highlighted in 2010 Audit Scotland report

59. In March 2010 Audit Scotland reported on the new arrangements for Managing NHS waiting lists (New Ways). One of the key messages of that report was that ‘there are some gaps in recording data about reviews of patients who are unavailable’, and another suggested that the Scottish Government and ISD Scotland should ‘consider issuing additional guidance about the treatment of patients who do not or cannot attend appointments to make sure that patients are managed fairly across Scotland’. Another recommendation was that ‘the Scottish Government and ISD Scotland should consider introducing a patient choice code which allows NHS boards to stop the waiting time clock for patients who choose to wait longer for an appointment or treatment’.54

60. In 2011, as part of its internal 12 month follow-up report on how its recommendations were being progressed, Audit Scotland pursued the implementation of the recommendation that guidance should be issued on the introduction of this new patient choice code. It was informed by the Scottish Government that the recommendation would be implemented ‘imminently’.55 The new guidance which included guidance on the use of the new code, was not issued until August 2012. There are now specific codes detailed in this updated guidance to be used to reflect patient choice. Specifically, these are for 'patient advised unavailability (appointment location)' and 'patient advised unavailability (named consultant)'.56 The Committee explored the basis for the period of time taken for this guidance to be issued in evidence with witnesses.

NHS Greater Glasgow and Clyde: We were aware of the Audit Scotland report that was published in March 2010 and the action plan that was attached to it, and we were aware that one of the recommendations was about amplifying the codes that would be available. The debate went on for a period of time and agreement was eventually reached across NHS Scotland on changes to the codes.57

ISD Scotland: The Audit Scotland report in 2010 was reasonably positive about a lot of the achievements that had been made. There was not a rush to immediately go out and fix something. There was a plan to continue on a path and continue to make improvements. That is where we are today.58

Scottish Government: Even if we had introduced a patient choice code at that time, we did not have systems that would have been able to support the data collection that would have been required to underpin it.59 

61. The Committee appreciates that: the 2010 AGS report on how boards had implemented the New Ways system was primarily a positive one;60 that unavailability levels were not at their peak when Audit Scotland work for this report was undertaken; and that there were practical barriers to the introduction of the new codes.61 It is regrettable that this constructive recommendation from Audit Scotland was not expedited, especially since Audit Scotland actively pursued this matter to ensure that the implementation of improvements did not lose momentum. If this recommendation had been implemented earlier then the extent of the misapplication of codes could have been more limited or have become apparent earlier. The Scottish Government and health boards have accepted all recommendations in the 2013 AGS report therefore the Committee expects that these recommendations will now be implemented

62. The Committee reminds Audit Scotland that it has the ability to raise issues highlighted in its 12 month follow-up reports with the Public Audit Committee.

The rise and fall in the use of unavailability codes

63. The AGS report found a rise in the use of unavailability codes, including social unavailability codes, from the introduction of codes in 2008 until 2011. The overall percentage of inpatients categorised as socially unavailable across Scotland rose from 11% in 2008 to 30% at the end of June 2011.62

64. Exhibit 6 of the report shows the trends in reported waiting times for patients on waiting lists and how NHS boards used unavailability codes in Scotland from March 2010 to September 2012. The report concludes from this information that:

AGS report: Towards the end of 2011, around the time concerns were raised about NHS Lothian, the use of unavailability codes began to reduce and the percentage of patients waiting longer than 12 weeks [the waiting time target at that time] started to rise. 

65. The Scottish Government, in both oral and written evidence, contested Audit Scotland’s suggested timing of the reduction in the use of codes.

Scottish Government: While it was reported in the Audit Scotland Report that unavailability started to reduce in late 2011 it actually started to reduce almost a year before from December 2010 (approximately one year before the issues in NHS Lothian were uncovered). This can be seen clearly in exhibit 6 in Audit Scotland’s report.63 

66. The figures upon which elements of Exhibit 6 are based are reproduced in table 1. These figures are the percentage use of unavailability codes across Scotland, excluding the figures from NHS Lothian. The figures show that the use of unavailability codes decreased in 2010 as suggested by the Scottish Government. They increased again, and then there was a more sustained decrease from late 2011, as suggested by Audit Scotland.

Table 1

Date

Percentage of inpatients coded as unavailable

Percentage of outpatients coded as unavailable

31 March 2010

31.5

5.2

30 June 2010

33.0

6.7

30 September 2010

31.1

8.1

31 December 2010

40.3

10.9

31 March 2011

36.9

8.3

30 June 2011

39.1

9.2

30 September 2011

36.6

9.0

31 December 2011

37.3

9.0

31 March 2012

28.6

6.3

30 June 2012

28.5

6.3

31 July 2012

28.5

6.5

31 August 2012

26.2

5.9

30 September 2012

22.6

5.4

The basis for the rise and fall in the use of codes

67. The suggestion in the AGS report is that there was a change in practices amongst health boards following the emergence of details of the situation at NHS Lothian, with unavailability codes used less when the nature of their use at NHS Lothian became apparent. The Committee raised this in evidence with witnesses to explore their understanding as to why the use of codes rose and then fell.

Capacity pressures

68. Audit Scotland found a pattern of an increase in the use of codes occurring in areas where there was pressure on the capacity of some hospital specialties to meet waiting time targets.64

69. It also observed that as Scottish Government policy has required waiting times to become shorter, the overall use of unavailability codes has increased. The AGS report also provides evidence that, as use of unavailability codes began to reduce, the percentage of patients waiting longer than 12 weeks started to rise. Exhibit 5 in the AGS report demonstrates this trend.65

70. The Scottish Government highlighted in evidence that it was understandable that there would be an interaction between the shift in policy and the use of codes, and that reducing waiting times targets would logically impact, to a degree, on the levels of use of unavailability codes.66

71. In addition, the Committee heard evidence that preparations for the Treatment Time Guarantee and injections of funding to provide more treatments where capacity issues existed explained a large proportion of the decrease in the use of codes. 67 68 69 70

72. Audit Scotland’s findings point to unavailability codes being increasingly used during a period of transition for the NHS in introducing shorter waiting time targets. This implies that the demands of implementing Scottish Government policy may have influenced the approach taken by health boards to managing waiting lists.

73. The Committee appreciates that there will be an increase in the use of social unavailability codes when waiting time targets become shorter for the reasons suggested by the Scottish Government. In addition, it appreciates that when capacity pressures are eased due to an increase in funding for additional treatments, then patients awaiting treatment in a particular location or with a particular clinician will receive the treatment they had been waiting for and so will no longer be deemed socially unavailable.

74. These reasons for changes in social unavailability contribute to a rise and then a fall in the use of codes, but do not account for the full extent of the use of codes in some specialties, and the extent of the subsequent drop off in the use of codes. Other reasons provided in evidence for the rise and fall are explored further below.

Patient choice

75. NHS Greater Glasgow and Clyde suggested that their use of codes was in large part due to a high number of patients preferring to await treatment in the location of their choice or by the clinician of their choice.

NHS Greater Glasgow and Clyde:…the underlying trend in Glasgow in the first quarter of 2011 was a significant rise in the number of patients who sought to be treated in a hospital of their choice or by a surgeon of their choice. Therefore, when patients were offered early access to an appointment across the common waiting list, a significant number of them declined and agreed to wait for the hospital or surgeon of their choice.71 

76. NHS Greater Glasgow and Clyde has more scope for allowing for patient choice than most other health boards, given the number of hospitals operating and the number of clinicians working in this highly populated area. It makes sense that the levels of social unavailability in this health board would be higher than in others, especially since the board was allowing patients to refuse more reasonable offers than in some other boards so more patients remained on the waiting list instead of being sent back to their GP (see paragraphs 30 to 32 above). Allowing for patient choice is therefore unlikely to be a primary factor for the high use of unavailability codes in the smaller health board areas.

Introduction of the codes in 2008

77. The Scottish Government also highlighted that, as codes did not exist prior to 2008, it is entirely legitimate that there should be an increase in their use following their introduction.

Scottish Government: We have previously advised Audit Scotland prior to the publication of the report on these reasons for this growth. The single most important factor in the rise is the fact that prior to 2008 we did not record social unavailability. This system started as part of the introduction of New Ways (which abolished the previous system of Availability Status Codes). As patients entered into the NHS system and as they were recorded on patient administration systems, it is inevitable that the number of patients recorded under such a system grows over the intervening months/years since 2008. This pattern is quite clear over the course of 2008/2009 when most of the growth took place.72 

Winter of 2010/11

78. Health board witnesses and the Scottish Government highlighted the spike in the use of unavailability codes in the winter of 2010/11 when bad weather prevented patients from attending appointments (this spike can be clearly seen in the figures for 31 December 2010 and 31 March 2011 provided in table 1).

NHS Greater Glasgow and Clyde: Going into the beginning of 2011, we had a significantly bad winter and a number of operations were cancelled because people could not get to healthcare premises. In some instances, operational problems meant that theatres were out of action, so we had to relocate and refer patients to different services.73

Scottish Government: It is evident from the published data that the NHS in Scotland suffered an additional spike in the use of such codes around the winter of 2010/11. In this quarter Social Unavailability grew significantly in relation to inpatient and day case Social Unavailability (as patients advised hospitals they could not travel for treatment).74 

79. The Scottish Government added that the fall in the use of codes was in part the result of its issuing of a recovery package to boards in December 2010, following the spike in the use of unavailability codes.75 The Committee acknowledges, as shown in table 1, that bad weather will doubtless have been a key factor in the increase in the use of unavailability codes in the winter of 2010/11.

80. The Committee would expect that patient unavailability would be one of a number of factors that would prevent large numbers of treatments being carried out. The main factors would appear to be that: patients could not travel; NHS staff could not travel; and/or bad weather caused operational problems meaning certain facilities such as operating theatres could not carry out procedures.

81. Supplementary information provided by the AGS in response to this evidence states that there does not seem to be any relationship between hospital cancellation rates and levels of unavailability. This information is based on figures from ISD Scotland which show that NHS service cancellation rates remained relatively stable over the winter while social unavailability rates rose quite markedly.76 This rise in social unavailability was the main contributor to a rise in overall unavailability.

Additional training

82. The increased amount of training taking place was also cited as a reason for a reduction in codes, as staff became better informed on how to use the codes appropriately. NHS Tayside gave evidence that the use of codes had decreased due to improved training that was provided in what was described as the ‘post-Lothian scenario’. Increased training and education to address misunderstandings of how to apply the complex guidance was cited as ‘the staff’s understanding of why the figures had fallen’.77 NHS Forth Valley stated in evidence that all health boards would have considered their approach to the application of codes when the issues at NHS Lothian emerged.78

83. This evidence from NHS staff suggests that one reason for the fall in the use of codes was because misapplication of codes reduced following the emergence of details of the practices at NHS Lothian, when steps were taken to rectify this situation. This would cause a decrease in the use of codes towards the end of 2011 and it would also cause the number of patients waiting over 12 weeks to increase. This is the trend observed in Exhibits 5 and 6 of the AGS report.

Conclusions on the rise and fall in the use of codes

84. The Committee accepts that all of the factors explained by the health boards and the Scottish Government have contributed to a rise and a fall in the use of codes in the NHS between 2008 and 2011. In addition, some of the reasons provided are compatible with the suggestion in the AGS report that the use of codes was higher in specialties with capacity pressures that were seeking to meet reduced waiting targets.

85. The AGS report pointed to a pattern in the use of social unavailability codes which saw them rise from 2008 up to 30% in June 201179, then fall dramatically at that point, around the time that information emerged regarding the manipulation of codes in NHS Lothian. The Scottish Government and health boards offered the Committee a variety of explanations for this trend, some of which were disputed by the AGS. The Committee concluded that this trend remains unexplained.

86. As detailed in the first section of this report, the lack of auditable information on the application of unavailability codes means that health boards or the Scottish Government could not definitively demonstrate to what extent each explanation offered contributed to the pattern across health boards of a rise and fall in the use of codes.

87. The Committee considers that health boards should have sufficient information to demonstrate that codes are being used for appropriate reasons. 80 Due to the lack of data in the audit trail on the use of codes, the Committee is not in a position to draw firm conclusions on the extent to which codes have been applied as a result of capacity pressures in the NHS, or the extent to which reducing waiting time targets may have impacted upon the use of codes (as outlined in the AGS report). This highlights the importance of ensuring accurate data is available in future to validate the positions of health boards and the Scottish Government on the performance of the NHS.

Monitoring of the increasing number of patients recorded as unavailable

88. Health boards, ISD Scotland and the Scottish Government all have roles to play in the process for the production, verification and analysis of information on the performance of the NHS. These roles are summarised below.

Health boards have accountability and responsibility to ensure that the figures that they submit to ISD Scotland are correct and that patient care is delivered. Health board chief executives all have a direct line of accountability to the Chief Executive of the NHS in Scotland.

ISD Scotland has a quality assurance role in monitoring the quality of the information that NHS boards submit to it…It is also responsible for providing performance management information to the Scottish Government but it does not have a role in challenging NHS boards on their performance. One of the direct lines of accountability of ISD Scotland is to the Chief Executive of the NHS in Scotland.81

The Scottish Government is responsible for performance management on a national level including considering information provided by ISD Scotland, such as emerging trends, and acting as a challenge function to individual health boards on their performance. 

89. Regular communication between these bodies happens in a number of ways including:

  • monthly meetings between health board chief executives,
  • monthly meetings between chief executives and Scottish Government officials; and
  • monthly and quarterly reporting of data from ISD Scotland to the Government (supplemented with meetings).

Level of focus on the increase in the use of unavailability codes

90. Paragraphs 65 and 66 of the AGS report provide examples of available data collated by ISD Scotland that were provided to the Scottish Government that pointed to potential capacity issues in some boards and specialities.

AGS report: Available data show that across all NHS boards between December 2009 and December 2011:

- the number of people waiting for an outpatient appointment increased by over seven per cent from 187,721 to 201,716

- the number of people waiting over 12 weeks increased four-fold from 1,275 to 5,548

- the number of people waiting for inpatient appointments increased by two per cent from 57,776 to 59,199; but the number of people waiting over 12 weeks increased over eight-fold from 208 to 1,772

- the number of inpatients coded as socially unavailable increased from 14,955 (23 per cent of patients on the waiting list) to 17,360 (26 per cent of patients on the waiting list).

These figures vary by NHS board and by specialty. Taken together, the available information suggests potential capacity issues in some boards and some specialties. It also raises questions about how boards were managing their waiting lists. While the Scottish Government and NHS boards recognised capacity pressures and risks to meeting waiting time targets, they did not give enough attention to ensuring that targets were being met appropriately...For example, the Scottish Government did not fully investigate the reasons for the high use of social unavailability codes across a number of boards, and the potential implications for capacity.82 

91. The situation at NHS Lothian came to light because of a ‘whistleblower’ who worked for the Board. As mentioned above, the Audit Scotland field work that informed the AGS report aimed to investigate whether problems at NHS Lothian were indicative of any widespread problems across the NHS. Members of the Committee expressed concern in evidence sessions that the extensive application of unavailability codes, including their inappropriate use, did not emerge as a result of checks and balances in the system. Some members questioned whether they would have come to light were it not for this whistleblower83. The Committee was provided with a number of reasons in evidence why the extent of the increase in the use of codes was not scrutinised in more detail. These are set out below.

Waiting time targets

92. A key finding of the AGS report is that the focus on meeting waiting time targets led to insufficient scrutiny of how they were being achieved.

AGS report: During 2011, the focus within the Scottish Government and NHS boards was on meeting waiting time targets and developing capacity in areas where patients were waiting longer. There was not enough scrutiny of the increasing number of patients recorded as unavailable. Better use of the available information could have helped identify concerns about the use of unavailability codes. It could have also identified wider pressures that were building up in the system around the capacity within NHS boards to meet waiting time targets.84 

93. ISD Scotland’s evidence acknowledged a focus on targets.

ISD Scotland: It is important to look at the context. At the time, social unavailability was a small element of the overall waiting list transition that we were managing. Most of the focus was definitely around achievement of the waiting time targets, progress towards future targets and so on, and not around social unavailability, which was a small part. It was a part that we were looking at, but it did not figure on any of the risk registers as something that people were extremely worried about. The term was not in widespread use.85 

94. Evidence from health boards also suggested that communications between health boards and between the Scottish Government and boards at monthly meetings had a regular focus on performance against national waiting time targets.

NHS Forth Valley: Waiting times would always be something that [health board executives look at together in terms of general performance. Yes, there would usually be a very high-level discussion highlighting any particular issues that we needed to focus on. That would be the general tone of it.86

NHS Tayside: Issues were not raised with us around social unavailability in the lead-up to the Lothian position. You can see from the information that came to us from ISD that the matter was never raised with us at meetings. Social unavailability was never raised with us as an issue at meetings with the Scottish Government access support team. Social unavailability was never raised at any of the national waiting times meetings pre-Lothian, certainly to my knowledge.87 

95. It is worth reiterating, as context to the approach taken by boards, ISD Scotland and Scottish Government, that the overall performance of the NHS, including periods of social availability, was within waiting time targets and therefore arguably, at a national level, there was limited cause for concern (see paragraphs 15 to 17 above).

NHS Forth Valley: I say that in overall terms—that is often what we looked at as a group—the performance, disregarding the stops and wherever anybody was on the list, was relatively good, so we would not have been worried by the global perspective on performance.88 

Awareness of explanations for the trend

96. The Committee also heard evidence to suggest that the increasing use of social unavailability codes may not have been subject to forensic scrutiny because those involved in identifying emerging trends were confident that they had sufficient explanations for the increase in the use of codes.

ISD Scotland: Prior to [New Ways], social unavailability, as you know, was not tracked and put into reports in the way that we currently track and report it...we took the view from the start that, clearly, social unavailability would rise because it was a new thing that we were measuring. We believed that there was a logic that, over time, as board waiting times reduced, essentially the pressure on unavailability would rise…We were aware of the social unavailability rises through the period.89 

97. The relaxing of the sign off requirements for information provided by boards by the Scottish Government in 2011 also suggests the figures showing increasing use of codes were not viewed as a cause for concern.

AGS supplementary submission:…the requirement for Chief Executive sign off on New Ways detailed data returns was not in place from throughout 2011 and early 2012 as the Scottish Government advised that this was no longer required after the New Ways system had bedded in. The sign off was reinstated during 2012.90 

98. The Chief Executive of the NHS in Scotland, Derek Feeley, stated in evidence that he did not think that the Scottish Government should have picked up on the rise in social unavailability before the NHS Lothian situation came to light because the Scottish Government understood the reasons for the rise and took steps to address it.91

Scottish Government: The rise in social unavailability in the period 2008 to 2010 occurred largely for the reasons that we have explained to the committee today. It was not an unexpected rise; it was a gradual and steady rise. Where there was a peak or spike in social unavailability, we looked at that spike and took appropriate action. There was no reason for us to act in any other way.92 

99. Scottish Government officials also confirmed in evidence that, because officials had no real concerns about the quality of the information from boards or the level of use of unavailability codes, the rise in the use of codes was not raised with Scottish Government ministers (this is with the exception of the rise in the use of codes due to the bad winter of 2010/11).93

100. The Committee notes that, as highlighted in the AGS report, there was information available to the Scottish Government to suggest that there were issues with the management of waiting lists in areas with capacity issues, including increases in the level of the use of social unavailability codes (see para 90 above).

101. The Committee appreciates that ISD Scotland and the Scottish Government were aware of reasons that explained an increase in the use of codes. The question is whether the reasons they were aware of fully justified the extent of the increase. The Committee considers that there was scope to scrutinise the increase in the use of codes more closely to ensure that this was occurring entirely for the reasons that ISD Scotland and the Scottish Government cited in evidence. Such work could have brought issues with the misapplication of codes, and the lack of information being kept by health boards, to light earlier.

102. The Committee considers that analysis of national performance figures should be undertaken by ISD Scotland as standard to ensure performance figures are entirely accurate and that patient experiences match the published figures. Verifying that recorded performance against targets is accurate should take place irrespective of whether NHS boards are exceeding or falling short of performance targets.

103. The Committee considers that, in addition to the checks and balances already in place, there is additional information that could helpfully be produced by health boards and ISD Scotland. This would be intended to ensure that, where future trends could be cause for concern, the NHS in Scotland possesses sufficient information to identify all of the causes of these trends and assess whether any improvements can be identified.

104. The Committee recommended above that all health boards should produce monthly information on the level of the use of unavailability codes, broken down by hospital and also by specialty. This should be considered alongside information on capacity pressures in these services to reassure boards of health boards that there are no patterns of codes being used excessively to relieve ‘pressure points’ in service delivery.

105. The Committee further recommends that ISD Scotland should require that this information is provided to it by all boards, in a standard format that allows it to collate these figures into national performance monitoring reports.

106. These reports should be able to identify where capacity pressures are occurring alongside a high incidence of unavailability codes in the same specialties, or in particular health boards, across Scotland. Reports should also detail overall use of social unavailability codes by boards, broken down by the new categories of reasons for social unavailability.

107. Emerging trends from these reports can then be discussed at meetings between chief executives of health boards and also at meetings between chief executives and Scottish Government officials.

The role of ISD Scotland

108. It should be acknowledged, in assessing the extent to which ISD Scotland and the Scottish Government could have identified issues with the figures, that the accuracy and quality of the data produced at health board level is primarily the responsibility of health boards.

ISD Scotland… From where we were standing, we had absolute assurance from each board that the figures that it was reporting were correct...We have to be able to separate activity going on in boards, and the way in which boards govern themselves, from ISD’s role as a keeper of national statistics.94 

109. The Committee welcomes ISD Scotland’s consistent collection of waiting time data from each health board which includes the entire patient wait including any periods of unavailability.

Quality assurance of data

110. The Committee explored with ISD Scotland the exact nature of its role in relation to performance information provided to it by health boards.

ISD Scotland: We routinely look retrospectively at the data that come to us for any unusual patterns. For example, if one board’s figures are an outlier, we will contact it and ask it not so much for an explanation, but to confirm that the data are correct. What we are really looking to do is to ensure that what we have been given is correct and there has not been a mistake somewhere in the submission of the data.95

We were in touch with, I think, three boards about the social unavailability increases that we saw. There was nothing in any of that that we regarded as untoward, or anything that we had as a concern...The organisation’s focus was on ensuring that the statistics were as good as they could be.96

Secondly, when we asked several boards why social unavailability was increasing, technical and operational reasons were usually given for that.97 

111. In evidence ISD Scotland stated that it was comfortable with its statistics, having questioned boards on the basis for unusual looking statistics that contributed to the overall figures.

ISD Scotland: We are comfortable with our statistics. We have talked about the rise in social unavailability, but that was fairly common across the piece. We asked questions when the occasional board looked odd. We have spent a lot of time talking about social unavailability, but that is only a small percentage of everything that the system measures.98 

Level of information provided from ISD Scotland to the Scottish Government

112. The AGS report states that ‘ISD Scotland was not clear about what issues to escalate to the Scottish Government’99 and highlighted examples where the Government did not have ready access to important information.

AGS report: ISD Scotland routinely has access to more information than the Scottish Government, for example retrospective changes to the number of patients coded as unavailable. Information on the level of retrospective changes was not part of the information that ISD Scotland made available to the Scottish Government in 2011 and ISD Scotland was not routinely monitoring retrospective changes at this time. The Scottish Government was not aware of additional information that may have helped identify possible concerns about how boards were meeting waiting time targets.100 

113. ISD Scotland witnesses were questioned in evidence as to whether the statistical anomalies in relation to the use of codes by health boards, which included information on NHS Lothian, had been highlighted to Government officials.

ISD Scotland: It comes down to what you mean by “raise”. If the question is whether the Government was aware of the statistics, in the way that anyone else who was looking at our website would have been aware of them, the answer is yes.101 

114. The Committee does not consider that having information available on a website is of the same value to Scottish Government officials as having anomalies in figures highlighted directly to them.

115. The Committee considers that ISD Scotland should ensure that potentially significant concerns, such as the levels of retrospective changes made by NHS boards, are highlighted to the Scottish Government as standard procedure.

116. The Committee appreciates that health boards are primarily responsible for accuracy of the data collated at health board level. However the Committee considers that scrutiny or audit could have placed more emphasis on:

  • providing additional information on codes, such as high levels of retrospective transactions, to the Scottish Government;
  • highlighting where there were statistical outliers to the general trend to the Scottish Government;
  • looking in more depth at the basis for the continuing increases in the use of codes as opposed to focusing in the main on the statistical outliers; and
  • requiring evidence based responses from health boards on the reasons for their boards producing outlier statistics.

117. The AGS report recommends that the Scottish Government and ISD Scotland should have discussions to clarify:

  • the role of each organisation in monitoring how boards are applying waiting list codes and performing against waiting time targets;
  • the process for raising concerns about issues within individual NHS boards.

118. The Committee recommends that the discussions between the Scottish Government and ISD Scotland that are proposed in the AGS report should cover the extent to which the Scottish Government expects ISD Scotland to:

  • highlight any concerning information, including trends, to the Scottish Government; and
  • seek evidence based responses from health boards on any future anomalies identified.

ANNEXE A: EXTRACT FROM THE MINUTES OF THE PUBLIC AUDIT COMMITTEE

3rd Meeting, 2013 (Session 4), Wednesday 27 February 2013

Section 23 report - Management of patients on NHS waiting lists: The Committee took evidence on the Auditor General for Scotland's report entitled "Management of patients on NHS waiting lists" from—

Caroline Gardner, Auditor General for Scotland;

Barbara Hurst, Director, Tricia Meldrum, Portfolio Manager, and Jillian

Matthew, Project Manager, Performance Audit Group, Audit Scotland.

Consideration of approach - Management of patients on NHS waiting lists (in private): The Committee considered its approach to the Auditor General for Scotland's report entitled "Management of patients on NHS waiting lists" and took evidence from—

Caroline Gardner, Auditor General for Scotland;

Barbara Hurst, Director, Angela Canning, Assistant Director, Tricia

Meldrum, Portfolio Manager, and Jillian Matthew, Project Manager,

Performance Audit Group, Audit Scotland.

The Committee agreed to take evidence, at a future meeting, from NHS Forth Valley, NHS Greater Glasgow and Clyde, NHS Tayside and ISD Scotland, followed by the Scottish Government on issues raised during discussion.

4th Meeting, 2013 (Session 4), Wednesday 13 March 2013

Section 23 report - Management of patients on NHS waiting lists: The Committee took evidence from—

Ian Crichton, Chief Executive, and Susan Burney, Director, Information

Services Division, NHS National Services Scotland;

Professor Fiona Mackenzie, Chief Executive, NHS Forth Valley;

Robert Calderwood, Chief Executive, and Jane Grant, Chief Operating

Officer - Acute Division, NHS Greater Glasgow and Clyde;

Gerry Marr, Chief Executive, and Dr Alan Cook, Associate Medical

Director, NHS Tayside;

Derek Feeley, Director General Health and Social Care and Chief

Executive NHS, John Connaghan, Director for Health Workforce and

Performance, and Richard Copland, Head of Access, Workforce and

Performance Directorate, Scottish Government.

Consideration of evidence - Management of patients on NHS waiting lists

The Committee agreed to defer its consideration of the evidence received at item 2 to a future meeting. The Committee also agreed to allow Audit Scotland to respond to issues raised in the evidence received at item 2, in writing.

5th Meeting, 2013 (Session 4), Wednesday 27 March 2013

Consideration of evidence - Management of patients on NHS waiting lists (in private): The Committee considered the evidence received at its meeting on 13 March 2013 on the Auditor General for Scotland report entitled “Management of patients on NHS waiting lists” and took evidence from—

Caroline Gardner, Auditor General for Scotland.

The Committee agreed to consider a draft report at a future meeting. The Committee also agreed to receive an update from Audit Scotland, later in the year, on some issues raised in the report.

6th Meeting, 2013 (Session 4), Wednesday 17 April 2013

Section 23 report: Management of patients on NHS waiting lists (in private): The Committee considered a draft report on the Auditor General for Scotland's report entitled "Management of patients on NHS waiting lists". The Committee agreed to consider a revised draft, in private, at its next meeting.

7th Meeting, 2013 (Session 4), Wednesday 1 May 2013

Section 23 report: Management of patients on NHS waiting lists (in private): The Committee considered and agreed its report on the Auditor General for Scotland's report entitled "Management of patients on NHS waiting lists". Various changes were agreed to (two by division).


Note of division in private: Mary Scanlon proposed that the following wording be retained as the second sentence of paragraph 20:

It is therefore concerning that Audit Scotland found hundreds of examples, when randomly sampling records, where patients remained on lists for long periods of time.

The proposal was disagreed to by division: For 4 (Iain Gray, Mark Griffin, Mary Scanlon, Tavish Scott), Against 5 (Colin Beattie, Willie Coffey, Bob Doris, James Dornan, Colin Keir), Abstentions 0.

Note of division in private: Bob Doris proposed the deletion of the second sentence in paragraph 20 to be replaced by:

Whilst acknowledging it represents a small number of the transactions randomly sampled by Audit Scotland, it is still concerning that Audit Scotland found hundreds of examples where patients remained on lists for long periods of time.

The proposal was agreed to by division: For 5 (Colin Beattie, Willie Coffey, Bob Doris, James Dornan, Colin Keir), Against 4 (Iain Gray, Mark Griffin, Mary Scanlon, Tavish Scott), Abstentions 0.

The Committee also agreed arrangements for the report’s publication.

ANNEXE B: ORAL EVIDENCE AND ASSOCIATED WRITTEN EVIDENCE

Please note that all oral evidence and associated written evidence is published electronically only, and can be accessed via the Public Audit Committee’s webpages, at:
http://www.scottish.parliament.uk/parliamentarybusiness/CurrentCommittees/29860.aspx

3rd Meeting, 2013 (Session 4), Wednesday 27 February 2013

ORAL EVIDENCE

Caroline Gardner, Auditor General for Scotland;

Barbara Hurst, Director, Angela Canning, Assistant Director, Tricia Meldrum, Portfolio Manager; Tricia Meldrum, Portfolio Manager, and Jillian Matthew, Project Manager, Performance Audit Group, Audit Scotland.

4th Meeting, 2013 (Session 4), Wednesday 13 March 2013

ORAL EVIDENCE

Ian Crichton, Chief Executive, and Susan Burney, Director, Information Services Division, NHS National Services Scotland; Professor Fiona Mackenzie, Chief Executive, NHS Forth Valley; Robert Calderwood, Chief Executive, and Jane Grant, Chief Operating Officer - Acute Division, NHS Greater Glasgow and Clyde; Gerry Marr, Chief Executive, and Dr Alan Cook, Associate Medical Director, NHS Tayside;

Derek Feeley, Director General Health and Social Care and Chief Executive NHS, John Connaghan, Director for Health Workforce and Performance, and Richard Copland, Head of Access, Workforce and Performance Directorate, Scottish Government.

WRITTEN EVIDENCE

Royal College of Nursing Scotland briefing paper on management of patients on NHS waiting times (166KB pdf)

Scottish Government written submission (229KB pdf)

Response from Audit Scotland following evidence session on 13 March 2013 (121KB pdf)


Footnotes:

1 AGS report Management of Patients on NHS waiting lists

2 AGS report Management of Patients on NHS waiting lists – p.3

3 Unavailability codes can also be applied for reasons of medical unavailability – this is where a patient has another medical condition that prevents treatment from proceeding at that time.

4 AGS report Management of Patients on NHS waiting lists – p.3

5 AGS report Management of Patients on NHS waiting lists – p.21

6 AGS report Management of Patients on NHS waiting lists – p.32

AGS, Public Audit Committee, Official Report, 27 February 2013; Col 1214

7 Auditor General for Scotland, Scottish Parliament Public Audit Committee Official Report, 27 February 2013, Col 1226

8 Auditor General for Scotland, Scottish Parliament Public Audit Committee Official Report, 27 February 2013, Col 1238

9 A 9 week target for an inpatient / day case wait applied at that time

10 AGS report Management of Patients on NHS waiting lists – p.29

11 This percentage relates to inpatients

12 AGS report Management of Patients on NHS waiting lists – p.20

13 Scottish Government, Scottish Parliament Public Audit Committee Official Report, 13 March 2013, Col 1314

14 Scottish Government written submission

15 Ministerial statement by the Cabinet Secretary for Health and Wellbeing, December 2012

16 Scottish Government, Scottish Parliament Public Audit Committee Official Report, 13 March 2013, Col 1313

17 NHS Greater Glasgow and Clyde, Scottish Parliament Public Audit Committee Official Report, 13 March 2013, Col 1273

18 Scottish Government written submission

19 Scottish Government written submission

20 AGS report Management of Patients on NHS waiting lists – p.7

21 Audit Scotland, Scottish Parliament Public Audit Committee Official Report, 27 February 2013, Cols 1226-7

22 AGS report Management of Patients on NHS waiting lists – p.30-31 and p.23

23 NHS Greater Glasgow and Clyde, Scottish Parliament Public Audit Committee Official Report, 13 March 2013, Col 1283

24 AGS report Management of Patients on NHS waiting lists - p.23

25 The work underway by health boards as part of action plans recommended by the Scottish Government, including aligning functionality of IT systems, is detailed in paragraph 42

26 AGS report Management of Patients on NHS waiting lists - p.24

27 AGS report Management of Patients on NHS waiting lists – p.23

28 AGS report Management of Patients on NHS waiting lists – p.18

29 NHS Tayside, Scottish Parliament Public Audit Committee Official Report, 13 March 2013, Col 1263

30 NHS Greater Glasgow and Clyde, Scottish Parliament Public Audit Committee Official Report, 13 March 2013, Col 1283

31 AGS report Management of Patients on NHS waiting lists – Exhibit 3, p.11

32 NHS Tayside, Scottish Parliament Public Audit Committee Official Report, 13 March 2013, Col 1298

33 New Ways guidance defines a reasonable offer as one where the patient is: offered up to two dates for an outpatient, inpatient or day case appointment, and given at least seven days' notice.

34 NHS Greater Glasgow and Clyde, Scottish Parliament Public Audit Committee Official Report, 13 March 2013, Col 1274

35 NHS Tayside waiting times arrangements, FTF Audit and Management Services, December 2012

36 Details of FTF Internal audit report in the AGS report Management of Patients on NHS waiting lists - p. 22

37 NHS Tayside waiting times arrangements, FTF Audit and Management Services, December 2012

38 NHS Tayside, Scottish Parliament Public Audit Committee Official Report, 13 March 2013, Col 1301

39 Scottish Parliament Public Audit Committee Official Report, 13 March 2013, Col 1311

40 NHS Forth Valley, Scottish Parliament Public Audit Committee Official Report, 13 March 2013, Col 1302-3

NHS Tayside, Scottish Parliament Public Audit Committee Official Report, 13 March 2013, Col 1301

NHS Greater Glasgow and Clyde, Scottish Parliament Public Audit Committee Official Report, 13 March 2013, Col 1312

41 Ministerial statement by the Cabinet Secretary for Health and Wellbeing, December 2012

42 NHS Tayside, Scottish Parliament Public Audit Committee Official Report, 13 March 2013, Col 1298

43 NHS Greater Glasgow and Clyde, Scottish Parliament Public Audit Committee Official Report, 13 March 2013, Col 1283

44 NHS Tayside, Scottish Parliament Public Audit Committee Official Report, 13 March 2013, Cols 1267-8

45 AGS report Management of Patients on NHS waiting lists – exhibit 10 p.38.

46 The waiting time target for outpatients if 9 weeks, for inpatients it is 12 weeks

47 AGS report, March 2010 Managing NHS waiting lists - p.25

48 AGS report Management of Patients on NHS waiting lists – p.5

49 AGS report Management of Patients on NHS waiting lists – p.17

50 NHS Greater Glasgow and Clyde, Scottish Parliament Public Audit Committee Official Report, 13 March 2013, Cols 1277, 1284 and 1308

51 AGS report Management of Patients on NHS waiting lists – p.35

52 NHS Greater Glasgow and Clyde, Scottish Parliament Public Audit Committee Official Report, 13 March 2013, Cols 1285-6

53 NHS Greater Glasgow and Clyde, Scottish Parliament Public Audit Committee Official Report, 13 March 2013, Col 1284

54 AGS report, March 2010 Managing NHS waiting lists – p.21

55Audit Scotland, Scottish Parliament Public Audit Committee Official Report, 27 February 2013, Col 1234

56 AGS report Management of Patients on NHS waiting lists – p.27

57 NHS Greater Glasgow and Clyde, Scottish Parliament Public Audit Committee Official Report, 13 March 2013, Col 1299

58 ISD Scotland, Scottish Parliament Public Audit Committee Official Report, 13 March 2013, Col 1300

59 Scottish Government, Scottish Parliament Public Audit Committee Official Report, 13 March 2013, Col 1332

60 ISD Scotland, Scottish Parliament Public Audit Committee Official Report, 13 March 2013, Col 1300

61 Scottish Government, Scottish Parliament Public Audit Committee Official Report, 13 March 2013, Col 1332

62 Scottish Government written submission

63 Scottish Government written submission

64 AGS report Management of Patients on NHS waiting lists – p.26

65 AGS report Management of Patients on NHS waiting lists – p.3 and 4 and Exhibit 5, p.19

66 Scottish Government written submission

67 NHS Greater Glasgow and Clyde, Scottish Parliament Public Audit Committee Official Report, 13 March 2013, Col 1264

68 NHS Tayside, Scottish Parliament Public Audit Committee Official Report, 13 March 2013, Col 1266

69 NHS Tayside, Scottish Parliament Public Audit Committee Official Report, 13 March 2013, Cols 1272-3

70 Scottish Government written submission

71 NHS Greater Glasgow and Clyde, Scottish Parliament Public Audit Committee Official Report, 13 March 2013, Col 1263

72 Scottish Government written submission

73 NHS Greater Glasgow and Clyde, Scottish Parliament Public Audit Committee Official Report, 13 March 2013, Col 1263

74 Scottish Government written submission

75 Scottish Government written submission

76 ISD Scotland D2b table - November 2012

77 NHS Tayside, Scottish Parliament Public Audit Committee Official Report, 13 March 2013, Col 1263

78 NHS Forth Valley, Scottish Parliament Public Audit Committee Official Report, 13 March 2013, Col 1287

79 This percentage relates to inpatients

80 This is with the exception of NHS Forth Valley

81 AGS report Management of Patients on NHS waiting lists – p.36

82 AGS report Management of Patients on NHS waiting lists – p.35

83 Mary Scanlon, Scottish Parliament Public Audit Committee Official Report, 13 March 2013, Col 1271-1272

84 AGS report Management of Patients on NHS waiting lists – p.34

85 ISD Scotland, Scottish Parliament Public Audit Committee Official Report, 13 March 2013, Col 1279

86 NHS Forth Valley, Scottish Parliament Public Audit Committee Official Report, 13 March 2013, Col 1287

87 NHS Tayside, Scottish Parliament Public Audit Committee Official Report, 13 March 2013, Col 1265

88 NHS Forth Valley, Scottish Parliament Public Audit Committee Official Report, 13 March 2013, Col 1287

89 ISD Scotland, Scottish Parliament Public Audit Committee Official Report, 13 March 2013, Col 1270

90 Supplementary written submission from the AGS - correspondence 27 March

91 Scottish Government, Scottish Parliament Public Audit Committee Official Report, 13 March 2013, Col 1341

92 Scottish Government, Scottish Parliament Public Audit Committee Official Report, 13 March 2013, Col 1342

93 Scottish Government, Scottish Parliament Public Audit Committee Official Report, 13 March 2013, Cols 1318-9

94 ISD Scotland, Scottish Parliament Public Audit Committee Official Report, 13 March 2013, Col 1272

95 ISD Scotland, Scottish Parliament Public Audit Committee Official Report, 13 March 2013, Col 1278

96 ISD Scotland, Scottish Parliament Public Audit Committee Official Report, 13 March 2013, Col 1270

97 ISD Scotland, Scottish Parliament Public Audit Committee Official Report, 13 March 2013, Col 1271

98 ISD Scotland, Scottish Parliament Public Audit Committee Official Report, 13 March 2013, Col 1304

99 AGS report Management of Patients on NHS waiting lists – p.34

100 AGS report Management of Patients on NHS waiting lists – p.36

101 ISD Scotland, Scottish Parliament Public Audit Committee Official Report, 13 March 2013, Col 1293

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