Audit Scotland has published the findings of its audit of the management of patients on waiting lists at NHS boards today, 21st February.
Its essential message is that measuring the meeting of targets must take second place to real scrutiny of how these ‘performances’ are achieved.
Audit Scotland undertook this study after it was discovered that waiting lists had been manipulated and performance misreported by NHS Lothian during 2011. What is described as ‘an inappropriate use of waiting list codes’ was also identified at NHS Tayside.
Back in 2010, Audit Scotland raised concerns about inconsistent application of waiting lists guidance and underlined the need for better information to enable boards to show they were managing patients properly.
The report released today covers the period from April to December 2011.
The Auditor General’s remarks
Caroline Gardner, Auditor General for Scotland, says: ‘Waiting times are very important to patients and are a major performance target for the health service.
‘The management and scrutiny of the waiting list systems have not been good enough.
‘NHS boards and the Scottish Government must improve the monitoring of boards’ use of waiting list codes if they are to retain public trust and assure patients they are being treated fairly.
‘During the period we reviewed, the Scottish Government and boards were focused on making sure waiting times targets were being met but not giving enough attention to how this was being done.
‘Better scrutiny of the increasing use of social unavailability codes could have highlighted concerns earlier.
‘It also could have identified where waiting times pressures were building in the system.’
Distorting practices identified
The Auditor General, as quoted above, referred to the the need for better scrutiny of the use of ‘social unavailability codes’ – widespread across Scotland in the period covered by the audit.
While it says that the scarcity of documentation makes it impossible to gauge what was human error and what was manipulation, today’s report says:
‘This code [Ed: social unavailability] was intended to give patients more flexibility; periods of time that patients are unavailable for treatment are not counted as part of their overall waiting time.
‘As national waiting times targets shortened over recent years the use of this code rose, from 11 per cent of patients in 2008 to more than 30 per cent in mid-2011.
‘It then started dropping from the end of 2011, around the time manipulation of waiting lists was found in NHS Lothian.’
The inference is clear to all – that this code was indeed in widespread use as a means of creating the appearance of improving performance in managing waiting times – and that its use dropped off when the game was up, with Lothian caught holding the parcel when the music stopped.
However, Audit Scotland has to be formally judicious.
The report simply says of this evidence: ‘The reasons for this are unclear, due to the limitations of waiting list management systems and the lack of evidence in patient records.’ Alongside this it notes that there were a small number of cases where manipulative practice could be proven.
The Government response
Following the report and this call from the national audit agency for better record keeping, better practice and more transparency, the Scottish Government, forewarned and with response in hand, has also announced today that, from this summer, 2013, for 12 months, it is to pilot an advice line on waiting times.
The pilot service will be run by health information service NHS Inform, part of NHS 24.
The advice line is part of a range of measures to increase transparency and understanding of waiting times in Scotland following the Audit Scotland report.
The measures planned are:
- adding waiting list rights advice to the NHS Inform menu
- sending letters to all day case and inpatients confirming any requests to have their treatment delayed for any reason
- improving the training of board liaison officers to enable them to offer specialist advice.
Not a word about improved management of waiting times themselves or of improvement of the scrutiny of such management and of the way their reported results are being achieved.
Not a word on effective record keeping – just more trees felled for letters, a spot of training and a phone line advice service on patient rights in relation to waiting times.
This itself suggests that the current NHS system cannot be relied upon to observe those rights in its own practice until it is forcibly reminded of those rights by one of the very few who feel able to do this.
Yes, knowing your rights is important – but a system which, at source, works in respect for those rights is the key to our malaise.
The reality is that most patients are afraid to complain and to insist upon their rights in case it prejudices the the way they are well treated.
Of those who will complain and insist, few will persist and fewer will achieve any real improvement to their own situation, never mind the general good.
None of these measures the government proposes to take in response to the Audit Scotland report and its call for better, is seriously about improving waiting times and improving the honesty of Health Boards’ reporting.
Health Secretary Alex Neil says: ‘Waiting times are amongst their lowest ever levels in Scotland and they continue to improve.
‘Patients have an entitlement to be treated as quickly as possible but also at a time that fits in with their lives.
‘We want to make sure that patients know what they are entitled to, what they can expect and what options are available to them.
‘This advice line will improve patients experience with the health service and make sure that if they need help and support they will get it.’
This last sentence is optimistic in the extreme, to the point of a happy disengagement with practical reality.
The nature of the planned advice line
We have asked the Scottish Government if the planned advice line on waiting times rights will operate with a choice of key pad options and an automated answer system; or whether it will be a discussion with a human being.
There would clearly be little more than a tokenist value in an automated system designed to meet the needs of the generality of callers in explaining their rights in the matter of NHS waiting times.
We have been assured by a government spokesman that, while there may be keypad options for a caller to choose from, there will a live discussion with a person at the other end of the line.