NHS waiting list scandal puts public trust at risk

Audit Scotland warns that public trust in the system has been jeopardised, and finds numerous examples of patients being listed as “socially unavailable” for treatment, meaning they fall outside waiting-time targets.

However, the authors said that because the management and scrutiny of waiting lists had “not been good enough”, there was a lack of evidence about what had happened to patients.

This lack of monitoring, as the Scottish Government and health boards pressed ahead with cutting waiting times, meant there was not enough information available to Audit Scotland to judge whether patients were taken off lists by mistake or deliberately to meet targets.

The watchdog’s report focuses on the use of so-called “social unavailability codes”, which increased from 11 per cent of patients on the waiting list in 2008 to more than 30 per cent in mid-2011, but then began to fall after the manipulation of waiting lists in NHS Lothian was  discovered.

As use of the codes dropped, the reported waiting times experienced by  patients increased.

Opposition parties said the “damning” report showed that thousands of patients had had their treatment delayed because of the preoccupation with meeting waiting time targets.

The Audit Scotland investigation was ordered after the discovery of manipulation of waiting lists and misreporting of performance by NHS Lothian in 2011. Practices included offering patients appointments in England and taking them off the waiting list when they declined. Inappropriate use of the codes was also reported in NHS Tayside.

NHS boards have come under increasing pressure as waiting time targets have reduced in recent years – from nine months for inpatient treatment in December 2003, to 18 weeks from referral to treatment in December 2011.

Under a system introduced in 2008, aimed at making the system fairer and more transparent, patients unavailable for treatment for medical or social reasons – such as being on holiday – were given a code, meaning the period the patients were unavailable was not included in their waiting times reported  towards the target.

The codes mean there can be large differences between reported and actual waiting times.

For example, Audit Scotland said that only 3 per cent of  patients awaiting treatment had a reported wait of more than nine weeks in the quarter ending June 2011. But 23 per cent had actual waits of more than nine weeks when periods of unavailability were taken into account.

Previous reports found that Lothian and Tayside were applying codes inappropriately. An investigation in Lothian revealed a culture of managers putting pressure on staff to find ways around the system to avoid failure to meet targets, including inappropriate use of the codes.

“Both these events have put public trust in the management of waiting lists at risk,” Audit Scotland said.

But its report, looking at waiting list management between April and December 2011, when the Lothian manipulation came to light, raises questions about whether the practice may have been more widespread. It highlights several examples of questionable use of unavailability codes, but limited evidence for the reasons behind these.

The report said patient management systems used by NHS Highland and Greater Glasgow and Clyde meant Audit Scotland could not identify and extract all the information it needed.

Audit Scotland’s analysis highlighted boards that appeared to have “extensive use” of unavailability codes. These included:

n NHS Greater Glasgow and Clyde, where staff said social unavailability was used extensively for patients who wanted to be seen at a specific hospital. For example, in early 2011, 70 per cent of patients – 900 people – waiting for orthopaedic treatment at the Western Infirmary were coded as unavailable.

n NHS Forth Valley, whose use of a code suggesting patients were willing to wait meant social unavailability in some areas was high compared with other boards. For example, 47 per cent of patients on the ear, nose and throat list were classed as socially unavailable, compared with a national average of 29 per cent.

n NHS Grampian, which in June 2011 had the highest use of unavailability codes in Scotland. For example, 51 per cent of people on the list for orthopaedic treatment had social unavailability codes compared with a national average of 38 per cent.

The report said that towards the end of 2011, when concerns were raised about NHS Lothian, the use of unavailability codes began to reduce and the percentage of patients waiting longer than 12 weeks started to rise across the country.

Audit Scotland said the report’s authors had found a small number of instances where the codes were used inappropriately. But it added: “The limitations of waiting list management systems and the lack of evidence in patient records mean that it is not possible to determine whether these instances were due to human error, inconsistent interpretation of the guidance, or deliberate manipulation of waiting lists.”

Caroline Gardner, Auditor General for Scotland, said: “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.”

Health secretary Alex Neil said: “This report covers a time period which ended 14 months ago and there have been changes to the system since then. The majority of the recommendations in this report are already under way.

“For example, the ability for boards to list a patient as socially unavailable was replaced by a new system last October, where patients will have more flexibility to agree when they want to be treated.”

However, Labour health spokeswoman Jackie Baillie said: “This damning report shows that there are thousands of Scots who have had their treatment delayed as a result of the SNP government focusing on targets, rather than patient care.”