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Waiting Times

– in the Scottish Parliament on 17th May 2012.

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Photo of John Scott John Scott Conservative

The next item of business is a debate on motion S4M-02905, in the name of Jackie Baillie, on health.

Photo of Neil Findlay Neil Findlay Labour

On a point of order, Presiding Officer. I wonder whether you can help me and other concerned members.

Two weeks ago tomorrow, the appalling report into the management culture at NHS Lothian was passed to the cabinet secretary. She sat on the report for a week before releasing it last Friday morning, when MSPs were safely out of the way back in their constituencies. Since then, there has been no statement from the Government, and no opportunity for constituency and regional members to raise points. Yesterday in the Parliament, members had to endure a non-debate on a parenting strategy that does not exist. Why did the Government not use that time to allow questions or a debate on the dreadful situation at NHS Lothian? Why has it taken Opposition time and an Opposition motion to drag the cabinet secretary to the chamber to break her uncharacteristic silence? Presiding Officer, members are supposed to hold ministers to account on behalf of our constituents. Can you please help us to carry out our duties?

The Deputy Presiding Officer:

Thank you. The business that is brought to Parliament is a matter for the Parliamentary Bureau, as you are aware. Government business is brought to the chamber by the Minister for Parliamentary Business and Chief Whip. That is not a point of order, but there will be an opportunity during this debate should the cabinet secretary wish to refer to your point.

I now call Jackie Baillie to speak to and move her motion. I trust that members have pressed their buttons if they wish to speak.

Photo of Jackie Baillie Jackie Baillie Labour

I welcome the opportunity to debate waiting times. We all know that if someone is ill, it can be an extremely worrying time. Getting a diagnosis and then getting treatment are, of course, essential to their recovery and wellbeing. We all appreciate that. We have family and friends who have waited anxiously for treatment, and we have constituents who are coping with that stress right now.

Anything that reduces waiting times is very welcome indeed and, like many other members, I am sure, I commend national health service staff for their unstinting efforts and hard work to minimise waiting times and provide the best possible treatment for patients. Progress has been made.

Members will be aware of the scandal of hidden waiting lists that has been exposed at NHS Lothian in recent weeks. Patients appear to have been offered treatment in England rather than in NHS Lothian as a means of removing them entirely from the waiting time guarantee. If the offer of treatment in England was refused, the patient was deemed to be unavailable and therefore exempt from the guarantee. Those patients were simply removed from the waiting list.

Not content with that sleight of hand, which denied people their rights, NHS Lothian went further. It adjusted the data retrospectively to make it appear that it was meeting waiting time targets. As many as 1,417 patients were wiped off the list in that way. If anyone is in any doubt about whether that was deliberate, they need only look at the situation now. In the space of just a couple of months, NHS Lothian has gone from no people breaching the waiting time guarantee to 3,500 people breaching the waiting time guarantee. That is simply extraordinary.

Just last week, we saw the publication of a damning report exposing the bullying and intimidation of staff in NHS Lothian with regard to achieving waiting time targets. I do not believe, unfortunately, that the deliberate distortion of waiting times or the culture of bullying and intimidation is confined to NHS Lothian.

If we take even the most cursory look at the numbers of those patients who were deemed to be unavailable for social reasons and were therefore dropped from the waiting time guarantee, there is a dramatic and unexplained rise since 2008 across Scotland. In 2008, the number of patients in that category was 4,967. As of last December, it was 15,824. The high point was in June 2011, when 20,662 patients were removed from the waiting time guarantee. That represents a fourfold increase in just a few years.

Photo of Jackie Baillie Jackie Baillie Labour

In a minute.

I welcome the fact that the figures are now going down, but if we are honest, that has happened only since the problem at NHS Lothian was exposed.

The same is true across the country, not just in Lothian. We need only look at the local pictures to see the truth of that. In NHS Ayrshire and Arran, the number of people who were removed from the waiting time guarantee was up threefold. In NHS Fife, the figure was also up threefold. NHS Grampian’s figure was up fivefold, and NHS Greater Glasgow and Clyde and NHS Lanarkshire’s figures saw a fourfold increase.

Photo of Nicola Sturgeon Nicola Sturgeon Scottish National Party

I have a genuine and very simple point, which I make in the interests of accuracy. Jackie Baillie just said something that I am sure she will concede was inaccurate. Would she care to correct what she said and concede that patients who have a period of social unavailability do not have their waiting time guarantee removed?

Photo of Jackie Baillie Jackie Baillie Labour

I think that the cabinet secretary is dancing on the head of a pin. Patients in those circumstances do not have a waiting time guarantee. This is far too important a matter for us to divide on issues of semantics; it is incredibly important. People outside the Parliament will not understand the cabinet secretary’s intervention.

The cabinet secretary’s amendment, which I studied closely, recognises that waiting times need to be monitored—and so say all of us—but the practice in question has been going on for the past four years. Was the situation monitored at any time over that period? Was the cabinet secretary told about the increases? Has she been let down by her civil servants, or did she know? Why has no action been taken before now?

There were warning signs. ISD Scotland—the people in Government who are responsible for collecting the waiting time statistics—takes great pains to ensure the validity of its data. It is quoted in The Sunday Times as saying that

“several health boards over the last few years” had been warned about the

“high levels of social unavailability”.

Again, I must ask whether the cabinet secretary knew and, if she did, what she did about it. Did her officials simply not tell her?

In 2010, Audit Scotland produced and published a report that highlighted concerns about the way in which patients and their waiting times were recorded. At the time, Audit Scotland said:

“NHS boards vary in how they deal with patients who do not or cannot attend appointments and this may not always be appropriate.”

It went on to say:

“The report also finds that the NHS is not accurately recording all relevant information about patient waits which makes it difficult to demonstrate that it is managing all patients correctly in line with the new guidance.”

That is too true. Here is an early warning sign, if ever I saw one. It was a matter of public record.

What did the cabinet secretary do to address those concerns? My fear is that the early warning signs were not heeded. After all, just days before the publication of the Audit Scotland report in 2010, the cabinet secretary addressed the annual Scottish National Party conference. On waiting times, she promised that

“All patients are now covered by the guarantee and no one—no one—is on a hidden waiting list.”

We know now that that is simply not true. What we have with the unavailable for social reasons category is nothing short of the SNP’s hidden waiting list. More than 20,000 people have no waiting time guarantee because they have been removed from the list to massage the figures.

It would be bad enough if that were the culture in just one health board, but there is mounting evidence that the use of the social unavailability category is much wider. Frankly, it is not good enough for health boards to inspect themselves, which is the option that the cabinet secretary favours. I believe that the people of Scotland deserve much greater openness and transparency, so I was delighted that Audit Scotland responded positively to our request for a Scotland-wide independent review. In its letter to me, it said:

“We share the widespread concern that there is evidence pointing to an inappropriate use of this code (describing patients as unavailable for ‘social reasons’ so they are removed from waiting lists)”.

Despite that, the cabinet secretary continues to deny that there is a problem, other than in NHS Lothian.

I turn to the culture of bullying and intimidation. It is shameful that any member of staff in the NHS should be treated in the way that was described in the NHS Lothian report. When shouting at clinicians and nurses in general surgery to move people on before it is clinically appropriate to do so becomes routine, we should all rightly be concerned. Such behaviour is unacceptable, but such was the pressure on achieving targets, both internally and externally, that a perverse incentive was created to distort waiting time figures.

The report makes for uncomfortable reading. Staff were afraid to report their concerns for fear of reprisal. In a recent freedom of information request by my colleague Richard Simpson, we asked all health boards how many cases there had been of whistleblowing or of concern. The response from NHS Lothian was that there had been none—there was not one recorded case of any concern having being raised about anything at all. If ever something underlined the case for a whistleblowing hotline, that response alone does.

There is a hotline in England and Wales, but the cabinet secretary resists having one in Scotland. One would be forgiven for thinking that she has something to fear from such an approach, given the level of resistance. However, whatever the reason, there can be no excuse for delaying any longer. I hope that the cabinet secretary heeds that call.

The cabinet secretary believes that the issue is just about NHS Lothian and that there is no problem anywhere else in the NHS. Again, I say that she is in denial. The British Medical Association has said that feedback from its members—the very doctors who deliver for patients on a daily basis—shows that the culture is not isolated to NHS Lothian and is more widespread.

I do not have a problem with the principle of setting targets, as they help people to focus minds and concentrate on what matters, but there must always be a balance between speed and clinical priorities. I fear that we are distorting clinical priorities in a way that is unhelpful to patients.

The SNP amendment is revealing. The approach is to deny that there is a problem and, if that does not work, to blame somebody else. If that, too, fails, the approach is to adopt the view that attack is the best form of defence. The amendment attacks the previous Labour-Liberal Democrat Administration. I regret the approach that health boards adopted that resulted in too many people being placed on availability status codes, thereby removing their waiting time guarantee. That was well over seven years ago. It was not acceptable then and it is certainly not acceptable now. There were fundamental differences, but I am running out of time, so I will not be able to explore them all.

We should compare that previous situation with the cynical manipulation of figures by the SNP, involving the use of social unavailability codes and offering patients operations that they could not possibly attend. There is no excuse for that sleight of hand and distortion of statistics, or for the wholesale removal of 20,000 people from their waiting time guarantee. The cabinet secretary must act now to stop the figures being fiddled.

I move,

That the Parliament welcomes the progress on waiting times since 1999 underpinned by the hard work of NHS staff, however notes that recent progress has been in a context of declining staff numbers; also welcomes the principle of the New Ways waiting times system initiated by the previous Labour-Liberal Democrat administration and implemented by the current SNP administration; however believes that, for waiting times guarantees to be meaningful, the public must have confidence that published statistics are a true reflection of actual waiting times; therefore expresses concern at reports identifying the misuse of social unavailability codes in NHS Lothian as well as allegations of a culture of bullying and intimidation in relation to meeting targets, particularly given that an internal investigation failed to fully uncover such problems; also notes that the NHS Information Services Division (ISD) figures show that the number of patients across Scotland being removed from normal waiting time guarantees for so-called social reasons increased from below 5,000 to as many as 20,662 for inpatient or day-case admissions between 2008 and 2011; is alarmed by newspaper reports that the ISD has raised concerns about high levels of social unavailability with a number of NHS boards in recent years; also notes the comments of Audit Scotland that it shares widespread concern that there is evidence pointing to the inappropriate use of this code and therefore welcomes the decision by the Auditor General for Scotland to carry out an independent examination of the use of social unavailability codes by NHS boards across Scotland, and believes that this is a necessary step if confidence is to begin to be restored in the integrity of published waiting times statistics and to properly establish that there are no hidden waiting lists.

Photo of Nicola Sturgeon Nicola Sturgeon Scottish National Party

I welcome the debate. I know how important waiting times are to the public and I am proud of the Government’s record on waiting times. I pay an unequivocal tribute to NHS staff. I know how challenging their jobs are, particularly in the current climate. They do a fantastic job and they deserve our thanks—not thanks with a “but” at the end, but our unqualified thanks, which is what they get from SNP members.

Before I turn to the staff’s progress on waiting times, I take the opportunity to thank staff for another extremely important achievement. Yesterday’s annual report from Health Protection Scotland confirmed the dramatic reduction in healthcare associated infection in recent years. There will always be more to do on that agenda, but we should not underestimate the amount of work that has been involved in reducing Clostridium difficile by 35 per cent and MRSA by 40 per cent in the past year alone. I am grateful to everyone who has been involved in that and I put on record my thanks to them.

Photo of Neil Findlay Neil Findlay Labour

That is all very well, but the staff do not want the cabinet secretary’s thanks; they want a safe working environment in which they are respected and in which they can perform the caring role that they engage in every day. They do not want the cabinet secretary’s thanks; they want action.

Photo of Nicola Sturgeon Nicola Sturgeon Scottish National Party

That is what they will get for as long as this Government is in charge.

If anything, progress on waiting times is even more impressive than progress on healthcare associated infection. Waiting times for in-patients and out-patients, and now for the whole patient journey, are at record lows. On cancer, the 62-day guarantee, which was set by the previous Labour Government but never even nearly delivered during its entire term of office, is now being consistently met, as is the newer 31-day target. As of October this year, we will for the first time have enshrined in statute a new 12-week treatment time guarantee.

Photo of Nicola Sturgeon Nicola Sturgeon Scottish National Party

I will make some progress and give way shortly.

All that progress is the result of the hard work and the commitment of tens of thousands of NHS staff, whose hard work is delivering better, quicker treatment for hundreds of thousands of patients. What happened in NHS Lothian was completely unacceptable, and it is of paramount importance that there is trust in, and transparency around, waiting times. I will return to both points in a few moments.

To imply, without evidence, that the massive achievement of staff, under this and previous Administrations, is somehow not real, is to do a massive disservice not to me or the Government but to every member of NHS staff whose hard work has delivered record low waiting times.

I say, genuinely and sincerely, to Labour, or indeed to anyone else, that if anyone has evidence that waiting time rules are not being applied properly in any board, bring it forward and it will be thoroughly investigated. If the evidence is found to have any substance whatsoever, the matter will be dealt with immediately and appropriately. Let me make clear again that I will not tolerate the manipulation of waiting times. However, suggestion and insinuation should not be used to undermine the efforts of staff, because, frankly, they deserve much better than that.

Photo of Richard Simpson Richard Simpson Labour

Let me be quite clear: the cabinet secretary is saying that she will not ask questions when she sees variation. The NHS Lothian figures were in the public domain, and there are many more figures in which there is substantial variation. However, the cabinet secretary says that she will not bother asking questions.

Photo of Nicola Sturgeon Nicola Sturgeon Scottish National Party

That is not what I am saying, and Dr Simpson knows that. I will come on in a second to exactly the questions that I am asking.

As I said, what happened in NHS Lothian was completely unacceptable. It is beyond the pale that any patient was made to wait longer than they should have done as a result of manipulation of waiting time figures. The culture that resulted in those malpractices—described in the report that I received last Thursday and that was published on Friday—is equally unacceptable.

The fact is that as soon as the practices came to light, they were investigated, exposed and dealt with. That is as it should be, and that is how it will always be under this Government. Let us remember that it was this Government that finally implemented the new ways waiting time system, and that it was this Government that abolished the hidden waiting lists officially known as availability status codes.

Let us remind ourselves of exactly how Labour’s ASCs worked. Patients who were given a code lost their waiting time guarantee altogether and were dumped on a list and forgotten about—Labour ministers used to deny their very existence. That list of Labour’s forgotten patients had peaked at 35,000 by the time that we took office. I take waiting times very seriously, but I will take no lessons from Labour on the transparency of our waiting time statistics.

Photo of Nicola Sturgeon Nicola Sturgeon Scottish National Party

No. I want to make progress.

The social unavailability aspect of the new system is nothing like the old, discredited system of Labour. The new system gives patients more choice in their treatment times to accommodate personal circumstances or deal with other underlying medical conditions. The fact is that that becomes all the more important the shorter that waiting times get. Unlike the situation with Labour’s system and contrary to what Jackie Baillie has told members in the chamber today, patients who have a period of social unavailability do not lose their waiting time guarantee.

Photo of Nicola Sturgeon Nicola Sturgeon Scottish National Party

Their waiting time clock stops for the time that they are unavailable and, for 75 per cent of patients who have a period of social unavailability, it is a period of less than three weeks—those are the facts.

We have a transparent system, but we must always ensure that it operates as it should and that the public have confidence in it. That is why I have asked all boards to conduct a detailed internal review into their waiting time management. Audit Scotland has approved the remit. Its objectives are to ensure that individual patient records are accurate; that systems are in place to ensure that patient management systems cannot be inappropriately changed; that reporting on waiting times is accurate and consistent; and that local guidance is consistent with national guidance.

The Deputy Presiding Officer:

The minister is in her last minute.

Photo of Nicola Sturgeon Nicola Sturgeon Scottish National Party

We will ensure that the findings of those investigations are made available not just to the Government, but to Audit Scotland. I welcome Audit Scotland’s announcement that it is carrying out a separate, further audit.

This Government will never ever shirk its responsibilities to patients: it will immediately expose any issues that arise and move swiftly to resolve them. However, we will also stand up for the record and achievements of staff who deliver so well for patients and who, thanks to the support and investment of this Government, are delivering record low waiting times for the benefit of patients all over Scotland

I move amendment S4M-02905.1, to leave out from first “welcomes” to end and insert:

“recognises the substantial progress made in reducing waiting times under both this and previous administrations; recognises that this is due to the hard work of all NHS staff in delivering shorter waiting times for patients across Scotland and in particular commends staff for continuing to achieve the 62-day cancer time target that was missed during the last Labour-led administration; welcomes the Patient Rights (Scotland) Act 2011 and the introduction of the treatment time guarantee later this year, which will help ensure that there is no return to the hidden waiting lists of the last Labour-led administration under which over 35,000 patients were denied their treatment guarantee; recognises that waiting times targets need to be properly monitored and therefore welcomes the forthcoming NHS boards’ reviews of their waiting times practices; further welcomes the fact that Audit Scotland will conduct a separate review of waiting times to build on its 2010 review, and believes that, taken together, these reviews will provide assurance about the transparency of waiting times across Scotland.”

Photo of Jackson Carlaw Jackson Carlaw Conservative

Dear, dear. It is difficult not to be depressed by the two opening speeches—not that there were not things within them that were of interest or true. The next election is in 2016 and we are having the debate only days after the publication of one of the most serious and damning reports that I have seen. If Jackie Baillie and Nicola Sturgeon want to go toe to toe, we will set up a boxing ring in the garden lobby and they can do so. Frankly, the public outside do not want to know what the previous Labour Government did or did not do, and they do not particularly want to know whether Nicola Sturgeon has done this, that or the next thing.

The failure that is identified in the report lies with Lothian NHS Board, and the report is one of the most damning indictments that I have seen. The concern of everybody in the chamber and beyond is about not only what was going on in Lothian NHS Board, but whether there is any suggestion that the practice could be more widespread and whether we should have concerns elsewhere. I accept that both sides believe that to be the case, but that should be the point around which the debate is centred and on which we are united. We are not having a hustings contest for last year’s election.

The one bright spot in all this is the clear evidence that staff at every level of Lothian NHS Board have a sincere appreciation of the job that they are doing and a profound commitment to it. Tribute has been paid to those staff, and anybody who has been involved in investigating any of this has given them nothing but credit for their effort and for the job that they have done.

The question is whether the practice is isolated or whether there are signs of concern elsewhere, beyond the scope of the report. I therefore welcome what the cabinet secretary has done in giving Audit Scotland a remit to look at other boards. Are there signs that, over time, such concerns have arisen? There are ways in which we could look at that to see whether signs have been emerging. The compensation that boards have paid has gone up from £2.7 million in 1999 to £26 million in 2009. When we have talked about compensation in the past, I have asked whether there has been a chain of accountability from that compensation back to the problem that was at its source or whether it has been used as a convenient way simply to park the issue and move on. That issue arose during the recent scandal in Ayrshire and Arran NHS Board, when it was clear that the effort all the time was to present, on behalf of the management, the best possible case without necessarily learning any lessons.

Photo of Richard Simpson Richard Simpson Labour

Would the member be surprised to learn that NHS Ayrshire and Arran failed to record 26 per cent of its referral-to-treatment notifications? Twenty-six per cent of episodes were not recorded by NHS Ayrshire and Arran—the same health board that he has just referred to.

Photo of Jackson Carlaw Jackson Carlaw Conservative

Naively, I am surprised. I would have thought that anybody should be surprised. Not only am I surprised, I am appalled. The situation needs to be investigated more widely.

The Bowles report paints a familiar picture of the present system of accountability sometimes giving people objectives and accountability without authority and of concern about how levels of detail often result in paralysis. I am concerned that that is what may be happening in local government, given the way in which we keep pushing things down to councils without giving them the correct level of authority. Given the issues of accountability, management practice and blame culture that the report identifies, if we are to take any lesson from the report it should be that we must stop blaming each other and focus on resolving the situation.

I am sure that, in the course of the debate, we will hear from Lothian members who have their own specific examples. I will return to them and to the report’s recommendations in my summing up.

The Government meets all the health boards annually in public session, but there is a lack of opportunity for members of the public to intervene in those proceedings. Many have complained about the small window for them to contribute, and it does need to be much greater.

I will comment on whistleblowing when I sum up. My final point at this stage is about work ethic. There is a concern that chief executives of health boards sometimes think that their role is to work less than the people who work for them. In fact, they should be working harder than the people who work for them. It is clear that, in the case that is covered by the report, the commitment was from the people who were doing the job at the coalface and not from the people who were responsible for ensuring that what they did was properly reported, that it was effective and that it put patient care first.

Photo of Elaine Smith Elaine Smith Labour

We come to the open debate. We are tight for time so, unfortunately, I will not be able to give time back for interventions. Speeches should be of four minutes.

Photo of Mark McDonald Mark McDonald Scottish National Party

I do not think that it is helpful to cast around aspersions and innuendo as to the motivations that lie behind decisions that are taken at NHS level, of which more later.

I was interested in Neil Findlay’s point of order. Although I am by no means an anorak on standing orders, I understand that there is an opportunity for any member to speak against the business motion. However, I do not recall that Neil Findlay or indeed anybody else chose to speak against the motion that set out the chamber business for this week, which included yesterday’s constructive and interesting—for the most part—debate on the national parenting strategy. However, what is a little political posturing between friends?

I have no constituency locus in the NHS Lothian situation and I would not seek to interfere given that I do not have an acute interest in it. I know that my colleagues who represent the area will undoubtedly have things to say on the situation. Needless to say, however, I think that the cabinet secretary’s response to it has given no lie to the fact that the Government views it in the most serious of terms. Some people could seek to fault the way in which she has chosen to intervene, as Mr Findlay has done, but they would do so for entirely the wrong reasons. We believe, and I am sure that most reasonably minded members would agree, that the cabinet secretary has responded in the most appropriate fashion.

Photo of Mark McDonald Mark McDonald Scottish National Party

I am sorry, but I have only four minutes. I am sure that the intervention would have been interesting. Some other time.

As a member who represents North East Scotland, I was interested to read a press release on Jackie Baillie’s website—yes, I am the one person who visits it—-that states:

NHS Tayside was ... dragged into the scandal.”

As a regional member for North East Scotland, I received the letter that Sandy Watson, the chairman of NHS Tayside, sent to Jackie Baillie seeking to correct her. He wrote:

“I am writing to you in response to the concerns that the Scottish Labour Party has raised about the management of waiting times lists in NHS Tayside ... The figures reported in The Sunday Times related to numbers of patients waiting for a new outpatient appointment. The example highlighted was that in November 2011 ISD said there were 21,032 patients waiting for a new outpatient appointment and this was subsequently revised to 18,815 patients. This was reported as ‘patients being removed from the waiting list’.

The reason for this revision, which we gave to both ISD and The Sunday Times prior to The Sunday Times publication, is transparent, straightforward and is entirely consistent with normal and acceptable routine working practice. It is not in any way related to the removal of patients from waiting lists ... I am sure you will agree with me when I say that in the talk of all these statistics patients are the most important thing and we will never forget that.”

Neither will the Government. I am sure that Ms Baillie did not mean to omit this matter from her opening speech

Photo of Mark McDonald Mark McDonald Scottish National Party

I am in my final 40 seconds, so I cannot.

I am sure that Ms Baillie merely ran out of time before using the opportunity to apologise to the hard-working and dedicated staff of NHS Tayside for the innuendo that she cast on them in the press in that manner.

For the benefit of other members, I will be happy to place a copy of the letter that I received in the Scottish Parliament information centre, as I am sure Jackie Baillie would have done, as she was the main recipient of it. It ill behoves any member to cast around innuendo and aspersions that do nothing to affect positively the morale of NHS staff. It would be far better if members paid attention to the matter at hand rather than seeking to score petty political points at the expense of our NHS staff.

Photo of Sarah Boyack Sarah Boyack Labour

I want to focus on the NHS Lothian report, because the revelations that emerged are deeply disturbing. From an individual report that highlighted the unacceptable offer of treatment for NHS Lothian patients in England, a systematic approach to manipulating waiting time figures and a culture of bullying were exposed.

The investigation of the management culture in NHS Lothian has provided evidence of suppression of information and an oppressive management style that contributed to a situation in which information on poor performance was not passed up the management structure, there was a no-bad-news culture, and staff were pressured to find solutions without support. That culture is clearly at odds with the stated values of the health board, which place patients first and foremost but put a premium on staff motivation and organisational reputation. Therefore, the report highlights tough questions that need to be answered. I am disappointed that the cabinet secretary commented only that what the report says went on was beyond the pale.

We all agree that waiting times matter—patients value them and staff work hard to deliver them—and we all want people to have confidence in NHS Lothian and the NHS in every other part of Scotland, but the report identifies that there is clearly still a problem with hidden waiting times. Richard Simpson’s intervention highlighted that. The management culture in NHS Lothian, which allowed the situation to persist, existed for some time and the behaviour became viewed as normal by staff. That is unacceptable.

Neil Findlay was absolutely right to say that it is not enough to acknowledge the dedication of staff. We have to look at the background of the report and the issues that were identified, and put together action. It is unacceptable for patients to be cared for by staff who are already under pressure without the additional stress of an oppressive management style. The unwillingness of staff to use whistleblowing policies due to a lack of confidence must concern every single member. Despite the clear evidence of bullying behaviour that the report identifies, the situation did not come to light for years rather than months. There are strong unions in NHS Lothian, but the staff did not go to them or whistleblow. There is a clear issue to do with staff being afraid.

The report is shocking and, having read it, I still have questions for the cabinet secretary. Did the Scottish Government allow the former chief executive to leave during the inquiry? Was that passed up to the cabinet secretary or her officials by NHS Lothian?

There is a clear governance and accountability issue in the report. As I said, I still have questions that I cannot answer even from reading such a detailed report. There is a paradox in it. NHS Lothian has won Investors in People accreditation, so it is clear that there is very good practice in it, but there is an oppressive management culture overall, and the report does not really pin that down.

We cannot just brush over matters and look to the future. We must ask what the interrelationship is between reductions in staff numbers, pressures on funding and oppressive management cultures. It is not enough to have some good workshops in the future; we must ask whether those issues are related.

It troubles me that it was patients who blew the whistle on waiting times. We would always expect staff to do that, but the staff in NHS Lothian were too afraid. Dr Richard Simpson’s proposal to establish a whistleblowers hotline is therefore crucial. There is evidence in England and Wales that that needs to be looked at. It is a clear issue on which we need to seek action.

We have the report on NHS Lothian, but there are huge pressures and significant population increases. Delivering excellence with tight funding is acknowledged to be a challenge, but there are still unanswered questions, and I would like the minister to reflect on them in summing up.

Photo of Jim Eadie Jim Eadie Scottish National Party

I welcome this important and timely debate on waiting times in NHS Lothian following the publication of the PricewaterhouseCoopers report in March and the subsequent investigation into its management culture, which was published last Friday. There can be no doubt but that trust and public confidence in NHS Lothian have been severely undermined since it came to light that managers at the health board deliberately doctored medical records to falsely record patients as being unavailable for treatment in order to meet waiting time targets. That behaviour, which the cabinet secretary has rightly referred to as a “betrayal” of patients, is totally unacceptable, has been roundly condemned and has no place in any part of our national health service.

It is the duty of Government to take swift action wherever and whenever such behaviour comes to light. That is exactly what the cabinet secretary has done in relation to NHS Lothian. She has acted swiftly and decisively following the investigation by requiring that all territorial health boards undertake a detailed audit of local waiting times management, with Audit Scotland agreeing the remit of the audit. In March 2010, Audit Scotland stated:

“The NHS in Scotland has made big changes in how it manages waiting lists since 2008 and these have made the system fairer for patients.”

Photo of Richard Simpson Richard Simpson Labour

I am slightly concerned about the fact that the published record of the spike in retrospective use of the exceptional way of dealing with social unavailability occurred in June and July 2011, yet it is only after having received the report nine months later that we are discussing the issue. Nothing was done on the basis of the published figures for months, until I raised the matter in Parliament last autumn.

Photo of Jim Eadie Jim Eadie Scottish National Party

I accept that the member has a track record on the issue and I give him credit for that. However, the idea that the SNP Government has anything to be ashamed of is ludicrous. It is the SNP Government that has overseen the implementation of new ways of managing waiting lists.

Photo of Jim Eadie Jim Eadie Scottish National Party

I have just taken an intervention, so I would like to make some progress.

I agree with other members that the public need to be assured that waiting times practices throughout Scotland are completely transparent and that the experience in NHS Lothian is isolated to that board and is not typical of the wider management culture in the NHS.

As we have heard again during the debate, the PricewaterhouseCoopers report found unacceptable levels of manipulation of waiting times figures. As a result, a separate critical incident investigation is under way.

At the beginning of March, the cabinet secretary took charge by insisting that PWC report to her and not to NHS Lothian as the health board would have wished. That ensured the appropriate corporate governance and we can now see that that robust approach was the right one, despite the very public protestations from Lothian NHS Board and the chair of the board at that time.

I agree with the comments made by Sarah Boyack who, in a powerful speech, sought to address some of the serious issues in the management culture at NHS Lothian. Members have rightly been concerned to ensure the independence of the investigation, and I acknowledge David McLetchie’s contribution in that regard. I believe that the process of investigation has been independent and that the recommendations offer a clear way forward. The report suggested that there should be a change in leadership style to a more co-operative approach; that values should be embedded in the organisation that make clear the difference between bullying and firm management; that trust and confidence should be re-established through a zero tolerance bullying and harassment policy; that there should be an external helpline; and that exit interviews should be carried out when staff leave the organisation.

Along with all my parliamentary colleagues, I have been appalled at what has happened. In implementing the recommendations, we need to see swift and decisive action by NHS Lothian to match that already taken by the cabinet secretary.

Photo of Richard Lyle Richard Lyle Scottish National Party

Although I agree that the situation that developed in NHS Lothian was unacceptable, I note that the cabinet secretary took swift and direct action to remedy the situation. I also note the announcement on 3 May that Audit Scotland has agreed the remit for health boards to review their waiting times practice. Those measures have been introduced to provide assurance that waiting times practices throughout Scotland are completely transparent.

Further to that, all health boards will embark on a detailed audit of local waiting times management and process as indicated in their internal audit programme for 2012-13.

Photo of Richard Lyle Richard Lyle Scottish National Party

No. I will do a Jenny.

Those audits will give the public unprecedented confidence in the waiting times system, which is currently delivering the shortest waiting times on record. In particular, in NHS Lothian, 76.5 per cent of in-patients and day cases were waiting less than the nine-week national standard.

As for the claim that NHS boards are manipulating waiting time figures to meet targets, was it not the SNP Government that abolished Labour’s hidden waiting lists, on which up to 35,000 patients were left with no waiting time guarantee? Scottish Labour hid the figures then, so it is rich that Scottish Labour raises the issue today. Meanwhile, the SNP Government has followed through with an 18-week waiting time. In December 2011, 92 per cent of patients were seen and treated within their target period.

In the relatively short time for which the Government has been in power, the NHS has met the 62-day cancer waiting time target, which I believe Labour failed to meet for the entire time that it was in government. In addition, targets have been met ahead of schedule.

I acknowledge that the PricewaterhouseCoopers report that was published in March 2012 found unacceptable levels of manipulation of waiting time figures in NHS Lothian, but the cabinet secretary has taken direct action to solve the alleged problems, and I compliment her on that swift action. [Interruption.] Labour members never like it, do they?

Photo of Richard Lyle Richard Lyle Scottish National Party

No.

NHS Lothian was required to investigate

“why such a culture exists in NHS Lothian, what the reasons for it are and what needs to be done about it”.

A steering group commissioned an independent report to investigate the allegations. That report found a blame culture caused by inappropriate management styles but found that most staff were not affected by the cultural problems. The report complimented the immense pride that many staff have in working for NHS Lothian and the excellent teamwork that is evident in many departments.

Trust and confidence should be re-established through better staff engagement; a zero tolerance bullying and harassment policy should be introduced; and exit interviews should be carried out with staff who leave. The approach should be reviewed in six to nine months through confidential interviews with managers.

I welcome the report and take on board the points that are raised in it. There is no evidence that such practices are more widespread, and the reviews that the SNP Government has commissioned will confirm that waiting time practices throughout Scotland are completely transparent.

The Deputy Presiding Officer:

I remind members to use full names when referring to other members.

Photo of Neil Findlay Neil Findlay Labour

I declare an interest, in that my wife is an NHS Lothian employee.

Not only did the cabinet secretary not come to the chamber to make a statement on the report but, now that we have a debate, she has been in the chamber for only a few speeches. I have no idea where she is, and she might at least have had the courtesy to remain to listen to members’ speeches.

I was shocked but not all that surprised by the findings of the report into the management culture at NHS Lothian, which exposed outrageous practices, threatening behaviour and the use of unacceptable language against staff, such as

“If you don’t reach your targets you can collect your P45” and

“those of you with mortgages and career aspirations had better be afraid”.

Such words and tactics are those of playground bullies, not caring professionals.

All this was prompted by the blatant manipulation of the waiting time figures. We have now uncovered what was going on, and it is clear that waiting times and the management culture are inextricably linked.

In looking into the issues, we are entitled to ask when the Scottish Government was first alerted to the bullying culture at NHS Lothian. Were the actions those of a rotten few, or was there a toxic mix of unrealistic Government demands against a backdrop of staff and resource cuts? Why does such a culture exist and what is to be done about it? How has the intolerable pressure that is being placed on the remaining staff, who are striving to meet waiting time targets, impacted on patient care? We need answers to those questions and many more.

I think that Sarah Boyack referred to the Investors in People report of November 2010, which started to expose some of the issues. It highlighted how

“some senior managers bully us with constant targets targets targets shouting and relentless pressure” and said that leadership was

“based significantly on the hierarchy and power and was often described as ‘command and control’.”

Terms such as “bullying”, “blame culture” and “fear” were littered throughout the report. Why did no one at NHS Lothian or Government level do anything about that at the time? What did the chairman and the board do? Did they inform the Scottish Government?

I am glad to see that the cabinet secretary has returned from her travels. Will she tell us when she knew about the problems at NHS Lothian? I will happily take an intervention from her if she wants to respond.

Photo of Nicola Sturgeon Nicola Sturgeon Scottish National Party

The exact chronology and chain of events are a matter of parliamentary record, in the statement that I gave to the Parliament about the PWC report. I am more than happy to discuss the matter further with any member.

Photo of Neil Findlay Neil Findlay Labour

I am sure that we will discuss it further. Why did it take so long for the practices and the bullying culture to come to light? The practices were not carried out only by people who have now left the organisation. What will happen to the people who remain? What responsibility lies higher up, at Government level?

I have many friends, relatives and constituents who work in NHS Lothian. They tell me about an NHS that is understaffed, in which staff are afraid to speak out, in which nurses cannot take a break during a 12 and a half hour shift and cannot get basic equipment, in which patients are boarded out to other wards several times during their stay, and in which morale is low and falling and the realities that staff face day in and day out are light years away from the spin and denials of ministers.

The report talked about the suppression of bad news, through a do-not-write-it-down policy. Reports were given a gloss and a positive spin and used oblique language.

The Deputy Presiding Officer:

You have 10 seconds.

Photo of Neil Findlay Neil Findlay Labour

Okay—I will wind up, although I have much more to say. This vital issue will run and run, and I hope that we will have more time to discuss it, because four minutes is not enough.

Photo of Joe FitzPatrick Joe FitzPatrick Scottish National Party

I point out that it was Labour’s decision not to concentrate on one subject this morning but to try to give everyone on its portfolio list a wee shottie in a debate. This is Labour’s debate.

Photo of Joe FitzPatrick Joe FitzPatrick Scottish National Party

I will take an intervention from Ms Baillie in a second, to give her a second chance to apologise to all the workers in NHS Tayside whom she besmirched in her press statement of 3 May. The item is still on her website and is still besmirching the hard-working staff at NHS Tayside, who have done a fantastic job to reduce waiting lists over the years. I will give Ms Baillie the opportunity to apologise to them and to make clear that she will remove the press statement from her website.

Photo of Jackie Baillie Jackie Baillie Labour

The approach of SNP back benchers and front benchers today has been to use NHS staff as a human shield for the failings of their Government. I take to heart what Jackson Carlaw said. There is a problem now and we need action now. Will the Government take action?

Photo of Joe FitzPatrick Joe FitzPatrick Scottish National Party

I am disappointed but not surprised that Ms Baillie did not apologise. I take it that she will remove the offending press statement, which attacks hard-working staff, from her website.

The motion represents an attempt to attack the SNP Government on waiting times, but the simple, irrefutable fact is that waiting times have come down under the SNP Government. The days are gone when tens of thousands languished on waiting lists without any guarantee of treatment and thousands more were on hidden waiting lists, which the Labour Party—sorry, Scottish Labour—designed specifically to fudge the figures. Politicians’ surgeries the length and breadth of the country were full of constituents protesting about long, worry-filled waits for treatment.

Right now, we have a Government that has achieved record waiting time reductions. We have the best-performing NHS in the United Kingdom. We should be proud of what our NHS has achieved. No one is suggesting that there is nothing to consider. The cabinet secretary made it clear that she takes seriously the concerns from Lothian, and the local member, Jim Eadie, made a passionate speech about his concern for his constituents. No one is trying to paper over the cracks where things are not right. However, let us put on record that our NHS is doing a fantastic job throughout the country.

In Tayside, the most recent figures show that 100 per cent of in-patients and day cases are waiting for less than nine weeks, 100 per cent of new out-patients are waiting 12 weeks or less, 97.1 per cent of patients are going from referral to treatment in under 18 weeks and 96.6 per cent of people in whom cancer is suspected are starting treatment within 62 days.

Those are fantastic results and a fantastic record, which is why NHS Tayside took the unusual step of copying all the regional and constituency members who represent Tayside into their response to Jackie Baillie, to make sure that her disingenuous press statement was put straight. It is disappointing that she has still failed to put the record straight today.

Another disappointing issue is that, when we talk about health, the Labour Party is always prepared to use health for political posturing, rather than bringing forward concrete ideas that could support our NHS workers across the country.

Photo of Jackson Carlaw Jackson Carlaw Conservative

I will concentrate on issues that arose from the one substantive and positive contribution to this debate, which came from Sarah Boyack. She looked into the detail of the report and, in the time available to her, prepared an analysis that pinpointed the key issue in all of this: that the management culture in NHS Lothian is what underpinned the inability of staff to feel confident to raise, publicly or elsewhere, the issues raised by what they knew was going on.

Photo of Jackson Carlaw Jackson Carlaw Conservative

I will, in a second.

I am reminded of an old school chum of mine, who was castigated on one occasion when he answered a question by saying, “As a result of Magna Carta, no-one could be put to death without their own consent.” It seems to me that that is the issue here: who is going to whistleblow to their own executioner? As a result of the culture, the fear and suspicion of staff is that if they speak up, they will, at the end of the day, face disciplinary procedure.

That is all the more unsettling because, as a result of NHS partnership information network guidelines that we have talked about in this Parliament before, staff cannot be disciplined if they whistleblow on the ground of patient safety, but either they do not know that or they do not have confidence in that, and clearly in Lothian health board—and potentially elsewhere—there may be issues as serious and substantive as the ones that we are discussing that are not coming to the surface because the culture precludes that from happening.

We have paid tribute to the considerable efforts, the passion and the commitment of staff on the ground who are delivering the targets, but the worry has to be, why has all this been going on? What is it all about? Is it about the CVs of chief executives and managers? I have seen them come across my desk. Is it because they want to be able to say, “I reduced waiting times” in NHS whatever it is? No they did not; it was the staff underneath them and their efforts that have contributed to the reduction in waiting times. Chief executives and managers do not want anything that is bad news. Jim Eadie says that the public need to be reassured that the management practices in NHS Lothian do not exist elsewhere but, standing here, we cannot be confident that that is the case.

I was asked by Dr Simpson if I was surprised about NHS North Ayrshire and Arran and I replied,

“Not only am I surprised, I am appalled”.

Similarly, we must accept that if a practice that surprises and appals us exists in NHS Lothian, it would be foolish and irresponsible of us to suppose that it is not happening anywhere else. The presumption should not be that it is happening, but that is what the investigation that the cabinet secretary has identified with Audit Scotland must uncover.

I come back to the depressing point about this debate. It is really not an occasion for a political trade-off, but I say to Richard Lyle—actually, I was going to ask on a point of order what “doing a Jenny” is, because I was not clear about that parliamentary expression—that when he said that this Government has been in power for a relatively short period of time, I had to think about that. It has been in power longer than MacDonald, Bonar Law, Chamberlain, Churchill—National, Attlee, Churchill—Conservative, Eden, Macmillan, Douglas-Home, Heath, Callaghan and Brown. For goodness’ sake—for Richard Lyle to say that ministers have not been in office long enough to know how to do their jobs is profoundly depressing for us all, so I do not think that that helped.

I say to the cabinet secretary that although I am upset by the tone of the motion and the amendment and the conduct of the debate, the motion is underpinned by a fundamentally serious issue. Our responsibility as politicians is to resolve it.

Photo of Michael Matheson Michael Matheson Scottish National Party

Some of these Opposition-led health debates create more noise than light in terms of detail and substance, and today’s was no exception.

In the desperation of some to throw around as much mud as possible in relation to this issue, there is a danger that we lose sight of the significant progress that has been made by the NHS in Scotland. Unlike some, I wish to say thank you to the staff for their tremendous efforts in ensuring that they have achieved so many targets and have improved the NHS beyond recognition in recent years. I am not using them as a human shield; I am giving them genuine recognition for their hard work and achievement.

It is worth recognising that, before 1999, there were no waiting time targets in the NHS in Scotland. Look at what has happened. Over the past 12 years, this Administration and other Administrations have seen the waiting times target being met, a substantial reduction in healthcare-associated infections and an improvement in the way in which we deliver healthcare, with more people receiving day care treatment and having shorter stays in hospital. All of those things illustrate the significant progress that has been made.

We must recognise that that progress has brought benefits to patients. Of key importance to the NHS is the quality of care and treatment that it provides to patients. In the in-patient experience survey in 2011, 85 per cent of patients said that their experience of treatment was good or excellent. Again, that underscores the commitment and the dedication of our NHS staff, which I am more than happy to congratulate them on and thank them for.

We should also recognise that the NHS in Scotland is performing well compared with other parts of the NHS in the United Kingdom. That is because we are not complacent; we have been driving reform in our NHS to ensure that it performs well. Scotland’s performance in relation to seven of the 11 major procedures is the best of any region in the UK. Further, our NHS’s move from being a body that largely focused on ill health to one that does more to prevent ill health has caused mortality rates to drop and life expectancy to increase. We have a proud record of delivering healthcare improvements in Scotland, and we need to recognise that.

Photo of Sarah Boyack Sarah Boyack Labour

I would not for a moment dispute the fact that, with extra resources and superb management, there has been big progress. Will the minister focus on the problems that were identified in the NHS Lothian report? The key problem is that, with less money and less staff, there are pressures. How do we get it right? What are the lessons?

Photo of Michael Matheson Michael Matheson Scottish National Party

I am just about to turn to those points. First, I should say that a lot of the allegations and innuendo that we have heard today have been about wider aspects of our NHS, not just NHS Lothian.

The Government has implemented the new ways guidance and has ensured that boards are taking it forward effectively. I have heard members talk about social unavailability and suggest that, in some way, a patient loses their waiting time guarantee, but they do not and it is factually incorrect to suggest otherwise. That is part of the mud slinging and does not help us to address the issue.

Jackson Carlaw, in his measured contribution, hit the nail on the head when he talked about how we can move forward from the findings in the NHS Lothian report and address the fundamental failings that it highlighted. Sarah Boyack and Jim Eadie also highlighted that, and drew attention to the serious failings in how the board handled the matter. Crucially, the report highlighted not one or two incidents of bullying and intimidation here or there, but a culture of bullying and intimidation, which the cabinet secretary has clearly said is unacceptable. That is why all 34 of the recommendations are being taken forward and the chair of NHS Lothian has been given the task of bringing forward a single integrated action plan that will address reporting, governance and culture to ensure that we can root out the unhealthy culture that has been allowed to develop in NHS Lothian.

We must also recognise that, although this report is damning in relation to the problems that were allowed to develop in NHS Lothian, the issues are confined to a small number of the 20,000 staff who work in NHS Lothian, many of whom, on a day-to-day basis, show tremendous professionalism and dedication to their work.

The report must be placed in the context of the limited number of staff who were perpetuating the culture of bullying and intimidation. However, we must ensure that the issue is addressed. As a Government, we are prepared to take the necessary action to ensure that the message is clear that bullying and intimidation will not be tolerated in any part of the NHS in Scotland.

Photo of Richard Simpson Richard Simpson Labour

Waiting times have been one of the success stories of the NHS throughout Scotland since 1997, underpinned by Labour’s decision to increase NHS funding radically in 2001. I hope that the time when patients could wait for years for an operation and could lie overnight on trollies has been consigned to history, although I hear stories from England about the trollies re-emerging.

However, the progress has stressed the system. The discovery that availability status codes—which, I say to Joe FitzPatrick, were created in the 1980s—that were designed only to allow patients to be removed temporarily from waiting lists were being wrongly used led Nicola Sturgeon, the then Opposition spokesperson, to attack Labour on the subject. The response was the creation, by Andy Kerr, of the new ways waiting times guidance, which was implemented by the SNP Government.

That is fine, but as I said in 2008, this is a complex system and it is likely that people will start gaming if they are under pressure. My warnings were ignored. In a speech in 2009, I said that doctors are being bullied by management in respect of targets and that it could become a serious issue. I did not know at the time that the Investors in People report in Lothian in 2010 would indicate, as Neil Findlay has said, that bullying was occurring in that health board.

The figures for social unavailability rose inexorably over the next two years and I again questioned whether gaming was going on. In other words, were we heading for a new scandal of hidden waiting lists? I was told that I was scaremongering. I am always being told that. The SNP’s complacency, which its supine back benchers demonstrated admirably today, is utterly breathtaking.

Forced by our exposure of one form of gaming in Lothian, the cabinet secretary has finally had to intervene. Otherwise, the Lothians initial internal whitewash report would have brushed the issue under the carpet. Do we have confidence that the investigation by other health boards, which she has instigated, will not do the same?

Is all now well and are all the other health boards managing the new system so that the target data, on which the waiting times claims are based, is real? That is what the cabinet secretary believes. She has dismissed my observations on the appendix of the Pricewaterhouse report—[Interruption.] She has. The appendix shows substantial variation, month on month, in other health boards’ use of exceptional retrospective correction of the social unavailability codes, yet I am told that this is not happening in any other health board.

Let us look at the central figures on waiting times, and bring a little reality to the situation. Yes, it was a new system in 2008 and, yes, it is complex, but here we are in 2012, with a self-congratulatory cabinet secretary trumpeting achievements, yet out of 111,000 referral-to-treatment incidents in the most recent reported set of statistics, 14,000 are unrecorded and unknown. We know that there are 7,700 patients for whom the referral-to-treatment guarantee has been broken—that is reported—but we know nothing about the other 14,000. How can we say that the waiting time guarantees are reaching the figures that the cabinet secretary keeps trumpeting?

The codes used in the PWC report were “other” or “patient contact”. I spoke to a Grampian general practitioner today in Mark McDonald’s constituency who said that he had re-referred a patient to gastroenterology this morning who had been removed from the waiting list having phoned and said that they were unavailable. Do not tell me that this is not happening. My GP colleagues—I have phoned 12 of them in the past week—are telling me repeatedly that this is happening. The combination of abusing the social availability status code, using “other” and “patient contact”, and short-term cancellation of clinics is causing massive disruption and considerable distress. That is not innuendo but reality, and the Parliament needs a reality check on the issue.

I decided to undertake a reality check by carrying out a freedom of information inquiry into the health boards—[Interruption.]

Photo of Tricia Marwick Tricia Marwick None

Would Mark McDonald please stop shouting across the chamber?

Photo of Richard Simpson Richard Simpson Labour

I asked the boards how many concerns have been raised. Whenever I have mentioned the new partnership information network arrangement for whistleblowing and raising concerns, the cabinet secretary has reassured me that all is well. NHS Highland and NHS Borders reported their quarterly statistics on concerns since 2010 as being excellent, and 12 other health boards had no concerns reported to them and no record of whistleblowing. Is the cabinet secretary really telling me that, despite the stress that our health service is under, no concerns are being expressed by any member of staff out there? That cannot be true.

The cabinet secretary must introduce a whistleblowers’ line, which England introduced following the Mid Staffordshire inquiry, and after the General Medical Council and the Nursing and Midwifery Council sent out their new guidance. I phoned the line and was told, “I’m sorry, but we cannot deal with concerns from Scotland, except to give general advice.”

That is not good enough and it is letting our staff down. The staff whom we value and who are doing a good job are not able to express their concerns, and there is a much more widespread culture in that regard than the cabinet secretary is prepared to admit.

In the past few months, I have carried out a detailed analysis of the figures that are being presented, but I will not talk about that today. I can tell the cabinet secretary that she was right to say that her job is not to micromanage the health service—no minister can do that, and we do not expect her to do so. However, we do expect her to ask questions. If her civil servants are not telling her about the striking variations that are occurring, they are not doing their job, and she is not doing her job in ensuring that they give her that information.

There is a potential scandal out there. I can tell the cabinet secretary that there are concerns in other areas, which I will talk about in the next few weeks once I have checked them with the local health boards.

I turn to Joe FitzPatrick’s figures for Tayside, and the letter from Sandy Watson, which I received because I cover part of that constituency. In the letter, NHS Tayside revealed something else that is very interesting: referrals that are made directly to nursing staff and to allied health professionals are not recorded in the waiting times system. It is true that the original ISD published figures included figures related to nurses and allied health professionals. However, that was a mistake, and it was corrected by the health board. If I, as a general practitioner, refer a patient to a specialist service in a hospital—for diabetes, for example, which is one of the big ones—why is that referral not subject to a waiting time guarantee?

The health service system is changing. The system of referral no longer goes from GP to consultant but concerns many different aspects of the health service. If the cabinet secretary really wants to protect patients and ensure that the system works well, and if she wants to support staff, rather than using them as a shield—as she has done blatantly today—she must ensure that staff are working in a safe situation in which they are free from bullying and are able to raise concerns. When they cannot or feel unable to do so, they should have a whistleblowing line to call for support. That will give the cabinet secretary the information that she wants.

The Government stands accused not of not trying its best, but of not asking questions and of being completely and utterly complacent.