“Management of patients on NHS waiting lists”

– in the Scottish Parliament on 21st February 2013.

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Photo of Tricia Marwick Tricia Marwick None

Good afternoon. The first item of business is a statement by the Cabinet Secretary for Health and Wellbeing, Alex Neil, on the Audit Scotland report “Management of patients on NHS waiting lists”. The cabinet secretary will take questions at the end of his statement and there should therefore be no interventions or interruptions. Members who wish to ask a question can press their request-to-speak button now. I call the cabinet secretary. Mr Neil, you have 10 minutes.

Photo of Alex Neil Alex Neil Scottish National Party

I welcome the opportunity to make a statement to Parliament on the report prepared by the Auditor General for Scotland, “Management of patients on NHS waiting lists”.

First, I welcome the findings and accept the recommendations of the Audit Scotland report, and in particular the fact that after extensive investigation no examples were found of any deliberate manipulation of waiting list records.

The Audit Scotland report is entirely consistent with and accords with the findings of the 15 internal audits reported to Parliament by me on 20 December, which also found no examples of deliberate manipulation.

I remind Parliament that this is the largest investigation into the management practices of waiting times ever carried out in NHS Scotland. Between both sets of audits, more than 500,000 transactions relating to periods of unavailability were scrutinised, and 400 staff were interviewed as part of that process. Consistent with the internal audit review last year, Audit Scotland commissioned consultants to extract extensive data from national health service board systems and to provide a breakdown of that data, which was then analysed in detail to identify any unusual patterns and practices. That information was used to select samples, which Audit Scotland used to carry out more targeted investigation of individual patient records.

I refer to some of the detailed findings of the report. Audit Scotland comments that

“Systems for managing waiting list information have inadequate controls” and that a number of different systems are in operation in Scotland. We accept that systems needed to be modernised and that information contained within those systems has to be timely and accurate and must serve patient needs.

Audit Scotland also makes several references to the rise in social unavailability since 2008 and the fall in 2011-12. There is a very simple explanation for that. The Government introduced the new ways system on 1 January 2008, scrapping the previously discredited hidden waiting lists system in which patients could be left without a guarantee for many years. When we took office, 30,000 patients languished forgotten on those hidden waiting lists, with no hope of quick treatment. Audit Scotland recognised that in its 2010 audit, in which it welcomed the introduction of the new system as being more open, transparent and fairer to patients and said that the NHS had “done well” to implement the changes.

Since 2008, boards have been gradually switching over to the new system, hence the rise in recorded periods of social unavailability. I would hope that members would recognise that the system was designed to be helpful for patients. It gave patients some choice and control over when they should come to hospital and allowed them to come at a time and on a date convenient for them.

One of the by-products of the significant reduction in waiting times is that some patients might need to delay routine attendances at hospital to accommodate their own personal preferences and social circumstances. Audit Scotland also recognised that social unavailability started to reduce in most boards in late 2011. That was partly a consequence of NHS Lothian switching how it recorded its patients. The reduction reflects the previous cabinet secretary’s instruction to NHS Lothian to immediately remove patients from the unavailability list and put them back on the treatment list.

Boards quality assuring their lists as part of the data migration to new systems as well as additional capacity being increased by boards locally, such as in NHS Greater Glasgow and Clyde, were other reasons for the reduction in social unavailability levels. We should also recognise that, in 2011-12, boards were preparing for the introduction of the new treatment time guarantee.

The report identifies that there was “not enough scrutiny” of the reasons for the increasing numbers of patients with periods of unavailability by the Scottish Government and boards. As part of the legislation relating to the 12-week in-patient and day-case legal treatment time guarantee, there is a requirement that periods of unavailability must be recorded and monitored. The legislation covers in-patients and day cases, and we have made it clear that that approach also applies to out-patients.

Over the past six years, waiting times have fallen dramatically and, according to our patient surveys, we have the highest level of satisfaction in the United Kingdom and the highest levels ever recorded in Scotland, with 88 per cent of patients being satisfied or very satisfied with their waiting time position.

We need to ensure that patients’ individual needs are met and that information is clear, consistent and readily understandable. That continues to be a high priority for the national health service in Scotland, and that is why I am pleased to announce that I am introducing a patient advice line to ensure that, if patients need help and support in relation to their waiting time rights, they will get it.

There is one additional point of clarification that I would like to make to members on the findings of the Audit Scotland report. NHS Tayside has now completed its detailed internal investigation into allegations of manipulation of waiting lists. I am pleased to advise members about the outcome of that investigation. NHS Tayside said:

“there was no evidence presented throughout the investigation to substantiate this allegation, no evidence found that managers sought to deliberately manipulate waiting times, nor any evidence that they sought to bully or coerce members of staff to inappropriately code waiting times data”.

Audit Scotland acknowledged the outcome of that investigation in its report.

In my previous statement to Parliament on waiting lists, I advised that we would swiftly follow up all the internal audit recommendations. That will also apply to the nine recommendations from the Auditor General. I am pleased to say that, as of today, more than 91 per cent of the recommendations from the internal audits and many of the recommendations from Audit Scotland have already been implemented. A small number of actions have an implementation period beyond March. The extended timescale reflects the complexity of some of the recommendations—for example, on upgrading and introducing new information technology systems, which in some cases requires recontracting. We are continuing to hold chief executives and chairs of NHS Scotland to account for that timetable.

I say again that boards will undertake a follow-up audit on the management of waiting times within the next 16 months to ensure that the planned improvements that have been requested have been made, and that they are working effectively.

I hope that that will finally put to rest some Opposition members’ accusations that NHS staff are involved in widespread dishonest and deliberate manipulation of patients’ records. I stand by the integrity and basic honesty of our 155,000 staff, and I expect members to support that position.

Photo of Jackie Baillie Jackie Baillie Labour

I thank the cabinet secretary for the advance copy of his statement.

It is really surprising that, as a nationalist, Alex Neil is relying on the “Little Britain” defence of “Computer says no.” Audit Scotland’s report on the management of waiting times is

“a wake-up call to the Scottish Government”.

Those are not my words—they are the words of the Royal College of Nursing. In the words of the British Medical Association—again, they are not my words—the systems are

“inadequate and have been open to manipulation.”

In short, the Scottish National Party has been accused of putting targets before patient care.

What Audit Scotland has exposed is that one in three patients was parked on hidden waiting lists. Their waiting time guarantees were suspended, and some were without an end date for that suspension.

Social unavailability reached a high point in July 2011, then NHS Lothian was rumbled and suddenly the numbers fell across Scotland. It was not that patients were being treated faster; at the same time, waiting times were going up. One in four patients had their waiting time guarantee breached but, miraculously, only 3 per cent were reported to the Scottish Government. As the cabinet secretary himself conceded on radio this morning, we can have no confidence in the reporting and monitoring systems.

The Scottish National Party crowed about having the lowest waiting times, but is it not true that none of those figures was real or based on fact? In its 2010 report, Audit Scotland warned the SNP about a problem with social unavailability. Nicola Sturgeon and the SNP knew about this in 2010 but they chose to turn a blind eye and do nothing about it.

I ask the cabinet secretary to please stop using the staff has a human shield; this is about him putting spin ahead of patient care. Is it not the case that we cannot trust the SNP with waiting times and certainly cannot trust it with the NHS?

Photo of Alex Neil Alex Neil Scottish National Party

Since this situation became public, Jackie Baillie has been quoted many times accusing people in the NHS all over Scotland of fiddling figures à la Lothian. Even members of her own party privately say to me that they are embarrassed by her continual attacks on the integrity and honesty of NHS staff in Scotland.

Under the Administration of which Jackie Baillie was a part, a total of 104,000 people were on waiting lists in Scotland, including the 35,000 on the hidden waiting list. The number of people on the waiting list in Scotland is now down to 65,000, including those designated as socially and medically unavailable. That represents a 40 per cent reduction in the waiting list since Nicola Sturgeon became health secretary.

As for Jackie Baillie’s accusation that we have hidden waiting lists, I will make two points. First, how can they be hidden when the information is public knowledge and is published and updated regularly on the Information Services Division Scotland website, which is open to everyone? If everyone else is so unsmart, why was Jackie Baillie herself not smart enough to find out that there was a problem when she looked at the website? Secondly, the 35,000 people on the previous Administration’s hidden waiting list lost their guarantee. No one on our list has lost their treatment guarantee.

All day Jackie Baillie has been quoting the figure of 23 per cent as part of some kind of attack on the numbers in relation to unavailability. I point out that a third of those people told us that they were medically unavailable. As a result, it is dishonest to make hay with that figure—that is extremely worrying in an Opposition party.

Finally—again, this information is in the public domain, so Jackie Baillie can go and check it out—if we look at the second quarter of 2011, which ended in June and is therefore relevant to this discussion, and include the people with unavailability, we can see that 94.3 per cent of patients under this Government and under Nicola Sturgeon met the 18-week guarantee. If we exclude those with unavailability, the figure was 97.3 per cent. At no time in the eight years from 1999 to 2007 did the Labour-Liberal Administration get anywhere near that kind of performance.

Photo of Jackson Carlaw Jackson Carlaw Conservative

I thank the cabinet secretary for the advance copy of his statement.

While no less concerned, Scottish Conservatives have attempted to steer an even course. I have no interest in perpetuating a debate between the present Government and its predecessor as to who did what best. We are concerned for patients.

We have had two sets of reports: the internal reports, and the report from Audit Scotland. At the very least, they have created anxiety and confusion in the public’s mind. Is there a case for some health boards to answer? Can the cabinet secretary assure the public that they can now have confidence in the system? Given that, in response to the internal audits, he suggested that he would consider repeating the exercise after 18 months, will he today, in the light of the information that we now have, give a more express commitment to do so? Could we have agreement to commission a further internal audit earlier than that—perhaps after 12 months?

Photo of Alex Neil Alex Neil Scottish National Party

I thank Jackson Carlaw for the tone of his question, which was much more reasonable and realistic than the tone that we heard from the Labour Party.

Jackson Carlaw’s suggestion of doing that audit quicker, within 12 months, is a very good one, and I am happy to accept it. I hope that that partly answers the part of his question about public confidence in the system.

More than 70 per cent of the population in Scotland are living in health board areas covered by TrakCare or an enhanced version of TrakCare, which is a very robust system and has been recognised as such by Audit Scotland. By the end of this year, more than 90 per cent of the population will be covered by that system. I am confident that, once all the systems are in place, we can have absolutely total confidence about the integrity and robustness of data collection in every health board in Scotland.

Photo of Bob Doris Bob Doris Scottish National Party

Does the cabinet secretary believe that there is a need for clearer recording of reasons for social unavailability, given that it is reported that 900 orthopaedic patients at Glasgow’s Western infirmary were deemed socially unavailable? For some patients, that was because they had opted to wait for their preferred hospital and consultant. Can the cabinet secretary confirm that such preferences are not part of the waiting time guarantee, that NHS Greater Glasgow and Clyde did not remove those patients from the waiting list, and that they were still being seen by their preferred clinician in the hospital of their choice?

Photo of Alex Neil Alex Neil Scottish National Party

Bob Doris is absolutely right in what he says, but I point out that, as a result of the reforms that were introduced last year by my predecessor, Nicola Sturgeon, as of 1 October last year we no longer have a category called social unavailability—it is simply called patient unavailability. If a patient advises the NHS board that, for whatever reason, they are unable to attend on a certain date, that is fully recorded and agreed with the patient. The options that are open to the patient are then explained to them and a way forward is agreed.

To ensure that there is no dubiety about that, either now or in future, the TrakCare system records all that information, including the reasons. Furthermore, the board is then required to send out a letter to the patient to confirm the conversation and the way forward for the patient’s care.

Photo of Richard Simpson Richard Simpson Labour

How does the cabinet secretary explain exhibit 8 in the report, which shows a ninefold variation in ophthalmology and a fivefold variation in orthopaedics for social unavailability? We know that those specialties are under the greatest pressure and, surprise, surprise, they are the ones where up to 50 per cent of patients, in different board areas, declared themselves unavailable. Are the SNP’s boasts on waiting times not actually based on fiction, as is made completely clear by exhibit 9? What SNP credibility is left with regard to the system as it has operated until this point?

Photo of Alex Neil Alex Neil Scottish National Party

I will quote from Audit Scotland in relation to our introduction of the new system—Richard Simpson will accept this as gospel, as his whole argument is based on what Audit Scotland says. In “Managing NHS waiting lists: A review of new arrangements”, which was published in 2010, Audit Scotland said:

“The NHS has done well to implement the new arrangements”, and people no longer

“remain on the waiting list indefinitely.”

In 2011, another report relating to the new system was published, “Measuring NHS waiting lists: Twelve-month summary impact report”. Let me quote exactly what Audit Scotland—not me or my predecessor—said:

“This audit provided assurance that the new arrangements are generally working well. The Scottish Government has developed further guidance about the areas where we raised concerns such as the treatment of patients who do not or cannot attend their appointments. ISD Scotland is continuing to work with NHS boards to improve the quality of New Ways data. There should not be any need to conduct a follow up study in the foreseeable future.”

Audit Scotland had full faith in the new system. Clearly, as a result, the allegations that have been made by the Labour Party are nonsensical. Having reviewed half a million files and more than a quarter of million transactions, and having interviewed 400 staff, although Audit Scotland did not bring itself to say so, it found no evidence of Lothian-style fiddling. It is totally unacceptable for the Labour Party to infer that there is that evidence.

The Presiding Officer:

If I am to call all members who want to be called, we will need shorter questions and answers.

Photo of Aileen McLeod Aileen McLeod Scottish National Party

One clear aspect that has come out of the Audit Scotland report is that the patient administration IT infrastructure was not robust enough when the audit was carried out. For example, NHS Greater Glasgow and Clyde had 11 different IT systems. What progress has been made in upgrading IT systems to meet the required standard?

Photo of Alex Neil Alex Neil Scottish National Party

Substantial progress has been made. As I said, 70 per cent of the population is now covered by TrakCare or an enhanced version of it, and by the end of the year more than 90 per cent of the population will be covered by that system.

In relation to Glasgow, Aileen McLeod is absolutely right. We inherited 11 different systems. There are now three systems, and that number is going down to one system—TrakCare. However, even though the old systems that we inherited from the previous Administration were not robust enough for interrogation by Audit Scotland to get the answers to its questions, when it did a manual check it found that there was no manipulation and no concern about the robustness of the information. We should bear it in mind that the manual check proved that there had been no Lothian-style fiddling in Glasgow.

Photo of Drew Smith Drew Smith Labour

Seventy per cent of all orthopaedic patients at the Western infirmary were marked as socially unavailable at the beginning of 2011. Nine hundred real people with painful conditions waited for treatment in Glasgow. Some of them might even have been Nicola Sturgeon’s constituents. Does the cabinet secretary not realise that it is not credible to say, and he is making a fool of himself to pretend, that Glaswegians were somehow twice as likely to be on holiday as people in the rest of the country in January and February 2011? Will he now, on behalf of Nicola Sturgeon, apologise to the thousands of patients across Glasgow who may have waited for longer than they needed to?

Photo of Alex Neil Alex Neil Scottish National Party

Not only am I not going to apologise, but I am going to say that I am proud of the fact that we have an 88 per cent satisfaction rate on waiting times from patients in NHS Scotland. Had there been any major problem with waiting times and waiting lists, Nicola Sturgeon’s surgery, my surgery and everybody else’s surgery would have been absolutely full of people complaining about the time that they had to wait. Quite frankly, if the Labour Party had anything like half the 88 per cent satisfaction rating that the NHS has had, it would have made a decent Opposition.

Photo of Jim Eadie Jim Eadie Scottish National Party

Given that there have been two robust and thorough investigations, initiated by the Government, into NHS Lothian, can the cabinet secretary provide an update on what steps have been taken to implement the changes at NHS Lothian so that patients in Lothian will never again be denied treatment because of the manipulation of waiting times and an unacceptable management culture?

Photo of Alex Neil Alex Neil Scottish National Party

A comprehensive programme has been implemented by the newly appointed chief executive, Tim Davison, and we already see a substantial improvement in waiting times and the number of people waiting for various procedures in NHS Lothian. I take this opportunity to pay tribute to the tremendous work that Tim Davison has undertaken since his appointment as chief executive of NHS Lothian. I think that it will soon be back to its rightful position, in these terms, as one of the best performing health boards in Scotland.

Photo of Jim Hume Jim Hume Liberal Democrat

The minister has again asserted that the situation was not widespread across Scotland, but the Audit Scotland report, from which the minister likes to quote, clearly states:

“The trends in NHS Lothian were similar to the rest of Scotland.”

Will he finally accept that the situation was not the fault of inadequate IT systems but was down to capacity issues in certain specialties and clinics across all boards? Will he take the opportunity to apologise to the hard-working NHS staff who were forced to amend patient records in order to achieve his Government’s targets without having the necessary tools to do that?

Photo of Alex Neil Alex Neil Scottish National Party

I hope that Jim Hume is never called to do jury duty because, if he looked at the evidence, he would see that nobody outside of Lothian is guilty of manipulation or any other kind of fiddling of waiting lists in NHS Scotland. [Interruption.]

Photo of Alex Neil Alex Neil Scottish National Party

Instead of trying to manufacture suspicions and innuendo against NHS staff, Mr Hume should accept that the situation is a historical one—the period that is covered by the Auditor General’s report ended in December 2011. We have accepted that there was a lack of sufficient robustness in the IT systems and are putting that right. When the problems at NHS Lothian were uncovered, my predecessor dealt with them effectively. The result is that we now have extremely robust systems. It is fair to say that we probably now have, in most of our health board areas, some of the most robust IT systems in the whole of the UK.

Photo of Colin Beattie Colin Beattie Scottish National Party

What policies will be brought into place to ensure that NHS boards will share good practice on enhancing performance reporting to monitor patients and waiting lists?

Photo of Alex Neil Alex Neil Scottish National Party

That is part of our interpretation of how to implement the original internal audit recommendations and Audit Scotland’s recommendations. I have also requested a monthly report from each of the 15 boards that are involved in the exercise so that I can check the progress of the implementation of the recommendations. Further, as I said to Jackson Carlaw, I will commission a comprehensive evaluation after about 12 months in order to ensure that the new systems are working properly throughout the national health service in Scotland.

Photo of Iain Gray Iain Gray Labour

Whatever Audit Scotland said in 2010, today it said:

“there was not enough scrutiny of how NHS boards were applying waiting list codes. Available information on increasing use of social unavailability codes should have highlighted potential concerns for the Scottish Government and NHS boards to investigate further.”

That information included evidence of increasing rates of social unavailability, the reported use of social unavailability codes for patient choice, and retrospective changes to waiting list data. There was not enough scrutiny.

Is the truth not that, for three or four years, Scottish ministers simply turned a blind eye to the evidence in order to make claims on waiting times that they knew to be inaccurate?

Photo of Alex Neil Alex Neil Scottish National Party

Every health board in Scotland is audited every year. Half of them are actually audited by Audit Scotland. Not one audit brought to our attention any of those problems. Auditors are employed to audit the systems as well as the books. [Interruption.]

Photo of Alex Neil Alex Neil Scottish National Party

They are pretty hysterical this afternoon, Presiding Officer. It is because they cannot get a story out of this.

The Presiding Officer:

Can we just get an answer, Mr Neil?

Photo of Alex Neil Alex Neil Scottish National Party

The reality is that all the normal auditing procedures were carried out and the moment that the issues came to light, my predecessor acted decisively and swiftly.

Photo of Gil Paterson Gil Paterson Scottish National Party

Most people would agree that a whistleblowers hotline would be an important thing to have in order to give the public confidence in relation to this issue. What steps will be taken to introduce a whistleblowing system, and when is that likely to happen?

Photo of Alex Neil Alex Neil Scottish National Party

I have already announced that, on 1 April, I will introduce a whistleblowing system throughout the NHS in Scotland. I hope to announce the details of that shortly.

Photo of Margo MacDonald Margo MacDonald Independent

Can I ask the cabinet secretary to strike out on a new road and remember that we are talking about patients, who get flu or who trip and fall over and therefore cannot keep appointments, and doctors, who get caught up in traffic accidents and so on? We are allowing ourselves to be driven by targets that are unattainable, and everyone is getting far too neurotic about it.

The Presiding Officer:

I think that that was a question, cabinet secretary.

Photo of Alex Neil Alex Neil Scottish National Party

We have achieved and exceeded the targets. Nevertheless, the underlying point that my friend Margo MacDonald made was that we should never forget that this is about patients. That is why we set the targets. Under the previous Administration the waiting time was six months. We reduced that to 12 weeks. I think that patients will benefit enormously from that huge reduction.