Key messages
Managing NHS waiting lists
A review of new arrangements 
Prepared for the Auditor General for Scotland
March 2010
Auditor General for Scotland
The Auditor General for Scotland is the Parliament’s watchdog for ensuring propriety and value for money in the spending of public funds. 
He is responsible for investigating whether public spending bodies achieve the best possible value for money and adhere to the highest standards of financial management. 
He is independent and not subject to the control of any member of the Scottish Government or the Parliament. 
The Auditor General is responsible for securing the audit of the Scottish Government and most other public sector bodies except local authorities and fire and police boards.
The following bodies fall within the remit of the Auditor General: 
•	directorates of the Scottish Government
•	government agencies, eg the Scottish Prison Service, Historic Scotland 
•	NHS bodies 
•	further education colleges 
•	Scottish Water 
•	NDPBs and others, eg Scottish Enterprise. 
Audit Scotland is a statutory body set up in April 2000 under the Public Finance and Accountability (Scotland) Act 2000. It provides services to the Auditor General for Scotland and the Accounts Commission. Together they ensure that the Scottish Government and public sector bodies in Scotland are held to account for the proper, efficient and effective use of public funds.

Key messages
Background
1. The time patients wait for treatment is important to them. On 30 September 2009, approximately 307,000 people were waiting for a new outpatient appointment or for admission to hospital as a day case or inpatient.1 
2. The NHS in Scotland needs to manage patients’ waits in line with national guidance and waiting times targets. In 2004, the Scottish Executive announced a new approach to managing patients’ waiting times, known as New Ways, which came into effect on 1 January 2008.2 
3. New Ways guidance set out how NHS boards should manage patients’ waits and measure and report waiting times consistently. It was intended to make the system clearer, fairer and more transparent and replaced the previous arrangements where some patients were excluded from waiting lists.3  
4. The new system introduces the concept of a waiting time clock to calculate the time that patients wait. The clock records the time between the hospital adding a referral for an outpatient appointment or treatment to the waiting list and a patient’s appointment or admission. It excludes periods when the patient is unavailable for treatment for medical or social reasons, such as having another medical condition which needs to be treated first or being on holiday. 
5. The new guidance places new responsibilities on patients to inform the hospital of changes in their availability. Patients who do not attend for appointments without informing the hospital in advance may be referred back to their GP and go back to the end of the waiting list. Exhibit 1 (overleaf) outlines the New Ways guidance and what this means for patients.
6. The maximum waiting time targets have reduced progressively in recent years.4 The current standard is 15 weeks (105 days) for a new outpatient appointment and up to a further 15 weeks for an inpatient or day case appointment.5, 6 Waiting times in all NHS boards have reduced and there is less variation among boards. For the three months ending 30 September 2009, the average waiting time for an outpatient appointment was just under seven weeks (47 days) and 99.9 per cent of patients waited 15 weeks or less.7 The average waiting time for inpatients and day cases was just over four weeks (29 days) and 99.9 per cent of patients waited 15 weeks or less.8 
7. From December 2011, a new target will be introduced. This will be a combined maximum wait of 18 weeks (126 days) between a patient being referred and the start of their treatment, including any tests and outpatient appointments.9 
Our study
8. We examined whether NHS boards are complying with New Ways guidance for managing patients and recording information. We focused on groups of patients in three specialties for in-depth analysis: orthopaedic outpatients, inpatients and day cases; oral surgery inpatients; and dermatology outpatients. We also looked at how the new arrangements affect patients. 
Key messages
1
New Ways has stopped people remaining on waiting lists indefinitely. It introduced significant changes to the way patient waits are managed, and the NHS has done well to implement the new arrangements. 
9. New Ways introduced a different way of managing patient waits across the NHS in Scotland. Before New Ways, the NHS used deferred waiting lists and availability status codes (ASCs) to exclude patients from waiting times guarantees because, for example:
•	they were not available for treatment for social or medical reasons
•	their treatment was either highly specialist or of low clinical priority
•	they had failed to attend previous appointments
•	the service they were attending was considered to be under significant stress. 
10. These practices were criticised because they were perceived to operate as hidden waiting lists, and did not provide an accurate picture of how many patients were waiting for treatment and for how long. It also led to some inconsistencies in how NHS boards managed their waiting lists and how they recorded information, contributing to concerns about the validity of national waiting times data.10 
11. Under the new guidance, waiting time standards now apply to all patients, including groups of patients who were previously excluded from waiting time guarantees. Across all specialties, in December 2007, just over 21,000 outpatients, inpatients and day cases waiting (nine per cent) had an ASC. At 30 September 2009, 25,480 outpatients, inpatients and day cases (eight per cent) were classed as being unavailable. These are patients who would have been excluded from guarantees under the previous system.
12. New Ways has brought to an end the practice of excluding people from waiting times guarantees and it has stopped people remaining on waiting lists indefinitely. Those who are unavailable for treatment are coded as either medically or socially unavailable and must be reviewed within 13 weeks so that they do not remain on the waiting list indefinitely. The NHS board then has to make a decision about how to manage the patient. For example, they may be classed as available and offered an appointment, or they may remain classed as unavailable and either kept on the list or taken off the list and referred back to the GP (Exhibit 1). 
13. In the three specialties we analysed, for the year 2008, the average length of unavailability ranged from 17 days for dermatology outpatients to 55 days for orthopaedic inpatients and day cases. 
14. New Ways introduced new arrangements for how boards should deal with patients who do not or cannot attend for an appointment or treatment. These patients can have their waiting time clock reset to zero which means they go back to the end of the waiting list or they can be taken off the waiting list and referred back to their GP (Exhibit 1). (See paragraph 31 of the main report for more information.)
15. People who are put back to the end of the list wait longer, but the average waiting time in 2008 in each of the three specialties we reviewed was around the 15 week (105 days) waiting time target. 
16. The new system was intended to make sure that NHS boards manage waiting lists and times fairly. It is a complex system which needs support from hospital staff, GPs, ISD Scotland and patients to help it work effectively. 
17. NHS boards have put a lot of time and effort into training staff in the new procedures, particularly medical records and administrative and clerical staff who work with complicated new rules for managing, coding and recording patient waits. It has taken time for training to be rolled out and for the system to be fully implemented but its aims are now largely being achieved, although some problems with recording and data quality remain. (See paragraphs 24 to 26 of the main report for more information.)
18. ISD Scotland developed a national database, known as the data warehouse, to store and analyse data which are imported directly from NHS boards’ own systems. Boards have made significant changes to their information systems to make them compatible with the new arrangements and the data quality requirements of the national data warehouse. 
2
New Ways is intended to ensure that all patients are managed consistently and fairly. NHS boards are able to apply elements of the guidance differently to reflect the clinical needs of patients and this has led to some differences in how patients are managed. NHS boards are recording most information required under the new guidance, but there are some gaps in recording data about reviews of patients who are unavailable and about transfers which make it difficult to demonstrate that they are managing these patients in the right way. 
19. New Ways guidance allows NHS boards to apply elements of the guidance differently. This allows clinicians to review individual cases to make sure that patients are not being put at risk, for example because they are taken off the waiting list or referred back to the end of the list.
20. If a patient fails to attend for an appointment without letting the hospital know in advance, the NHS board can remove them from the waiting list and refer them back to their GP, or move them to the end of the waiting list (Exhibit 1). They can also remove a patient from the waiting list if the patient cannot attend after being given a reasonable offer.11  
21. Although ISD Scotland reports concerns about the quality of data on did not attend and could not attend rates before June 2009, the national data suggest that boards vary in the way they are applying the guidance in relation to people who did not or could not attend their appointment. Some boards may put a patient to the end of the waiting list after the first time they fail to attend an appointment. Others are more likely to keep patients on the waiting list unless they fail to attend more than once. There is also variation within boards and specialties, which may reflect clinical decisions about patients’ needs.
22. NHS boards are recording most information in line with the guidance. Data items, such as the date that patients are entered on to the waiting list, are recorded in all the cases we reviewed. However, there are gaps in some information that should be recorded, particularly the reviews of patients classed as unavailable for their appointment or treatment (Exhibit 2, overleaf).12 
23. There are also gaps in the information recorded about transfers of patients within a board and between boards. This makes it difficult for boards to guarantee that these patients are being managed in line with New Ways guidance. (See paragraphs 47 and 48 of the main report for more information.)
24. Introducing the new system to all NHS boards in Scotland was a big project. It introduced significant changes to the type of data recorded and it has taken time to resolve some initial problems. ISD Scotland and NHS boards reported concerns about the quality of some of the new data, although ISD Scotland noted that the boards have made a lot of progress with improving data quality. Problems with did not attend, cannot attend and cancellation rates have now been resolved. (See paragraph 51 of the main report for more information.)
25. Recording data items clearly and accurately will become even more important when the new combined 18-week target from referral to treatment comes in from December 2011. NHS boards will need to report on, and will be held to account for, their performance against this target.
3
Information for patients, and about patients, needs to improve to ensure that the new system operates effectively. Shorter waiting times mean that patients get less notice of appointments and the NHS needs to communicate well to avoid any confusion or delays that may affect patients being able to attend.
26. Shorter waiting times targets mean that patients now get less notice of hospital appointments. From 1 January to 31 March 2009, patients were entitled to at least 21 days’ notice of an appointment. Since April 2009, NHS boards only need to give patients a minimum of one week’s notice.13, 14 
27. Patients need enough notice to be able to make appropriate arrangements such as organising childcare, accessing transport and taking time off work. Patients and carers can find it difficult to make arrangements in a shorter timescale, particularly people in more vulnerable groups. The patients we spoke to were generally happy with the notice period they were given, although participants in our focus groups felt that appointments should be offered two to four weeks in advance for non-urgent cases. However, this can be difficult for NHS boards as they are working to shorter waiting times targets.
28. NHS boards need to make sure that communication with patients is effective. All patients need information about their appointment that they can easily understand, so that they can make arrangements to attend. This is especially important for patients who may need additional help, for example older people, homeless people, people with learning difficulties and those whose first language is not English. Ten boards provide some communication tailored to individual needs, but they do not always provide these materials when they initially contact the patient.15 
29. GPs and hospitals have a shared responsibility for communication. GPs are responsible for encouraging patients to respond to letters and phone calls from the hospital, advising patients of the implications for them of not attending and letting the hospital know of any change to the patient’s details.16 Two-thirds of patients interviewed in our survey did not recall receiving any information from their GP about what might happen if they could not attend an appointment. Few participants in our focus groups were given information about New Ways from their GP and they requested more information when they are referred.
30. The amount and type of information included in letters to patients varies among boards and across specialties within boards. Hospitals in 12 boards send out the national information leaflet or their own tailored leaflet when a patient is invited for an appointment.17  
31. Some people need additional support to help them both understand information from the hospital and attend for appointments. Only four per cent of the patient records we reviewed had any information recorded about patients’ additional support needs. NHS boards reported that hospitals rarely receive this information from the GP, and different computer systems are not able to transfer it automatically. 
32. Almost all of the 337 people with a disability or long-standing condition who responded to our patient survey felt that the hospital handled their needs sensitively. However, just under half of those who said they would have liked additional support were offered it and just over a third actually received support. 
Key recommendations 
NHS boards should:
•	record all New Ways data, including information on patient reviews and transfers, to ensure that all patients are being managed in line with the guidance and that this is demonstrated in a clear way
•	improve systems for recording patients’ additional needs and put appropriate support in place for those who need it
•	ensure that communication with patients takes account of any need for additional support and tailor information to meet these needs
•	continue to work with primary care to improve communication with patients so that both primary care staff and patients are clear about their responsibilities under the new system, particularly the implications for patients of not attending their appointments
•	use the Audit Scotland checklist detailed in Appendix 4 of our report to help improve how they manage waiting lists.
The Scottish Government and ISD Scotland should:
•	consider issuing additional guidance about the treatment of patients who do not or cannot attend appointments to make sure that patients are managed fairly across Scotland, while still allowing for clinical judgement.
1	Waiting Times Statistics, ISD Scotland, http://www.isdscotland.org/isd/3454.html 
2	Fair to All, Personal to Each, Scottish Executive Health Department, 2004.
3	New Ways of defining and measuring waiting times: Applying the Scottish Executive Health Department guidance, version 3.0, ISD Scotland, 2007.
4	When the delivery date for a target has been reached that target becomes a standard.
5	These are separate targets for cardiology, cardiac surgery, cataract surgery, cancer treatment, hip fractures, diagnostic tests and waits at emergency departments.
6	The waiting times targets do not apply to mental health and obstetrics. The outpatient target does not apply to patients waiting for a homeopathy appointment or those who have not been referred by a GP or dentist.
7	We use the word average when we are referring to the median. The median is the number in the middle when the values are put in order from lowest to highest. 
8	Waiting Times: Statistical Publication Notice, ISD Scotland, 24 November 2009, http://www.isdscotland.org/isd/6059.html  
9	18 weeks: The Referral to Treatment Standard, Scottish Government, 2008.
10	Review of the management of waiting lists, Audit Scotland, 2002.