Key messages
Management of patients on NHS waiting lists
Prepared for the Auditor General for Scotland
February 2013

Key facts

228,700
Patients waiting for an outpatient appointment on 30 September 2012

55,100
Patients waiting for inpatient treatment on 30 September 2012

31% in 2011 / 11% in 2008
Of inpatients in Scotland were socially unavailable for treatment on 30 June

3% reported / 23% actual
Of inpatients had a wait of over nine weeks in the quarter ending June 2011 (actual waits include any time patients are recorded as unavailable or have their waiting time clock reset)

5%
Decrease in the number of patients on waiting lists for inpatient treatment between September 2009 and September 2012, with an increase in the number of patients still on waiting lists after 12 weeks, from 130 to 1,617

What’s this report about?
Public trust in nationally reported waiting time statistics is at risk following evidence of manipulation in NHS Lothian during 2011 and an internal audit report on the inappropriate use of unavailability codes in NHS Tayside during 2012. Our audit aimed to identify whether NHS Lothian’s manipulation of waiting lists in 2011 was an isolated incident or whether it was an indication of widespread problems across the NHS. We carried out a detailed audit of NHS boards’ electronic patient management systems, and analysed how boards were applying waiting list codes in patient records between April and December 2011. This covered the period when evidence came to light that waiting lists were manipulated in NHS Lothian.
Key messages
•	The systems used to manage waiting lists have inadequate controls and audit trails, and the information recorded in patient records is limited. This means that it is not possible to trace all the amendments that may have been made to the records of patients waiting for treatment, or to identify the reasons for them. 
•	Social unavailability codes are intended to give patients more flexibility, but most patients’ records that we reviewed did not include enough information to verify that unavailability codes had been applied properly after discussion with the patient or their GP. The percentage of people waiting for inpatient treatment who were given a social unavailability code rose from 11 per cent in 2008 to just over 30 per cent at the end of June 2011. The proportion of patients coded as socially unavailable was higher in some specialties, such as orthopaedics and ophthalmology. The use of this code started to reduce in most NHS boards in late 2011, and the percentage of patients waiting longer than 12 weeks started to rise. The reasons for this are unclear, due to the limitations of waiting list management systems and the lack of evidence in patient records.
•	Our sampling found a small number of instances in which unavailability codes were used inappropriately. The limitations of waiting list management systems and the lack of evidence in patient records mean that it is not possible to determine whether these instances were due to human error, inconsistent interpretation of the guidance, or deliberate manipulation of waiting lists.
•	During 2011, the focus within the Scottish Government and NHS boards was on meeting waiting time targets and developing capacity in areas where patients were waiting longer. There was not enough scrutiny of the increasing number of patients recorded as unavailable. Better use of the available information could have helped identify concerns about the use of unavailability codes. It could have also identified wider pressures that were building up in the system around the capacity within NHS boards to meet waiting time targets.
•	Patients and staff have raised a number of concerns about the management of waiting lists. The Scottish Government has announced that it will pilot a national confidential phone line during 2013 to respond to these and other concerns. In order to safeguard patients’ interests, it is important to have effective whistleblowing policies and an environment where people can raise concerns safely and know that they will be acted upon.
Recommendations
The Scottish Government and NHS boards should:
•	monitor and report the use of waiting list codes and ensure that they are being applied appropriately and consistently, and in line with updated national guidance issued in 2012
•	use information about the use of waiting list codes, alongside waiting time performance data, to:
–	identify where staff may be applying codes inconsistently or inappropriately 
–	help plan and manage the capacity needed to meet waiting time targets.
NHS boards should:
•	make sure that electronic systems have an audit trail to enable scrutiny of waiting list systems, and that good controls and safeguards are in place to provide assurance that waiting lists are being managed properly
•	ensure that information is recorded within patient records about the reasons for applying waiting list codes
•	communicate clearly with patients about their rights and responsibilities under waiting time guidance and legislation
•	ensure effective whistleblowing policies and procedures are in place and publicised.
Non-executive directors of NHS boards should:
•	ensure they have the full range of information available to scrutinise how their board is applying waiting list codes and planning and managing capacity to meet waiting time targets.
The Scottish Government and ISD Scotland should clarify:
•	the role of each organisation in monitoring the application of waiting list codes and performance against waiting time targets
•	the process for raising concerns about issues within individual NHS boards.
What happens now?
The full report can be accessed on our website – www.audit-scotland.gov.uk. We will present our report to the Scottish Parliament’s Public Audit Committee. The Committee can call relevant people at the Scottish Government and other public bodies to discuss the issues our audit has raised.
We will also monitor progress against our recommendations through our audit work.