Management of patients on NHS waiting lists – audit update
Auditor General for Scotland
Prepared by Audit Scotland
December 2013

Auditor General for Scotland
The Auditor General’s role is to:
•	appoint auditors to Scotland’s central government and NHS bodies
•	examine how public bodies spend public money
•	help them to manage their finances to the highest standards 
•	check whether they achieve value for money. 
The Auditor General is independent and reports to the Scottish Parliament on the performance of:
•	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 Police Authority, Scottish Fire and Rescue Service.
You can find out more about the work of the Auditor General on our website: www.audit-scotland.gov.uk/about/ags

Audit Scotland is a statutory body set up in April 2000 under the Public Finance and Accountability (Scotland) Act 2000. We help the Auditor General for Scotland and the Accounts Commission check that organisations spending public money use it properly, efficiently and effectively.

Summary

Key facts
250,729
Patients waiting for an outpatient appointment on 30 September 2013

50,478
Patients waiting for inpatient treatment on 30 September 2013

41%
Patients with patient-advised unavailability in September 2013 who were unavailable because they wished to be treated by a specific doctor or at a specific hospital

98%
Eligible inpatients seen within their legal guarantee of 12 weeks in September 2013

36%
Inpatients unavailable in September 2011

18%
Inpatients unavailable in September 2013

Background
1.	The time patients wait for treatment is very important to them. It has also been a major NHS performance target since 2003. Waiting time targets have reduced over recent years, from nine months for inpatient treatment in December 2003 to 18 weeks from referral to treatment in December 2011. The length of time that patients wait has also reduced. Across Scotland, about 250,700 patients were waiting for an outpatient appointment and about 50,500 patients were waiting for inpatient treatment on 30 September 2013., 
2.	Audit Scotland published a report on the Management of patients on NHS waiting lists on behalf of the Auditor General for Scotland in February 2013. The audit involved a detailed review of NHS boards' electronic waiting list systems and analysing how boards applied waiting list codes in patients' records between April and December 2011. Waiting list codes include patient unavailability and reasons for removal from the waiting list. Our audit followed evidence that NHS Lothian had manipulated waiting lists in 2011. We aimed to identify whether NHS Lothian's manipulation of waiting lists in 2011 was an isolated incident or more widespread across the NHS. We did not find evidence of manipulation elsewhere. Our main findings were:
•	The systems boards used to manage waiting lists had inadequate controls and audit trails, and the information they recorded in patient records was limited. This meant that it was 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.
•	The percentage of people waiting for inpatient treatment who were given a social unavailability code rose considerably between 2008 and 2011. This started to reduce in most NHS boards in late 2011 as the percentage of patients waiting longer than 12 weeks started to rise. The reasons for this were unclear.
•	During 2011, the focus within the Scottish Government and NHS boards was on meeting waiting time targets. There was not enough scrutiny of the available information that could have helped identify concerns about how boards were using unavailability codes.

3.	We presented our report to the Public Audit Committee of the Scottish Parliament in February 2013. The committee subsequently took evidence from accountable officers within the Scottish Government, NHS National Services Scotland and a number of NHS boards. The committee published its own report in May 2013. It also asked the Auditor General to provide an update by the end of 2013, to receive an independent perspective on the progress made by the Scottish Government and NHS boards.
4.	The Cabinet Secretary for Health and Wellbeing has asked chief executives of NHS boards for an update on progress against internal audit reports on waiting times (published in December 2012), by mid-December 2013.

About the audit
5.	This audit update focuses on the progress by the NHS in improving audit trails and monitoring how they manage waiting lists. Our objectives were to provide an update on the following:
•	How have trends in NHS boards' use of waiting list codes and waiting time performance changed during 2013?
•	Have NHS boards improved how they manage and monitor NHS waiting lists?
•	Have the Scottish Government and Information Services Division (ISD) Scotland improved how they report and monitor waiting list information?
6.	The methodology for the audit update included:
•	interviews with the Scottish Government and ISD Scotland (part of NHS National Services Scotland)
•	a review of the latest ISD Scotland published waiting times data
•	a review of NHS board documentation which aimed to assess whether there have been improvements in how boards monitor and manage their waiting lists, including:
–	board papers, performance reports and examples of letters sent to patients about the treatment time guarantee
–	reports on progress against the recommendations in our earlier report as well as those in boards' internal audit reports and the Public Audit Committee report.

7.	Our previous report gives more detailed information on waiting list guidance and how NHS boards should manage patients on waiting lists, including the use of unavailability codes.
8.	We have prepared a number of report supplements which can be found on our website:
•	a self-assessment checklist for NHS boards to use when considering how to improve their performance
•	issues for non-executive members of NHS boards to consider in relation to management of waiting lists within their own boards
•	a summary for patients of what they need to know if they are on a waiting list.

Key messages
1.	The Scottish Government and ISD Scotland have been working closely with NHS boards to implement recommendations from Audit Scotland, internal auditors and the Parliamentary Public Audit Committee. NHS boards are putting in place better controls and audit trails in the systems they use to manage NHS waiting lists. They have also improved the information they use for monitoring and reporting to their boards of directors. In particular, there is a stronger focus on how boards record and monitor the reasons for patient unavailability.
2.	Most NHS boards are meeting the requirement to treat patients within 18 weeks of referral to hospital, including any required outpatient appointments and diagnostic tests. The percentage of people waiting over 12 weeks for an outpatient appointment has increased from three per cent (5,993 people) in September 2012 to five per cent (11,544 people) in September 2013. Recent Scottish legislation to guarantee that all eligible people receive inpatient treatment within 12 weeks is challenging, and only three NHS boards have achieved this each month since the guarantee was introduced in October 2012.
3.	Our previous report highlighted that the use of unavailability codes began to reduce in late 2011. This trend has continued during 2012 and 2013. The introduction of new waiting time guidance and unavailability codes allow boards to separately identify patients who are recorded as unavailable because they chose to be seen within the board area, or by a specific consultant. Across Scotland, boards have recorded that 41 per cent of non-medical unavailability is for these patient choice reasons.
4.	The new waiting time guidance should benefit patients by giving them a guarantee of when they will be treated. It has taken time for the NHS to update its IT systems to take account of the new guidance and audit recommendations. This means that NHS boards are currently providing less detailed information on waiting times to the Scottish Government and ISD Scotland, and nationally published information is currently less comprehensive than before. The Scottish Government and ISD Scotland have put in place processes to get additional information from boards on how they are managing their waiting lists, but some gaps still remain. The Scottish Government expects this to be resolved in early 2014.

Key recommendations
The Scottish Government should:
•	agree with NHS boards what information they should be reporting nationally to allow it to monitor how boards manage NHS waiting lists.
ISD Scotland and NHS boards should:
•	work together to put in place the necessary changes to NHS boards' electronic systems as quickly as possible so that they can provide detailed inpatient waiting times data to ISD Scotland. This will allow better monitoring at a national level and more comprehensive public reporting.
NHS boards should:
•	ensure their management of waiting lists includes scrutinising how they use all waiting list codes, not just unavailability codes
•	implement the national controls framework to assess whether they have all the necessary controls in place to manage waiting lists, and address the gaps they need to fill
•	implement our previous recommendation about making sure they identify patients with additional support needs and provide the required support
•	ensure letters to patients about the treatment time guarantee provide clear and detailed information
•	use the new codes to monitor unavailability due to patient choice reasons as part of their overall capacity planning
•	use the tool being developed by ISD Scotland to monitor indicators for the management of waiting lists and benchmark their performance against other boards.

Progress since our February 2013 report
Most NHS boards are meeting the 18-week referral to treatment standard but performance against other standards is less consistent
9.	NHS boards are expected to treat patients within the following timescales:
•	Since December 2011, NHS boards have been required to meet the 18-week referral to treatment (RTT) standard. The standard is for 90 per cent of patients to have started treatment within 18 weeks of being referred to hospital, including any outpatient appointments and diagnostic tests.
•	Since March 2010, no patient should have to wait more than 12 weeks for their first outpatient appointment.
•	In October 2012, the Patient Rights (Scotland) Act 2011 brought in the Treatment Time Guarantee (TTG). Under this, eligible inpatients and day case patients have a legal right to receive treatment within 12 weeks of their treatment being agreed.

10.	Thirteen NHS boards met the standard of 90 per cent of patients treated within 18 weeks from their referral to hospital in the month ending September 2013. Most boards have continually achieved this standard since December 2011, although NHS Forth Valley has not achieved it since May 2012 and NHS Lothian since September 2011.
11.	Performance against the two other standards for outpatient appointments and inpatient treatment is less consistent (Exhibit 1). At a national level, the 12-week TTG is not being met and performance against the standard that all outpatients should be seen within 12 weeks has been deteriorating.
12.	Performance in individual NHS boards varies. No board met all three standards in September 2013, although NHS Greater Glasgow and Clyde and the Golden Jubilee National Hospital missed meeting all three standards by less than one per cent (Exhibit 2). Six of the 15 boards met the TTG in September 2013 and another four boards were within one percentage point of meeting it. NHS Forth Valley and NHS Lothian did not meet any of the standards.
NHS boards are finding the new TTG challenging
13.	The TTG requiring NHS boards to treat all inpatients within 12 weeks is challenging. Only three boards have met this each month since the guarantee was introduced in October 2012 (NHS Orkney, NHS Western Isles and the Golden Jubilee National Hospital).
14.	In the boards that have consistently not met the TTG, the percentage of people waiting over 12 weeks is small. The highest percentages of inpatients waiting over 12 weeks in the month ending September 2013 were in NHS Grampian (3.9 per cent, 88 people) and NHS Lothian (8 per cent, 354 people). These boards have plans to increase the number of patients they can see. For example, NHS Lothian spent an additional £27.2 million on working towards waiting times targets in 2012/13. This included spending on private sector healthcare, other NHS boards, and additional staffing and activity within the board. It has identified that it needs to invest £50 million to expand its internal services and fund its use of other healthcare providers over the next two years.
15.	NHS boards failing to meet the waiting times standards indicates pressure on their capacity. There are risks this pressure will increase as demand continues to grow. Auditors have highlighted the risks of NHS boards meeting increasingly demanding targets while also making increased financial savings. The Scottish Government is continuing to work with NHS boards to help them meet waiting time standards in a way that they can maintain. Our NHS financial performance report highlighted the increasing vacancy rates for consultant and nursing staff between March 2011 and March 2013.  This may affect boards' ability to meet waiting time targets. The Scottish Government is providing funding so that the Golden Jubilee National Hospital in Clydebank and the Scottish Regional Treatment Centre at Stracathro Hospital in Angus can see more patients. These are national NHS services that all boards can refer patients to, if they do not have enough capacity to treat them locally.

More patients are waiting longer for outpatient appointments
16.	Across Scotland, 4.6 per cent of patients (11,544 people) on the waiting list for an outpatient appointment had waited over 12 weeks in the month ending September 2013. This is an increase from 2.7 per cent (5,993 people) in September 2012. No NHS board achieved the standard in September 2013 and in NHS Forth Valley about 20 per cent of patients (3,052 people) were on the waiting list for over 12 weeks for an outpatient appointment. NHS Forth Valley has reported there are a number of services where it is experiencing rising pressures and rising patient demand. The board has plans to address these pressures by recruiting additional staff and increasing the number of appointments and theatre sessions available. 
17.	The Scottish Government is currently working with NHS boards to reduce the length of time patients wait for outpatient appointments. It is carrying out some modelling work to estimate future demand in high volume specialties such as ophthalmology and orthopaedics. Demand for outpatient appointments has increased over the last three years but the number of people seen has not increased to the same extent. This suggests that the pressure on outpatient waiting times is likely to continue and NHS boards are finding it difficult to meet the standard as outpatient referrals continue to increase. Between September 2010 and September 2013, across Scotland:
•	the size of the waiting list for outpatients at a census on the last day of September increased by 20 per cent, from 208,583  to 250,729 people
•	the number of outpatients actually seen during the quarter only increased by eight per cent, from 328,021 to 352,881 people (an average of about 117,600 people each month).

Use of unavailability codes has reduced considerably
18.	People on waiting lists may be unavailable for treatment for various reasons. The time they are unavailable is not included in their overall waiting time. Before October 2012, NHS boards could code patients as medically or socially unavailable. In October 2012, the Scottish Government introduced new patient-advised unavailability codes. This means that, since then, NHS boards have been able to identify patients who are recorded as unavailable for patient choice reasons, including patients wanting to be seen within the board area or by a specific consultant. The new patient-advised codes cover a range of non-medical reasons that patients may be unavailable, including:
•	on holiday
•	personal commitment
•	work commitment
•	academic commitment
•	carer commitment
•	wishes to see a named consultant
•	wishes to be treated within the local health board area.

19.	Our previous report highlighted that the use of all unavailability codes began to reduce in late 2011, around the time concerns began to be raised about the way NHS Lothian was managing its waiting lists. This trend has continued over the past two years across Scotland. Between September 2011 and September 2013, the use of unavailability codes reduced from about 11 to five per cent for outpatients, and from about 36 to 18 per cent for inpatients (Exhibit 3). However, inpatient non-medical unavailability has increased slightly in some NHS boards over the last year (Exhibit 4).

About 40 per cent of patient-advised unavailability is due to patients choosing to be seen within their local area or by a specific doctor
20.	Our previous reports on the management of NHS waiting lists highlighted that NHS boards could not identify capacity problems caused by patients wanting to be treated at their local hospital. This was due to the lack of separate unavailability codes for patient choice. The introduction of new patient-advised unavailability codes in October 2012 means that NHS boards can now identify patients recorded as unavailable for patient choice reasons. The guidance states that using these codes would be unusual and would not be expected to affect large numbers of patients. 
21.	Across Scotland, in September 2013, 41 per cent of inpatients coded as non-medically unavailable were for reasons of patient choice – 25 per cent for patients wishing to see a specific consultant and 16 per cent for patients wanting to be treated within their health board area (Exhibit 5). The other two main reasons for boards using non-medical unavailability codes are for social reasons: personal commitments (24 per cent) and holidays (19 per cent). NHS boards should now monitor and use this information to consider if they need to increase local capacity to meet patient needs.
There is variation in NHS boards' use of new unavailability codes
22.	We are unable to look at trends in how NHS boards are using new patient-advised codes. This is because it took some time for boards to update their electronic systems to enable them to start reporting these new codes to ISD Scotland. Since April 2013, all boards except NHS Highland have been reporting a breakdown of patient-advised codes for inpatients to ISD Scotland. This is due to limitations in NHS Highland's electronic system.  It plans to upgrade its system in March 2014.
23.	In September 2013, the highest percentage of patients non-medically unavailable for reasons of patient choice were in NHS Greater Glasgow and Clyde (68 per cent of all patients unavailable) and NHS Grampian (60 per cent of all patients unavailable). NHS Greater Glasgow and Clyde has the highest use of the patient-advised unavailability code for wishing to see a specific consultant (51 per cent compared to the Scottish average of 25 per cent). NHS Grampian has the highest use of the code for patients wishing to be seen in their own health board area (39 per cent compared to the Scottish average of 16 per cent). These boards have reported specific pressures on their ability to provide services locally:
•	In NHS Greater Glasgow and Clyde, demand is high in some hospitals, particularly for ophthalmology, due to patients wanting to be seen at their local hospital rather than at another hospital within the board area. The board is recording this using the patient-advised code for wishes to be see a specific consultant. It is reviewing how to reorganise services to better meet high demand in particular hospitals.
•	NHS Grampian has identified a lack of capacity within its area and has reported that many patients are not willing to travel to the Golden Jubilee National Hospital in Clydebank or the Scottish Regional Treatment Centre at Stracathro in Angus. The board has invested in additional theatres, which will be operational in Woodend Hospital and Aberdeen Royal Infirmary from early 2014, and is in the process of recruiting additional consultants. 

Patients now get letters about their status on the waiting list, but these could be clearer
24.	Since October 2012, NHS boards have been required to send letters to patients covered by the TTG. This means patients should have better information and a clearer understanding about what is happening with their waiting time and when they should expect to be treated. NHS boards must:
•	inform patients of their rights and responsibilities
•	confirm when they have been added to a waiting list
•	make them aware of any changes in their status on the waiting list that affects their treatment guarantee date, for example if the hospital has recorded a period of unavailability for the patient
•	apologise to patients if they are not seen within their treatment guarantee date, explain the reasons why and how patients can make a complaint.

25.	This is a significant improvement and there are examples of good practice. But the clarity and level of detail in these letters varies greatly among boards. Letters should be written in plain language and be easy to understand. In the initial letter sent to patients after they have been added to the waiting list, eight boards do not include the date by which the patient has a right to be treated under the TTG. Boards are generally better at stating the dates in letters to patients when they are unavailable, and explaining how this affects their treatment guarantee date.
26.	As a minimum, the letters should:
•	explain to the patient that they have a right to receive treatment within 12 weeks and specify the date when they should be treated by, ensuring they explain clearly what the date relates to and why it is important
•	include the start and end dates of recorded unavailability and the reason for unavailability; or the date when the patient's unavailability should be reviewed where the end date is not known
•	explain the reasons for any changes to the patient's waiting list status and the implications of that change. Examples include the patient's waiting time being reset to zero due to them not attending an appointment, or the patient being removed from the waiting list and referred back to their GP
•	include the new date that the patient should be treated by to comply with their TTG if there are any changes to the patient's waiting list status, such as a period of unavailability or if the patient's waiting time has been reset to zero
•	explain what the board considers a reasonable offer, including treatment at facilities outside the board area
•	explain what the patient's responsibilities are in relation to attending for treatment and notifying the hospital if they are unable to attend or dates they are unavailable 
•	include clear details about how to get in touch with the hospital.

27.	There are examples of good practice in some boards where clear and detailed information is provided to patients, such as NHS Dumfries and Galloway (Case Study 1). NHS Forth Valley is working with patient groups in drafting its letters. A number of boards have also developed leaflets to include with letters. NHS Lanarkshire has produced a useful factsheet for patients receiving treatment. It shows the steps involved, depending on their circumstances, and anything the patient needs to do at each stage.
28.	The Scottish Government introduced a waiting times information telephone line and website in October 2013. These aim to provide patients with general advice about waiting times, how long they should typically expect to wait, and their rights and responsibilities.

Case Study 1
Examples of good practice in NHS boards providing information to patients about their treatment time guarantee (TTG)

Information provided to patients	Examples of good practice	
Patients' rights under the TTG	NHS Dumfries and Galloway
The initial letter to the patient when they are added to the waiting list includes: 
•	a statement that the patient is eligible to be treated within 12 weeks under the TTG and the date they should be seen by 
•	the specialty they are waiting for
•	an explanation of what happens next in terms of the hospital contacting the patient about an appointment and a telephone number for the patient to let the hospital know about any dates they are unavailable
•	confirmation that the board does not accept requests for treatment to be deferred for longer than three months.	
How the board explains what it means by a reasonable offer	NHS Forth Valley
The initial letter to the patient when they are added to the waiting list clearly defines where the patient may be seen:
"To ensure you are admitted for your treatment within 12 weeks you could receive an offer of appointment from NHS Forth Valley, Golden Jubilee National Hospital, any private facility or, in some special circumstances, any site in Scotland."	
Patient unavailable for treatment	NHS Dumfries and Galloway
If the patient is unavailable, the board sends a letter stating:
•	the hospital has been notified that the patient is unavailable and whether this is medical or non-medical
•	the start date and end date of the period of unavailability
•	the patient's amended guarantee date under the TTG
•	"adjusting for unavailability, this means we will offer you an appointment on or before [guarantee date]. This is the maximum that you should have to wait, we will of course endeavour to see you sooner."	
Patient leaflets	NHS Lanarkshire
The patient leaflet that the board sends:
•	is written in plain language
•	clearly explains patients' rights and responsibilities under the TTG
•	asks patients to make the hospital aware if they have any additional support needs
•	lists other waiting time standards that apply.
•	The board also gives patients a factsheet at their outpatient appointment:
•	it includes flow charts to explain what happens in the following situations – the patient is added to the waiting list; the patient requires more tests before a decision is made about treatment; the patient needs a pre-assessment before being treated; and the patient needs to take some time to decide whether to proceed with treatment.
•	each flow chart shows the steps involved and timescales, including if patients need to make an appointment for pre-assessment or contact their doctor to confirm they wish to proceed with treatment, and when a date for treatment will be sent to the patient.
•	it highlights what the patient has to do, such as notifying the hospital if they are unable to attend an appointment.
NHS Ayrshire and Arran, Borders, Forth Valley, and Greater Glasgow and Clyde also produce patient leaflets.	

Source: Audit Scotland

NHS boards need to further improve how they meet patients' additional support needs
29.	We previously recommended that NHS boards should ensure that they identify patients with additional support needs, such as a disability or requiring a translator, and provide them with the support they require. The Scottish Government asked all NHS boards to provide it with written assurance in August 2013 that they are addressing this recommendation. The responses show that there is limited progress in most boards.
30.	NHS boards' systems generally are not set up to:
•	prompt staff referring patients to hospital for treatment to provide information about patients' additional support needs
•	have a specific field to enter information on patients' additional support needs into the electronic system
•	collect this information in a consistent way.

31.	This means that information about patients' additional needs is not always available for patients referred to hospital for treatment. Most boards still rely on the GP, or other referrer, identifying patient needs as part of the referral letter. This information is usually recorded as free text in the general notes in the electronic referral, rather than being identified separately. Without comprehensive information on patients' additional needs, boards are unable to provide assurance that all patients receive the support that they require. Seven boards have fields within hospital electronic systems to record any additional support that patients need, and five are planning to introduce these. No boards reported that patients' additional support needs are taken into account in a systematic way when considering where and when to offer patients an appointment.
32.	NHS Lothian has a comprehensive action plan for 2013/14 to improve the way it meets patients' additional support needs. This involves amending its electronic system, including setting it up to automatically generate patient letters that are specific to individuals' identified needs, for example in larger text or in a different language. The board expects the developments to the electronic system to produce better data to monitor whether it is managing patients appropriately for their needs.
33.	NHS Greater Glasgow and Clyde is one of six boards that has a specific field for additional support needs in the electronic referral system and it has also set up alerts within the system. The board carried out an audit to confirm that staff are using this information when arranging patients' appointments.

Better controls and audit trails are being put in place
34.	Our previous report highlighted that the systems used to manage waiting lists had inadequate controls and audit trails (See Exhibit 4 on page 15 in our previous report). We recommended that NHS boards should have:
•	an audit trail that allows scrutiny of their waiting lists systems, for example to identify and investigate unusual patterns such as high numbers of changes to waiting list codes in patient records
•	good controls and safeguards in place to provide assurance that they are managing waiting lists properly. This includes how they manage both their electronic waiting list system and the electronic patient records, for example, by limiting the number of staff with access to the system and ensuring there are fields for recording all relevant waiting list codes and sub-codes. 

35.	All NHS boards have improved their systems and controls for managing waiting lists, including: 
•	updating their guidance on managing waiting lists
•	monitoring how they use unavailability codes
•	sending letters to patients receiving inpatient treatment about their waiting time and any changes that may affect this, including periods of unavailability
•	introducing manual monthly audits of a sample of patient records, as recommended by the Public Audit Committee
•	implementing a controls framework, developed by NHS boards and the Scottish Government (see paragraphs 48 to 50)
•	amending the electronic systems they use to manage waiting lists, such as incorporating new waiting list codes for unavailability and making some additional data recording fields mandatory for staff. For example, five boards have now set a mandatory field for staff to record information on the reasons for patient unavailability if they record the patient as being unavailable.

36.	NHS Forth Valley and Tayside also monitor trends in how individual staff members are using waiting list codes. NHS Lanarkshire plans to use information on how waiting list codes are being used to target training to individuals where managers identify a need.
A confidential phone line has been set up for staff who have concerns about patient care
37.	We highlighted in our previous report that NHS boards must provide a safe environment for staff to raise any concerns about the management of patients' care. This includes any concerns about the way in which boards are achieving waiting times and ensuring they are maintaining their focus on patients and their needs at all times. Several NHS boards reported that they have updated their whistleblowing policies and made staff aware of the policies, for example through training. For example, NHS Borders is asking staff who book patient appointments to provide evidence that they have read and understood its new whistleblowing policy. NHS Forth Valley is displaying posters across hospitals to raise staff awareness about its policy.
38.	In April 2013, the Scottish Government launched a National Confidential Alert Line run by Public Concern at Work, an independent whistleblowing charity. NHS staff can raise concerns about patient safety and quality of care in confidence. Legally trained staff provide support and advice, and where appropriate, they can pass concerns to the appropriate regulatory body for investigation. At the end of September 2013, there had been 74 public interest issues raised by NHS staff. From the information available, it is not clear how many of these related to concerns about the management of waiting lists.

An electronic benchmarking tool is being developed to help boards monitor and compare their performance
39.	We recommended previously that NHS boards should monitor and report their use of waiting list codes to ensure they are being used appropriately and consistently. We also recommended that boards consider this information alongside waiting times performance to help plan and manage their capacity. Monitoring in NHS boards has improved and three boards have waiting times dashboards – easy-to-read information summaries – to monitor a wide range of indicators (NHS Lanarkshire, Lothian and Tayside). Most boards are monitoring a number of waiting list indicators. All are now monitoring their use of unavailability codes and over half are monitoring retrospective changes to waiting list codes, the number of times patients' waiting times are reset to zero and cancellation of appointments by the hospital (Appendix 1). All NHS boards have started to carry out monthly audits of a sample of the records of patients on waiting lists. These should also provide some further monitoring information.
40.	ISD Scotland is developing an electronic benchmarking tool of key indicators that compares performance for each board. This uses information extracted from NHS boards' electronic systems, for example use of unavailability codes, retrospective changes to waiting list codes, and resetting the patient's waiting time clock to zero. The tool will be interactive. It will be kept under review and additional indicators added over time as required. Users can monitor and compare their board's performance against specific indicators over time using data at different levels, including:
•	inpatient/day case or outpatient
•	all specialties or individual specialty
•	NHS board
•	all of Scotland.

41.	The benchmarking tool will be available from January 2014. This should be a significant improvement in monitoring and benchmarking, but NHS boards should continue to improve their own internal monitoring. There are a number of key indicators that boards should monitor locally (Exhibit 6). Boards should monitor these over time at both NHS board and individual specialty level to identify trends over time and variation between specialties. Some of these indicators will be included in the ISD Scotland benchmarking tool. Other information will only be available to NHS boards locally from detailed analysis that they are able to carry out in their own electronic systems.
42.	Only seven boards are monitoring the numbers of offers of treatment outside the board area that they make to patients, and how many of these are accepted or refused. A number of boards said this was difficult to do in their electronic systems. We previously recommended that NHS boards should monitor this as part of their monitoring of local capacity to ensure they have enough skilled staff, equipment and facilities to treat people within waiting time targets.
43.	Almost all referrals from GPs are electronic, which means the information goes directly into the hospital waiting list system without delay. Some referrals are still paper-based rather than electronic and this can lead to delays in patients being added to the waiting list system. The date a patient is added to the waiting list is the date the patient was referred, so their waiting time should not be affected but it reduces the time the hospital has to treat them. For example, referrals from community optometrists and dentists are still mainly paper-based. The Scottish Government plans to work with NHS boards during 2014 to put the IT in place that they need to increase electronic referrals from dentists and optometrists.
NHS boards' scrutiny has improved
44.	We previously highlighted that in the past there was not enough scrutiny of how NHS boards were applying waiting list codes and the focus within the Scottish Government and NHS boards was on meeting shorter waiting time targets and developing capacity. Since late 2011, NHS boards have improved how they scrutinise waiting list codes and the range of information reported to their boards of directors (executive and non-executive directors) and other committees. Five NHS boards provide comprehensive monitoring reports to their board of directors or its committees, including NHS Tayside (Case Study 2).
45.	A number of boards have developed scorecards or other performance monitoring tools. They use these to look at performance at hospital, specialty, consultant and individual patient levels. Service managers and management teams use these reports to manage waiting lists, for example to avoid patients waiting longer than target times. Operational teams or waiting list management teams generally consider this information at least every week.
46.	All NHS boards provide waiting time monitoring reports to their board of directors. These generally focus more on performance against waiting time targets than on how the board is managing the waiting list. Twelve NHS boards also include information on rates of unavailability, although not all break it down to specialty level. Most reports to boards of directors include information on performance at specialty level and actions to increase capacity where required. A number of boards plan to improve their performance reporting further as their monitoring continues to develop.
47.	NHS Borders, Dumfries and Galloway, Lothian and Western Isles have provided development sessions for non-executive directors about managing waiting lists in their boards. NHS Ayrshire and Arran worked with non-executive directors to improve the content of reports on waiting times and NHS Forth Valley agreed with non-executive directors the methodology for auditing a sample of outpatient patient records. This is to improve non-executive directors' understanding of waiting lists arrangements and enable them to provide effective challenge about the board's performance.

Case Study 2
Example of detailed monitoring of waiting list information

NHS Tayside developed a waiting list dashboard and started reporting on a range of indicators from 1 April 2013, including:
•	number and percentage of patients with current unavailability at the end of each month
•	number and percentage of patients with unavailability that has been applied retrospectively
•	number and percentage of patients where unavailability ends the day before their appointment or admission
•	members of staff who have created five or more periods of unavailability in one hour
•	number of patients recorded as Did Not Attend
•	number of patients removed from the waiting list without an appointment.

Staff and managers can use it to analyse various levels of data, from directorate and hospital level, to individual patient level. This means they can identify individual patient cases where they may need to take action.
The indicators are reported for each specialty and the board's Waiting Times Accountability Group, which meets monthly and reviews the reports. This information is included in the monthly waiting times risk assessment reports to the Executive Management Team. Specialty general managers submit monthly signed reports to the chief operating officer and the Executive Management Team providing assurance that staff are complying with the local waiting times policy.  Information on patients unavailable at the end of the month is also reported to NHS Tayside's board of directors.
Source: Audit Scotland based on information from NHS Tayside

The Scottish Government and NHS boards have introduced a controls framework for managing NHS waiting lists
48.	The Scottish Government has worked with all NHS boards to develop a waiting times controls framework that can be applied to the different ways of managing patients and the electronic systems in place. It was issued to boards in October 2013. This is a useful framework that will allow NHS boards to assess whether they have the necessary controls in place to manage waiting lists and identify any gaps they need to address.
49.	The controls framework includes electronic and manual controls for the different stages of managing waiting lists. It covers controls for how the NHS board:
•	manages the patient referral
•	issues appointments to patients
•	records, in the electronic system, patient unavailability, patients who did not attend (DNA), patients who could not attend (CNA) and patients who had their waiting time clock reset because of a DNA or CNA 
•	issues letters to patients waiting for inpatient treatment about their waiting list status
•	reports and scrutinises information to monitor how they are managing waiting lists at different levels, from operational team to board of directors level
•	limits staff access to the electronic system
•	securely stores and backs up the data
•	ensures that the electronic system uses national waiting times codes
•	provides appropriate staff training.

50.	The controls framework helps the board to identify if there are specific aspects of the controls that it needs to improve, for example areas where their controls do not meet recommended practice. The Scottish Government expects NHS boards to update the matrix and report whether they are complying with the controls to an appropriate committee within their board at least quarterly. They should also use the controls framework on an ongoing basis as part of their internal quality assurance processes.

Less detailed information about waiting times is currently available at a national level
51.	It has taken time to make the required changes to NHS boards' electronic systems for them to be able to provide the data to ISD Scotland's national waiting time database (Exhibit 7). This was due to a number of reasons:
•	the Scottish Government finalised the new waiting time guidance later than planned to ensure that it addressed the concerns about the way NHS Lothian was managing patients on waiting lists
•	the Scottish Government asked NHS boards and ISD Scotland to incorporate recommendations from the subsequent audit reports published in late 2012/ early 2013 in the specifications for changes to electronic systems
•	during 2011/12 and 2012/13, five NHS boards implemented new electronic systems.

52.	Before October 2012, NHS boards were providing ISD Scotland with a full breakdown of their waiting time data. ISD Scotland used this to analyse waiting times data in each board and published tables and charts comparing boards' performance. It also reviewed each board's data and queried any anomalies. NHS boards are still providing this detailed information for outpatients, with the exception of outpatient patient-advised unavailability. But they have not been able to provide it for inpatient data since October 2012. Instead, they have been providing limited, summarised inpatient data. Since late 2012, ISD Scotland has been receiving less detailed information from NHS boards' electronic systems and is not able to carry out the same level of analysis and reporting as it could previously for inpatients. This means that less comprehensive information on inpatient waiting times is currently available publicly. The gaps in inpatient information currently submitted to ISD Scotland include:
•	individual patient level data
•	data broken down by specialty
•	the number of patients removed from the waiting list and the reasons
•	the number of patients who did not attend or could not attend appointments, or had their appointments cancelled by the hospital
•	the actual time patients waited compared to the wait recorded against the waiting time target, excluding any periods of unavailability or clock resets.

53.	In the absence of nationally reported detailed waiting time data from NHS boards, the Scottish Government is getting additional information from boards on how they are managing their waiting lists. Each board is providing the Scottish Government with weekly performance monitoring reports on performance against the TTG and monthly reports on waiting times. These provide additional detailed information that boards are not currently providing to ISD Scotland. Some gaps still remain in the data available on inpatients, including:
•	data at individual patient level
•	a breakdown of the reasons for patients being removed from the list
•	the number of patients who did not attend or could not attend appointments, or had their appointments cancelled by the hospital
•	the actual time patients waited compared to the wait recorded against the waiting time target.
54.	NHS boards plan to start providing detailed waiting times data to ISD Scotland again by February 2014. It is anticipated that they will be able to provide historical data back to October 2012. ISD Scotland plans to publish the historical data which will allow trend analysis for the period when there were gaps in the data, including use of new patient-advised unavailability codes.

The Scottish Government and ISD Scotland have been working closely with NHS boards on improving the management of waiting lists
55.	In addition to the weekly and monthly monitoring reports from NHS boards, the Scottish Government has been getting regular updates on progress against audit recommendations from our report, and the reports from boards' internal auditors and the Public Audit Committee. Internal monthly reports are also provided to the Scottish Government Health and Social Care Management Team.
56.	ISD Scotland has agreed more formal communication and quality assurance processes with NHS boards, including reinstating a requirement for chief executives to sign off the waiting time data they provide on their board. It is planning closer scrutiny of a range of waiting times data. This includes plans to provide NHS boards and the Scottish Government with an electronic dashboard to monitor a number of indicators (see paragraphs 40 and 41, and Exhibit 6).
57.	We recommended that the Scottish Government and ISD Scotland should clarify:
•	the role of each organisation in monitoring how boards are applying waiting list codes and performing against waiting time targets
•	the process for raising concerns about issues within individual NHS boards.

58.	The Scottish Government and ISD Scotland have now clearly set out their roles and responsibilities for scrutinising how NHS boards manage waiting lists. They also have monthly meetings to discuss NHS boards' performance on waiting times.

Endnotes