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

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
What’s this report about?
Audit Scotland published a report on the Management of patients on NHS waiting lists (PDF)  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. This 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.
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?
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 inpatient 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.
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.