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AU/S2/06/R3

3rd Report, 2006 (Session 2)

Tackling waiting times in the NHS in Scotland

CONTENTS

REMIT AND MEMBERSHIP

THE REPORT

ANNEXE A – EXTRACTS FROM THE MINUTES

Extract from the Minutes – 3rd Meeting 2006 (Session 2)
Extract from the Minutes – 4th Meeting 2006 (Session 2)
Extract from the Minutes – 8th Meeting 2006 (Session 2)
Extract from the Minutes – 9th Meeting 2006 (Session 2)

ANNEXE B – ORAL EVIDENCE AND ASSOCIATED WRITTEN EVIDENCE

4th Meeting 2006 (Session 2), 21 March 2006

ORAL EVIDENCE

Dr Kevin Woods, Head of Scottish Executive Health Department and Chief Executive of the NHS in Scotland
John Connaghan, Director of Delivery, Scottish Executive Health Department
Dr Bob Masterton, Medical Director of Ayrshire and Arran Health Board
Jill Young, Chief Executive, Golden Jubilee National Hospital
Dr Kenneth Ferguson, Medical Director/Deputy Chief Executive, Golden Jubilee National Hospital

SUPPLEMENTARY WRITTEN EVIDENCE

Letter from the Clerk to Jill Young, Chief Executive, Golden Jubilee National Hospital
Submission from the Golden Jubilee National Hospital
Letter from the Clerk to Jill Young, Chief Executive, Golden Jubilee National Hospital
Submission from the Golden Jubilee National Hospital
Letter from the Clerk to Dr Kevin Woods, Head of Scottish Executive Health Department and Chief Executive of the NHS in Scotland
Submission from the Scottish Executive Health Department

Remit and membership

Remit:

  1. The remit of the Audit Committee is to consider and report on-

    (a) any accounts laid before the Parliament;

    (b) any report laid before or made to the Parliament by the Auditor General for Scotland; and

    (c) any other document laid before the Parliament concerning financial control, accounting and auditing in relation to public expenditure.

  2. No member of the Scottish Executive or junior Scottish Minister may be a member of the Committee and no member who represents a political party which is represented in the Scottish Executive may be convener of the Committee.

(Standing Orders of the Scottish Parliament, Rule 6.7)

Membership:

Mr Brian Monteith (Convener)
Susan Deacon
Margaret Jamieson
Mrs Mary Mulligan
Eleanor Scott
Margaret Smith
Mr Andrew Welsh (Deputy Convener)

Committee Clerking Team:

Clerk to the Committee
Shelagh McKinlay

Senior Assistant Clerk
Joanna Hardy

Assistant Clerk
Clare O'Neill

3rd Report, 2006 (Session 2)

Tackling waiting times in the NHS in Scotland

The Committee reports to the Parliament as follows—

INTRODUCTION

  1. This report sets out the Committee’s findings in relation to the Auditor General for Scotland’s (AGS) report entitled “Tackling waiting times in the NHS in Scotland” (AGS/2006/2).

EVIDENCE

  1. The Committee held one oral evidence session on 21 March 2006. The following witnesses gave evidence to the inquiry:

    Jill Young, Chief Executive and Dr Kenneth Ferguson, Medical Director/Deputy Chief Executive, Golden Jubilee National Hospital; Dr Kevin Woods, Head of Health Department and Chief Executive, NHS Scotland, John Connaghan, Director of Delivery and Dr Bob Masterton, Medical Director of Ayrshire and Arran Health Board.

  2. Written evidence received by the Committee can be found at Annexe B.

FINDINGS AND RECOMMENDATIONS

  1. The Committee’s main findings and recommendations are set out at Appendix A.

WAITING TIMES TARGETS IN THE FUTURE

Preparing for new targets for waiting times and the abolition of ASCs

  1. The Auditor General’s report1 stated that between March 2001 and September 2005 the number of inpatients and day case patients with a guarantee waiting longer than six months had reduced from 11,573 to 1,249. Between June 2003 and September 2005 the number of patients with an Availability Status Code (ASC) had increased from 28,349 to 35,048, representing around 32% of all patients waiting for care. ASCs are assigned to patients who are unavailable or medically unsuitable for treatment. Patients with an ASC lose their waiting time guarantee.
  1. The AGS report also highlighted the significant progress made by the NHS in achieving waiting time targets for new outpatient appointments. The number of outpatients with a guarantee waiting longer than six months fell from 53,759 to 11,854 in the year to September 2005. The number of outpatients with ASCs also reduced over this time period.
  1. During evidence, the Committee heard that, since the publication of the AGS report, the waiting times picture in Scotland has improved further. Targets for the end of 2005 have been met for inpatients, day cases, outpatients and for patients waiting for cardiac procedures.
  1. Conclusion: The Committee recognises and commends the NHS in Scotland for the work which has been carried out nationwide leading to progress in reducing the longest waiting times.
  1. From December 2007, a guarantee of a maximum 18 week wait for out-patients, in-patients and day cases will be in place. (The current guarantee is six months). ASCs will no longer be used from the end of 2007.2 Of these changes, Dr Kevin Woods said “We are confident that we are on track for that and we can meet the challenge. The modelling and planning work that is undertaken in the Health Department and in NHS Boards means that we have a clear view across the NHS of the numbers of patients who will need to be seen and treated. The NHS has capacity plans in place at board level to deal with all that.” (Col 1492)
  1. The Committee heard that the increase in ASCs between 2003 and 2005 (numbers peaked at 35,910 in June 2005) was due to removing the backlog of patients that had been waiting a long time and the transition from the previous method of compiling waiting lists which involved putting some patients on deferred lists. (Col 1496)
  1. The Committee also heard Dr Woods say that “It is the principal responsibility of the Boards to achieve a balance between capacity planning and the use of financial resources”, and that all Boards have included detailed plans on how to achieve the new targets and abolish ASCs in their local delivery plans. (Col 1495) These plans need to specify when and how Boards will assess patients who currently hold an ASC and demonstrate that capacity is in place to treat these patients if required.
  1. Boards submitted local delivery plans to the SEHD on 1 March 2006 and the Committee heard that the SEHD would then examine the plans to ensure that caseloads and targets can be met on a national basis. (Col 1494) In order to gauge the cost of implementing more demanding targets, it is imperative that SEHD evaluate the capacity which will be required to meet them; both in terms of staffing and facilities at the local and regional level.
  1. Conclusion: The Committee, from the evidence available, is not able to say whether sufficient plans are in place to ensure the achievement of the new targets. The Committee believes that there is a risk that the new targets will not be achieved or that budgets will be overspent if this planning work is not sufficiently robust.
  1. Recommendation: SEHD must ensure that local and regional capacity and workforce plans are sufficiently joined up and will support the achievement of the new waiting times targets. In responding to the report, SEHD should provide evidence from its review of local delivery plans that the plans provide for assessing and, where necessary, treating patients who currently have an ASC.

ROLE OF THE GOLDEN JUBILEE NATIONAL HOSPITAL

Long term role

  1. The Committee heard that the Golden Jubilee National Hospital (GJNH) has been increasing its activity year on year since it was established as an NHS resource and its flexibility has been a key feature of its success in reducing long waits. (Col 1498) Evidence provided to the Committee highlighted that a large degree of flexibility at the GJNH is needed to respond to local needs. For example, when activity cannot be delivered locally due to consultant illness or retirement (col 1501) and to respond to particular pressure points which require additional activity in different specialties from one year to the next. (Col 1502)
  1. The Committee heard that the SEHD is working with the GJNH to develop the role of the hospital in the future. The addition of the West of Scotland cardiothoracic unit will occupy space in the hospital which is currently unused, thereby decreasing overhead costs per case. (Col 1503) The hospital will have a continuing role in orthopaedics, general surgery and ophthalmology. Demand for ophthalmic and certain orthopaedic procedures will increase in future years due to an ageing population and the GJNH is planning to increase activity in these areas in anticipation of these trends. The hospital will also take on a key role in diagnostic imaging. The Committee also heard that the hospital will continue to provide flexibility in other specialties. (Col 1505)
  1. The Committee heard that Boards and SEHD are evolving the ways in which local Boards work with the GJNH through regional planning. (Col 1506) Work such as the West of Scotland demand and capacity plan will assist the GJNH in predicting demand. (Col 1501) The NHS Forth Valley case study contained in the AGS report3 describes how patients who may need and be willing to go to the GJNH are identified in good time, enabling the Board to respond rapidly to spare capacity by identifying additional demand.
  1. The Committee also heard, however, that there is a “fine balance” between forward planning and flexibility. (Col 1499) Recruiting consultants to reduce costs requires a degree of confidence about future levels of activity. (Col 1506) The achievement of planned patient numbers, the mix of procedures and subsequent impact on costs and income were key risk areas for 05/06 identified by the auditors.4 The AGS report recommended that the hospital should develop its role in a specified range of specialties which may conflict with a continued role in offering flexible capacity across a wide range of specialities.

  2. Conclusion: The Committee recognises the flexibility demonstrated by the GJNH and NHS Boards in trying to ensure capacity at the hospital is fully used. The Committee also recognises the work being done by the hospital and NHS Boards to develop a sustainable level and mix of activity in the future. However, the Committee remains unclear about the balance between, and the sustainability of, the various roles envisaged for the hospital in the future.


  3. Recommendation: SEHD and GJNH should keep the balance of services offered by the hospital under constant review and consider whether the projected levels and types of activity will enable the hospital to secure value for money in the longer term.

Costs at the GJNH

  1. The AGS report5 stated that the average cost for an orthopaedic procedure at the GJNH in 04/05 was £9,692, compared with £3,467 nationally.
  1. During evidence, Jill Young asserted that the complex case mix of procedures performed at the Golden Jubilee, combined with the fact that there is no A&E function, means that the unit cost per procedure at the GJNH is higher than the national average. The fact that the hospital is not yet utilised to its full capacity means that overheads are high and this further contributes to high costs. (Col 1503)
  1. The AGS report6 revealed that the way consultants are paid at GJNH means that staff costs for some types of surgery are approximately double the average in Scotland as a whole. The Committee heard that GJNH is in transition from using visiting consultants to employing staff under standard pay terms and conditions. (Col 1506) Supplementary written evidence supplied by the GJNH reveals that a significant proportion of activity at the hospital is still remunerated with waiting list initiative or fee per case payments.
  1. Conclusion: The Committee notes the progress being made at the GJNH with recruiting or remunerating visiting consultants under NHS terms and conditions but believes this has not yet gone far enough. Further progress will depend on how the role of the hospital develops in the future.
  1. Recommendation: The GJNH must take account of the impact of future changes in its role and activity on cost per case at the hospital.

VALUE FOR MONEY OF WAITING TIMES INITIATIVES

  1. The Committee notes the AGS report concern that waiting list activity funded using non-recurring funding can be more expensive both in the independent sector and in the public sector under the terms of the NHS consultant contract. The Committee also notes Dr Woods’ statement that the NHS in Scotland is trying to shift the balance away from non-recurring funding although there will always be some role for it. (Col 1514)
  1. Accurate NHS tariffs are necessary in order to assess value for money and to make comparisons between public and independent providers. During oral evidence and by providing supplementary written evidence, SEHD have demonstrated how planned bulk purchases of orthopaedic procedures from independent providers have brought prices down close to the level of NHS tariffs.7 Independent sector prices for cataract surgery are higher than published NHS tariffs. (Col 1515)
  1. Conclusion: The Committee recognises that the reductions that have been achieved in some private sector prices have improved value for money for waiting list activity. However, the Committee believes that more could be done to shift the focus from spending on short term waiting list initiatives towards funding service redesign which will keep waiting times down on a sustainable basis.
  1. Recommendation: The SEHD should review the balance of recurring funding and the use of waiting list initiatives to ensure a sustainable approach to the reduction of long waits.

INVOLVING PATIENTS

  1. The AGS report found that “Involving patients in decisions about when and where they are treated could improve waiting times.”8 The Committee notes a disparity between Boards’ view of patients’ willingness to travel and the results of a survey carried out by Audit Scotland. (Col 1507)
  1. “Some Boards told us that patients are unwilling to travel to the GJNH…But not all Boards are actively encouraging the use of the GJNH or offering it…as an alternative.”9
  1. Dr Masterton, during evidence stated that clinicians, in his experience, have no concerns regarding sending patients out of their local area for treatment.
  1. Conclusion: The Committee is disappointed with the apparent lack of consistency in Boards’ practice of referring patients to the GJNH.
  1. Conclusion: The Committee agrees with witnesses that it is normally preferable to treat patients in their local area but believe that more patients should be offered the opportunity of being treated sooner at GJNH. (Col 1507)
  1. The AGS report stated that the results of Audit Scotland’s patient survey revealed that nearly half of all patients felt that they were “not really involved at all” in the decision about their treatment10. Supplementary evidence submitted by SEHD11 demonstrates that Boards have been provided with standard guidance on patient involvement.
  1. Conclusion: The Committee notes that common standards for patient involvement have been issued.
  1. The Committee heard that Boards are expected to ensure that all offers of treatment are reasonable and SEHD have informed Boards of what constitutes a reasonable offer of treatment. (Col 1509-1510)
  1. Conclusion: While the Committee is supportive of the promotion of treatment outside the local area in order to improve waiting times it is satisfied there is no compulsion under national guidelines for patients to agree to be treated outside their Health Board area.
  1. Recommendation: SEHD must ensure that, as Boards come under greater pressure with the introduction of tougher waiting times targets, good practice regarding patient involvement and choice continues to be applied. In responding to this report, SEHD should state how the Department and Boards ensure that common standards for patient involvement and patient choice are applied locally and how this is monitored.

WHOLE SYSTEM APPROACHES

Addressing the causes of long waits

  1. SEHD’s own policy and guidance documents advocate the use of whole systems approaches12 yet much of the current funding is directed at getting treatment for patients who have been waiting a long time rather than addressing the underlying causes of long waits. The AGS report estimates that £116 million was spent on tackling waiting times in 2004/05. The Committee heard that £74.5 million of this was allocated on a recurring basis, although the AGS report shows that a proportion of this (£45.7 million) is spent by the GJNH where NHS Boards must negotiate the activity provided for their patients each year.
  1. The Committee also heard that SEHD hopes to control demand for hospital admissions through the investment in primary, community and anticipatory medicine. Its publication “Delivering for Health”13 sets out its proposed approach. (Cols 1511-1512)
  1. SEHD will intervene where they feel that a Board is falling short of agreed plans for local health systems. In this way, it is hoped that Boards who fail to keep pace will not be seen to be “rewarded” by having their burden lifted by using the GJNH. (Cols 1512-1513)
  1. Conclusion: The Committee welcomes the shift towards treating patients in primary and community settings as this should yield benefits for the patients.
  1. Recommendation: In responding to this report, SEHD should provide evidence that resources are indeed being transferred into non-hospital settings.

Incentives for whole system working and the role of the Delivery Group

  1. The AGS, in his report, recommended that SEHD “should develop incentives for hospitals and primary care to adopt collaborative approaches to reduce waiting times”14
  1. The Committee heard of several approaches adopted by SEHD to reduce waiting times. For example, the SEHD have held an event to showcase innovations and changes being pursued throughout the health service in Scotland. (Col 1516) A specific example of good practice and innovation which has become embedded in normal practice is the redesign of the outpatients programme. (Cols 1516-1517) The performance management process was also referred to as a mechanism for encouraging and monitoring Boards’ progress in developing whole system approaches. (Col 1516)
  1. The Committee heard that the new Delivery Group will bring this information-sharing and performance management work together with the CCI’s redesign approaches and the NWTU’s role in accessing capacity to clear backlogs. (Cols 1518-1519)
  1. The AGS report states that the Centre for Change and Innovation (CCI) under spent its budget for capital items under the Outpatient Programme. This was partly because most Boards were not in a position to meet the future running costs of new assets.15 This underlines the need to ensure that the funding available is structured in such a way that it encourages and enables Boards to develop solutions that deliver sustained reductions in waiting times.
  1. Conclusion: The Committee is unclear how the Delivery Group will bring together the different approaches that have been used to tackle waiting times to date. The Committee is not persuaded that incentives are in place for those Boards which successfully redesign services and successfully build capacity in non-hospital settings.
  1. Recommendation: SEHD must ensure, through the Delivery Group, that good practice which was initiated through Centre for Change and Innovation initiatives or which has evolved locally is translated and embedded into practice nationwide. SEHD should consider what incentives or rewards exist for Boards which are successful in bringing about change. If no such incentives are in place, SEHD should consider how to remedy this.

OTHER ISSUES

Clinical governance

  1. Where treatment is offered outside the NHS Dr Masterton stated that “care is taken to ensure that clinical governance is as good as the NHS” (Col 1508)
  1. Recommendation: The Committee recommends that in responding to this report, SEHD state how it ensures that standards of clinical governance in the GJNH and the independent sector are as high as those in the public sector.

Appendix A

KEY FINDINGS AND RECOMMENDATIONS

WAITING TIMES TARGETS IN THE FUTURE

Preparing for new targets for waiting times and the abolition of ASCs

  • The Committee recognises and commends the NHS in Scotland for the work which has been carried out nationwide leading to progress in reducing the longest waiting times. (para 8)
  • The Committee, from the evidence available, is not able to say whether sufficient plans are in place to ensure the achievement of the new targets. The Committee believes that there is a risk that the new targets will not be achieved or that budgets will be overspent if this planning work is not sufficiently robust. (para 13)
  • SEHD must ensure that local and regional capacity and workforce plans are sufficiently joined up and will support the achievement of the new waiting times targets. In responding to the report, SEHD should provide evidence from its review of local delivery plans that the plans provide for assessing and, where necessary, treating patients who currently have an ASC. (para 14)

ROLE OF THE GOLDEN JUBILEE NATIONAL HOSPITAL

Long term role

  • The Committee recognises the flexibility demonstrated by the GJNH and NHS Boards in trying to ensure capacity at the hospital is fully used. The Committee also recognises the work being done by the hospital and NHS Boards to develop a sustainable level and mix of activity in the future. However, the Committee remains unclear about the balance between, and the sustainability of, the various roles envisaged for the hospital in the future. (para 19)
  • SEHD and GJNH should keep the balance of services offered by the hospital under constant review and consider whether the projected levels and types of activity will enable the hospital to secure value for money in the longer term. (para 20)

Costs at the GJNH

  • The Committee notes the progress being made at the GJNH with recruiting or remunerating visiting consultants under NHS terms and conditions but believes this has not yet gone far enough. Further progress will depend on how the role of the hospital develops in the future. (para 24)
  • The GJNH must take account of the impact of future changes in its role and activity on cost per case at the hospital. (para 25)

VALUE FOR MONEY OF WAITING TIMES INITIATIVES

  • The Committee recognises that the reductions that have been achieved in some private sector prices have improved value for money for waiting list activity. However, the Committee believes that more could be done to shift the focus from spending on short term waiting list initiatives towards funding service redesign which will keep waiting times down on a sustainable basis. (para 28)
  • The SEHD should review the balance of recurring funding and the use of waiting list initiatives to ensure a sustainable approach to the reduction of long waits. (para 29)

INVOLVING PATIENTS

  • The Committee is disappointed with the apparent lack of consistency in Boards’ practice of referring patients to the GJNH. (para 33)
  • The Committee agrees with witnesses that it is normally preferable to treat patients in their local area but believe that more patients should be offered the opportunity of being treated sooner at GJNH. (Col 1507) (para 34)
  • The Committee notes that common standards for patient involvement have been issued. (para 36)
  • While the Committee is supportive of the promotion of treatment outside the local area in order to improve waiting times it is satisfied there is no compulsion under national guidelines for patients to agree to be treated outside their Health Board area. (para 38)
  • SEHD must ensure that, as Boards come under greater pressure with the introduction of tougher waiting times targets, good practice regarding patient involvement and choice continues to be applied. In responding to this report, SEHD should state how the Department and Boards ensure that common standards for patient involvement and patient choice are applied locally and how this is monitored. (para 39)

WHOLE SYSTEM APPROACHES

Addressing the causes of long waits

  • The Committee welcomes the shift towards treating patients in primary and community settings as this should yield benefits for the patients. (Para 43)
  • In responding to this report, SEHD should provide evidence that resources are indeed being transferred into non-hospital settings. (para 44)

Incentives for whole system working and the role of the Delivery Group

  • The Committee is unclear how the Delivery Group will bring together the different approaches that have been used to tackle waiting times to date. The Committee is not persuaded that incentives are in place for those Boards which successfully redesign services and successfully build capacity in non-hospital settings. (para 49)
  • SEHD must ensure, through the Delivery Group, that good practice which was initiated through Centre for Change and Innovation initiatives or which has evolved locally is translated and embedded into practice nationwide. SEHD should consider what incentives or rewards exist for Boards which are successful in bringing about change. If no such incentives are in place, SEHD should consider how to remedy this. (para 50)

OTHER ISSUES

Clinical governance

  • The Committee recommends that in responding to this report, SEHD state how it ensures that standards of clinical governance in the GJNH and the independent sector are as high as those in the public sector. (para 52)

ANNEXE A

Audit committee

extract from the minutes

3rd Meeting, 2006 (Session 2)

Tuesday 21 February 2006

Members Present:

Margaret Jamieson Mr Brian Monteith (Convener)
Mary Mulligan Eleanor Scott
Margaret Smith Andrew Welsh

Apologies were received from Susan Deacon

Tackling Waiting Times: The Committee received a briefing from Audit Scotland on the AGS report entitled "Tackling waiting times in the NHS in Scotland" (AGS/2006/2).

Consideration of Approach to AGS Reports (in private): The Committee considered its approach to the AGS reports entitled “Tackling waiting times in the NHS in Scotland” (AGS/2006/2). The Committee agreed to hold an inquiry into the AGS report entitled “Tackling waiting times in the NHS in Scotland“ (AGS/2006/2) and agreed to make a request to the Conveners Group and the Parliamentary Bureau to hold an oral evidence session at the Golden Jubilee National Hospital.

Audit Committee

Extract from the minutes

4th Meeting, 2006 (Session 2)

Tuesday 21 March 2006

Members Present:

Susan Deacon Mr Brian Monteith (Convener)
Mary Mulligan Eleanor Scott
Margaret Smith Andrew Welsh

Apologies were received from Margaret Jamieson

Tackling Waiting Times: The Committee took evidence on its inquiry into the AGS report entitled “Tackling waiting times in the NHS in Scotland” (AGS/2006/02) from-

Jill Young, Chief Executive and Dr Kenneth Ferguson, Medical Director/Deputy Chief Executive, Golden Jubilee National Hospital; Dr Kevin Woods, Head of Health Department and Chief Executive, NHS Scotland, John Connaghan, Director of Delivery and Dr Bob Masterton, Medical Director of Ayrshire and Arran Health Board.

Tackling Waiting Times (in private): The Committee considered the evidence taken at agenda item 3. The Committee agreed to write seeking clarification on a number of issues raised during discussion.

Audit Committee

Extract from the minutes

8th Meeting, 2006 (Session 2)

Tuesday 16 May 2006

Members Present:

Susan Deacon Mr Brian Monteith (Convener)
Mary Mulligan Eleanor Scott
Margaret Smith Andrew Welsh

Apologies were received from Margaret Jamieson

Tackling Waiting Times (in private): The Committee considered a draft report on its inquiry into the AGS report entitled “Tackling waiting times in the NHS in Scotland” (AGS/2006/2). The Committee agreed to consider a further draft report at a future meeting.

AUDIT COMMITTEE

EXTRACT FROM THE MINUTES

9th Meeting, 2006 (Session 2)

Tuesday 30 May 2006

Members Present:

Susan Deacon Margaret Jamieson
Mr Brian Monteith (Convener) Mary Mulligan
Eleanor Scott

Apologies were received from Margaret Smith and Andrew Welsh

Tackling Waiting Times (in private): The Committee considered a draft report on its inquiry into the AGS report entitled “Tackling waiting times in the NHS in Scotland” (AGS/2006/2). The report was agreed to.

Official Report 21 March 2006

ANNEXE B

SUPPLEMENTARY WRITTEN EVIDENCE

LETTER FROM THE CLERK TO JILL YOUNG – 30 MARCH 2006

At the meeting on 21 March you kindly agreed to provide the Committee with the following documents and information:

  • A breakdown, by Board, of the reasons for cancellations of procedures at the Golden Jubilee; (Col 1499)

  • Details of your medical staff costs, particularly detailing the fall in costs since the period covered by the report which was mentioned in evidence (Col 1506) I would be grateful if this information could distinguish between the different terms and conditions under which medical staff work (e.g. how much of the medical staff costs are paid out to medical staff employed by GJNH and how much to staff employed by other Boards; how much is paid out under a fee per procedure arrangement; and how much under the consultant contract etc.)

Submission from the golden jubilee national hospital – 7 april 2006

I refer to your letter of 30 March regarding the above and my PA Joan Coleman's subsequent telephone call to advise that we only routinely collect cancellations by code, not by Board as stated in your letter. Please find attached Appendix 1 detailing the number of cancellations and reasons by each clinical specialty together with Appendix 2, cost information of medical staff.

Number of Cancellations by Clinical Speciality
April 2005 – December 2005

Specialty Total No of cancellations Comments
General Surgery 345 Mostly category 6,9,11
ENT 88 Mostly category 1,2
Orthopaedics 180 Mostly category 1,4
Ophthalmology 217 Mostly category 4,5
Scopes 476 Mostly category 3,6,7
Minor Procedures 364 Mostly category 9,12
Plastic Surgery 32 Mostly category 4,12
Cardiac Surgery 13 Mostly category 5
Cardiology 74 Mostly category 4,7,11
TOTAL 1789  

Cancellation codes monitored:

  1. Failed Pre assessment
  2. Cancelled on admission or day prior to surgery
  3. DNA
  4. Cancelled by GJNH
  5. Cancelled by referring hospital
  6. Cancelled by patient
  7. Social reasons
  8. Too short notice
  9. Patient declined treatment at GJNH
  10. Already had procedure done at referring hospital
  11. Reason unknown
  12. No response from patient to GJNH correspondence

Cost Information of Medical Staff

Consultant medical Staff Costs 2004/05 & 2005/06

  1. 2005/06 changes in consultant staffing since 2004/05 to reduce costs:
  • Two additional full-time orthopaedic surgeons employed on NHS contracts
  • One additional locum full-time orthopaedic surgeon employed on NHS contract
  • One part-time ophthalmologist remunerated under NHS contract
  • All ‘see and treat’ activity remunerated on sessional basis under NHS contract
  • The full year effect now realised of:

    • All cardiology activity remunerated on sessional basis under NHS contract
    • All cardiac surgery remunerated on sessional basis under NHS contract
    • All anaesthesia activity remunerated on sessional basis under NHS contract.

    The consultant medical staff average cost per surgical procedure in 2004/05 was £610. For the 9 months to 31 Dec of the 2005/6 year, this reduced to £523.

  1. Types of Consultant payments
  • NHS Consultant Contract basic rate
  • NHS Waiting List payment (3 x basic rate)
  • Sessional payment (based on NHS Waiting list payment)
  • Fee per case – based on BUPA private payment minus 25%

* Note – we do not routinely collect the breakdown of the payments split by volume of activity. We are actively moving our payment from the Fee per case to NHS contract rates as can be seen by the % figures for 2005/06.

Details of Medical Staff Costs

CLINICAL SPECIALITY PAYMENT BASIS ACTIVITY 2005/06 ACTIVITY 2004/05
ACTUAL % OF TOTAL ACTIVITY % paid via
NHS CONTRACT
ACTUAL % OF TOTAL ACTIVITY % paid via
NHS CONTRACT
Orthopaedic surgery NHS Consultant contract basic rate
NHS waiting list initiative payment
1685 13 100 1535 16 22
Cardiac surgery NHS Consultant contract basic rate
NHS waiting list initiative payment
297 2 100 397 4 100
Anaesthesia NHS Consultant contract basic rate
NHS waiting list initiative payment
N/A N/A 100 N/A N/A 100
Cardiology NHS Consultant contract basic rate 1310 10 100 1124 12 0
Endoscopy NHS Consultant contract basic rate
Fee per Case - BUPA minus 25%
2364 18 31 1582 16 0
Ophthalmology NHS waiting list initiative
Fee per Case – BUPA minus 25%
2575 20 20 1386 14 0
Minor Procedures Sessional Payment 1200 9 0 682 7 0
General Surgery Fee per Case - BUPA minus 25% 1967 15 0 1663 17 0
Plastic Surgery Fee per Case - BUPA minus 25% 756 6 0 615 6 0
ENT Fee per Case - BUPA minus 25% 803 6 0 722 7 0
See and Treat NHS Waiting list initiative payment As required N/A 100 Asrequired N/A 0

LETTER FROM THE CLERK TO JILL YOUNG - 24 APRIL 2006

Thank you for the information contained in your letter of 7 April on cancellations and consultant medical staff costs. I would be grateful for some clarification on the figures in your letter.

The information you have provided on cancellation codes sets out a number of possible codes for each figure (e.g. “mostly 6,9,11”). It would be helpful if the Committee could see the actual number of cancellations attributable to each code.

On consultant costs, for some types of surgery you have supplied two different payment bases, could the committee please have figures for each payment basis? Without this, it is not possible, for example, to determine what proportion of orthopaedic procedures were carried out under the basic rate of pay, and what proportion were carried out under the waiting list initiative payment.

If you need any clarification of this request please do not hesitate to contact me. It would be preferable to receive the documents in electronic format if possible so that they can be distributed among members easily. I would be grateful if the information could be sent to us by Friday 28 April 2006.

SUBMISSION FROM GOLDEN JUBILEE NATIONAL HOSPITAL - 28 APRIL 2006

Further clarification on cancellations

APRIL 05 - DECEMBER 05

SPECIALTY No.1
Failed Pre-assessment
No.2
Canx on admit
No.3
Patient DNA'd
No.4
Canx by GJNH
No.5
Canx by ref Hosp
No.6
Patient canx
No.7
Social/date not suitable
No.8
Too short notice
No.9
Patient declined
No.10
Already had surgery
No.11
Reason unknown
No.12
No response
TOTAL
General Surgery 42 19 29 5 84 30 40   20 22 13 3  307
ENT 12 16 13 5 10 10 12 1 4   8    91
Orthopaedics 50 8 12 18 39 4 11 1 28 6 7    184
Ophthalmology 9 6 30 13 37 34 12   43 44 8 4  240
Scopes     185 7 29 108 58 5 54 18   16  480
Minor procedures   2 1 3 6 8 6   71 29 1 265  392
Cardiology   6 18 4 13 13 25 4 15 5 5    108
Cardiac surgery 4 3     3   1         1  12

Breakdown of Consultant Staff Payment

CLINICAL SPECIALITY

PAYMENT BASIS

% ACTIVITY REMUNERATED ON PAYMENT BASIS

Orthopaedic Surgery

  • NHS consultant contract basic rate
  • NHS waiting list initiative payment
  • Fee per case (BUPA minus 25%)

58
17
25

Cardiac Surgery

  • NHS waiting list initiative payment

100

Endoscopy

  • NHS consultant contract basic rate
  • Fee per case (BUPA minus 25%)

43
57

Ophthalmology

  • NHS waiting list initiative payment
  • Fee per case (BUPA minus 62%)

2
98


Letter from the clerk to dr kevin woods – 30 march 2006

During evidence at the meeting on 21 March, you kindly offered to provide the Committee with the following information and documents:

  • A Board by Board breakdown of the numbers of patients with a guarantee and the number of those with an Availability Status Code (Col 1497)
  • A note of the revised guidance issued to Boards on dealing with patients who cannot attend and did not attend, including the appendix on what constitutes a reasonable offer of appointments and admission (Col 1509)
  • A Guide to Good Waiting Times Practice (Col 1509)
  • A note on the guidance issued to Boards on the Department’s expectations of Boards regarding offers made to patients (Col 1509)
  • A note of the 2005 NHS in Scotland tariffs for orthopaedic and cardiac procedures (Col 1514)

Submission from the scottish executive – 18 april 2006

Breakdown of the numbers of patients with a guarantee and those with an Availability Status Code

NHSSCOTLAND - INPATIENT AND DAY CASE WAITING LIST ON 30 SEPTEMBER AND 31 DECEMBER 2005

  30 SEPTEMBER 2005 31 DECEMBER 2005
  Number Of Patients On The Waiting List Number Of Patients With A Guarantee Number Of Patients With Availability Status Codes Number of Patients On The Waiting List Number of Patients With A Guarantee Number of Patients With Availability Status Codes
Argyll & Clyde 9,783 6,423 3,360 9,631 6,308 3,323
Ayrshire & Arran 8,251 5,673 2,578 7,843 5,361 2,482
Borders 1,746 1,315 431 1,665 1,215 450
Dumfries & Galloway 3,391 2,590 801 3,163 2,265 898
Fife 7,970 5,534 2,436 7,970 5,311 2,659
Forth Valley 5,239 3,611 1,628 5,373 3,627 1,746
Grampian 10,002 6,439 3,563 9,773 7,045 2,728
Greater Glasgow 20,451 12,994 7,457 19,985 12,622 7,363
Highland 5,743 4,340 1,403 5,695 4,278 1,417
Lanarkshire 15,113 10,574 4,539 14,690 10,093 4,597
Lothian 13,841 9,129 4,712 14,062 9,141 4,921
Orkney 523 412 111 453 328 125
Shetland 550 329 221 532 355 177
Tayside 6,421 4,846 1,575 6,698 4,850 1848
Western Isles 799 566 233 838 595 243
SCOTLAND 109,823 74,775 35,048 108,371 73,394 34,977

Preparing for ‘New Way’s - Interim Guidance

Introduction

In December 2004, the Scottish Executive in its document ‘Fair to All, Personal to Each’ announced new and revised waiting times targets for outpatients, inpatients and daycases, and selected clinical conditions. These shorter wait targets will become operational from the end of 2007 and will be accompanied by new ways of defining, recording and measuring waiting times designed to make measurement and reporting of waiting more transparent, consistent and fair. The following link will take you to the document on the Scottish Executive’s web site: http://www.scotland.gov.uk/library5/health/ftap-00.asp.

A multi-disciplinary group of Health Service and Scottish Executive Health Department staff has been working on revised ‘New Ways’ definitions. A copy of the proposed new definitions is attached at Appendix A. Please read these before considering these interim guidance notes.

Working to the ‘New Ways’ definitions will require specific computer software to record and measure waiting times under the new rules and work is currently ongoing to ensure this software is available in good time to allow for training and testing before implementation at the end of 2007.

This interim guidance is intended to assist NHS staff responsible for managing waiting lists in hospitals over the next three years as they move towards implementing the ‘New Ways’ definitions. The amount of work to be done will vary from hospital to hospital and to help ensure that the transition to ’New Way's is as smooth as possible and does not result in Boards inadvertently breaching targets, everyone will want to take careful stock of their current situation and plan for the future.

This guidance sets out the key issues, suggests some steps that will be helpful in managing through the next 2-3 years and provides advice on tackling particular issues that will arise in this period. Hospital staff will, of course, know what will work best in their area. This document is therefore not intended to be prescriptive but to be a prompt and a guide to essential local planning between now and the end of 2007.

Key Issues

Availability Status Codes (ASCs), detailed in Appendix B, will be abolished with effect from 31 December 2007 (See ‘New Ways’ definitions for future handling of CNAs, DNAs and those medically/socially unavailable; low clinical priority and highly specialised treatments will no longer be reasons for excluding patients from the maximum waiting times guarantee).

Periods of unavailability will be subtracted from the patient’s total waiting time so need to be accurately recorded and measured.

All patients on the inpatient and the outpatient lists at 31 December 2007 will have a guaranteed maximum wait of 18 weeks and so will need to be treated by 6 May 2008 at the latest, unless they have been removed from the waiting list or have been suspended for appropriate reasons identified and recorded under the revised New Ways definitions.

Where to start?

A two-pronged approach to the current waiting list is recommended:
1. To consider how to reduce the numbers of patients with ASCs being added to the inpatient and outpatient lists (see Appendix B) from early 2005:

Until end 2007, hospitals will still need to record Could Not Attends (CNAs) and Did Not Attends (DNAs) as at present but there is nothing to stop hospitals adopting, now, the ‘New Ways’ approach to patients who fail to attend their appointments or who make multiple requests for changes to their appointments. Such an approach is recommended. Hospitals might also consider adopting the reasonable offer approach to help reduce CNAs and DNAs by ensuring that dates suit patients.

Hospitals will need to develop protocols for handling patients currently on the lists with codes 3, 4 and 9 (see Appendix B) as these codes have no equivalent in ‘New Ways’. Not only will all patients currently holding these codes have to be reviewed and either treated or referred back to primary care by the end of 2007, any patients given these codes between now and the end of 2007 will also have to be treated or referred back in this way. It would be good practice for hospitals to consider how to manage down the number of additions to the list with codes 3, 4 and 9 from now on.

Similarly, medically unfit patients (currently ASC A) will still need to be recorded. However ‘New Ways’ requires that a likely end date for the period of unavailability is recorded and that patients should not be added to waiting lists if the clinician cannot identify a likely end date. It is recommended that hospitals start collecting such information now even though the computer software may not record it other than as free text at present.

Similarly, for periods of social unavailability, hospitals are recommended to consider adopting the practice of collecting information on a likely end date even though this may be as free text in the interim period before revised software becomes available.

The result of taking time to collect these additional dates is that it will be easier to move to ‘New Ways’ when the time comes and the computer software is available.

It may be possible to engage local GPs to develop work on referral protocols and it will be necessary to discuss with GPs how the revised approach to referring patients back to primary care after DNAs and repeated CNAs will work.

2. To consider how to tackle the tail of long waiters already on the list:

Clearly, a thorough review of patients on the list with ASCs must be carried out before the end of 2007. From the end of that year, hospitals will have 18 weeks to treat all patients who are sitting on their lists with an ASC as ASCs will be abolished on 31st December, 2007. If current numbers of ASC holders were still on lists at that date, this is unlikely to be manageable.

Some hospitals have already started a thorough review of all ASC cases using dedicated resource, with clinical input, to contact patients and check if they are available and/or still want/need the procedure for which they are recorded as waiting. Clearly this will be a major task for some hospitals but is much more manageable if it is started now, avoiding major resource and capacity problems later. GPs may provide useful input to developing protocols relating to this review.

What else can be done?

As well as tackling the ‘two ends’ of the list, as described above, it is recommended that hospitals consider pooling of waiting lists for a specialty where this is clinically appropriate. Protocols may be designed to guide this work and it will be essential to record the clinical agreement that a patient is suitable for a pooled list. Clearly, this suggestion affects the overall management of waiting lists and will require top level clinical and managerial agreement. The cultural issues involved may be significant.

Business Processes

Current business processes for waiting list management could be reviewed to take account of the need to capture additional information for ‘New Ways’.

Low clinical priority procedures

The Health Department is considering the provision of guidance on procedures which are of low clinical priority with a view to helping achieve a consistent approach across Scotland. Medical Directors will be involved in considering the issues.

What about communication?

It is absolutely essential that everyone in the NHS Board and its operating Divisions who may need to take action on the issues raised in this interim guidance are informed about what needs to be done and why. Some of this work will be done at national level but hospitals must ensure that all relevant staff are briefed on this guidance and the issues it covers. Hospital clinicians, GPs, senior hospital management, Medical Records staff, Information Management and Technology (IM&T) staff, secretarial staff and directorate managers are examples of key staff who need to be fully informed and involved.

Clearly, patients will need to be informed in due course and it is planned that this will be a national initiative nearer the changeover time. In the meantime there are opportunities to improve communications between patients, GPs and hospital services to ensure all parties are kept informed of patients’ waiting status, rights and responsibilities.

What about training?

Training materials will be provided, along with revised computer software, to support the new approach and definitions. The ‘New Ways’ definitions will have flowcharted examples provided to aid staff in translating theory into practice. Hospitals should start planning now to introduce and cascade training to all relevant staff.

This document does not claim to be fully comprehensive but is provided to raise awareness and get the necessary planning underway as soon as possible.

Appendix A

NEW WAYS DEFINITIONS

1) What is a reasonable offer of an appointment / admission?

1.1 regardless of method of offer (written/verbal/combination) the patient should be offered a minimum of three dates all of which should be at least three weeks in advance ; see section 1.4 for ‘short notice’ guidance

1.2 patient education on the process will be crucial and on the joint responsibilities of the service, GPs and patients

1.3 a) offers within the patient’s health board area, and meeting conditions in 1.1, will be considered to be reasonable offers

b) unless clinically inappropriate, patients will be considered as transferable within the clinical team in their health board area

c) offers of appointment / admission, meeting conditions in 1.1, to services outwith the patient’s area, where the service is not provided locally, e.g. regional and national services, will be considered reasonable offers

d) at times, particular services may come under pressure and there may be a need for patients to be treated outwith their area of residence in order to provide the service within the required waiting time; to facilitate this, a patient’s willingness to accept such a transfer must be established as early as possible, preferably at the initial appointment; subsequent offers to patients willing to transfer will be considered to be reasonable offers

1.4 a) to assist in planning and scheduling, it is essential to collect information on the availability of each patient and their willingness to be admitted at short notice

b) declining a short notice offer would not result in any detriment to the patient as this will not be considered a reasonable offer; however, once a short notice offer is accepted by the patient it is regarded as a reasonable offer

1.5 a) verbal contact with patients, as is being planned for the patient focussed approach to outpatient appointments, is recommended for inpatient and daycase admission planning

b) some contact with patients may need clinical involvement rather than purely administrative input

1.6 any letter sent offering an appointment/admission will need prompt delivery to ensure the reasonable offer conditions in 1.1 are honoured

2) How should Could Not Attends (CNAs) be defined and managed, assuming a reasonable offer of appointment / admission has been made?

CNAs: Assuming a reasonable offer of appointment / admission has been accepted, if a patient contacts the hospital to ask to reschedule their admission / appointment date the following should happen:

2.1 the CNA details (e.g. date of cancellation and explanatory text) are recorded on the system

2.2 original date of addition to list remains

2.3 the waiting time is reset to zero from the date at which the cancellation is made

2.4 the patient should be made a further reasonable offer

2.5 a) if a patient asks to reschedule an appointment or admission for a 2nd time, advice of the responsible healthcare professional should be sought and

b) unless clinically inappropriate the patient should be removed from the waiting list and returned to GP care; if remaining on the waiting list the reason should be recorded and 2.3 and 2.4 apply and

c) the patient and GP should be informed if the patient is being removed from the list and the GP can re-refer

2.6 problems resulting from hospital operational circumstances should not result in any detriment to the patient; for example, the cancellation of a clinic, at short notice, must result in the patient being made a further reasonable offer as soon as possible

3) How should Did Not Attends (DNAs) be defined and managed?

DNAs: Assuming a reasonable offer of appointment / admission has been accepted, if a patient does not report for treatment, with no prior discussion, the following should take place:

3.1 DNA details (date and explanatory text) to be recorded on system

3.2 DNA to be confirmed as factually correct (any letter should be sent to patient and copied to GP)

3.3 a) advice should be sought from the responsible healthcare professional in order to determine further actions and

b) unless clinically inappropriate the patient should be removed from the waiting list and returned to GP care;

if remaining on waiting list, the reason should be recorded and the waiting time reset to zero; the original date of addition to list remains and

c) the patient and GP should be informed if the patient is being removed from the list and the GP can re-refer

3.4 if appropriate, the patient should be made a further reasonable offer

4) How should periods of unavailability be managed?

Unavailability, for patients without a date for treatment, is defined as being a period of time when the patient is unavailable for treatment for medical or social reasons. Within the guidelines set out below, time recorded as unavailable for treatment will be subtracted from a patient’s reported waiting time.

Medically unavailable:

4.1 medically unfit patients should not be added to the waiting list if there is no estimated end date to their unavailability

4.2 a) where unavailability for medical reasons occurs during the waiting period and is likely to be more than 7 days, the start date and likely end date should be added to the system

b) if no end date is known, the patient should be reviewed at 13 weeks

c) if no end date is known at that review, advice should be sought from the responsible healthcare professional in order to determine further actions

d) unless clinically inappropriate the patient should be removed from the waiting list and returned to GP care ; if remaining on waiting list the reason should be recorded

e) the patient and GP should be informed if the patient is being removed from the list and the GP can re-refer

Socially unavailable:

4.3 socially unavailable patients should not be added to the waiting list if there is no known end date to their unavailability

4.4 unavailability of up to 7 consecutive days would be noted, for management purposes, but will not be subtracted from the patient’s waiting time

4.5 a) any greater periods of unavailability will have the start date and end date recorded and this time subtracted from the patient’s waiting time

b) the responsible healthcare professional will be informed

c) if no end date can be given the patient will be reviewed at 13 weeks

d) if no end date is known at that review advice should be sought from the responsible healthcare professional in order to determine further actions

e) unless clinically inappropriate the patient should be removed from the waiting list and returned to GP care; if remaining on waiting list the reason should be recorded

f) the patient and GP should be contacted to inform them if the patient is being removed from the list and the GP can re-refer

Appendix B

AVAILABILITY STATUS CODES

(these will cease from 1/1/08)

A for patients with medical constraints that prevent admission for treatment

2 where the patient has asked to defer admission for personal reasons or refused an offer of admission or an outpatient appointment has been rescheduled for his/her convenience

3 in individual cases where, after discussion with the patient, the treatment has been judged of low medical priority

4 for highly specialised treatments identified at time of placing the patient on a waiting list.

8 for patients who did not attend (DNAs)

9 in the circumstances of exceptional strain on the NHS such as a major disaster, major epidemic or outbreak of infection, or service disruption by industrial action

Managing Waiting Times

A Good Practice Guide

Improving waiting times is a key priority for the NHS in Scotland. Patients expect to wait less for treatment and reasonable waiting times are indicative of a well-managed and efficient health service. This guidance supports the recommendations of the Audit Scotland report, “Review of the Management of Waiting Lists in Scotland” and builds on the commitments in the White Paper “Partnership for Care”. The approach outlined is about achieving sustainable reductions in waiting times and planning services through a “whole systems approach” from initial contact in primary care through to discharge from hospital.

“Partnership for Care” signalled a step change in the way in which we collect and record information for our outpatient services. Collecting information about outpatient referrals and recording and understanding how our outpatient waiting lists perform is vital to the delivery of services. With good information, communication with the patient, the GP and hospital practitioners can be improved. Good information also enables NHS Boards to act quickly where there are service deficiencies, and to plan and deliver services which meet national and local targets.

I believe that every patient has the right to expect treatment within a reasonable period of time. Delivering an improvement in waiting times and meeting our national standards is a key responsibility for all those involved in the care of patients. Improving waiting times is therefore about partnership between different parts of the health service, and particularly about partnership between primary and secondary care.

This Good Practice Guide provides a summary of accepted good practice in the management of waiting times. The approach is straightforward and emphasises the active management of waiting times in a structured and methodical way. This guidance is designed to support the outpatient action plan and the change and innovation programme in general.

WHY WAITING TIMES ARE IMPORTANT

Waiting times are important to patients because:

  • The patient’s condition may deteriorate while waiting and in some cases the effectiveness of the proposed treatment may be reduced.
  • The very experience of waiting can be extremely distressing in itself.
  • The patient’s family life may be adversely affected by waiting.
  • The patient’s employment circumstances may be adversely affected by waiting.
  • Excessive waiting times may be symptoms of inefficiencies in the healthcare system and should be addressed as part of good management.

A comparatively short period of waiting which is managed in the patient’s best interests may support the appropriate scheduling of routine and emergency care and ensure the most urgent patients are seen first. Excessive waiting times, however, must be reduced. The Health White Paper, “Partnership for Care”, holds NHS Boards accountable for a three-tier approach to improving waiting times by:.

  1. Ensuring that national targets will be met.
  2. Ensuring that condition specific targets set by NHS Quality Improvement Scotland are delivered.
  3. Requiring NHS Boards to set challenging local targets which reach and then exceed national targets.

The national waiting time standards which all NHS Boards must achieve as a minimum are outlined in Appendix A of this guide.

1.2 THE REASONS FOR UNACCEPTABLE WAITING TIMES

There are a number of reasons why waiting times may become unacceptable:

  1. There may be insufficient provision of services to meet demand.
  2. There may be poor management of additions to the waiting list. This may result in patients being added to the waiting list before they are ready for treatment or added for treatments that later prove to be inappropriate.
  3. There may be poor management of admissions from the waiting list. This may result in patients waiting longer than necessary as patients are admitted in any order, without adequate consideration of each individual patient’s waiting time or clinical urgency.
  4. There may be poor administration of the waiting list and poor communication with patients. This may result in waiting list information being out of date and patients not being properly informed of admission dates.

The patient also has important responsibilities in supporting the efficient use of healthcare resources

and shortening waiting times by:

  • providing accurate information to healthcare professionals;
  • updating general practice and hospital services of any changes in circumstances, and in particular changes in contact details;
  • attending appointments as arranged and avoiding cancelling appointments at short notice.

1.3 IMPROVING WAITING TIMES

To be effective, plans to improve waiting times should take account of the entire waiting time journey, commencing with the initial outpatient referral and working through assessment and diagnostic tests to treatment and discharge from hospital.

To effectively develop plans to improve waiting times, each health system should:

  • Manage Demand – ensuring each referral represents the most appropriate decision for the care of the individual patient.
  • Manage the Queue – ensuring waiting lists are well managed and patients are called for treatment in appropriate order.
  • Manage Capacity – providing efficient and effective services that meet the level of demand from appropriate referrals.
  • Provide Leadership – ensuring that all parts of the local NHS work together to achieve waiting time improvements in the best interests of patients.

Management of Demand

A patient’s waiting time normally commences within primary care. There should be a close partnership between primary and secondary care in managing and delivering improved waiting times. This should include shared information on waiting times and agreement on local waiting time standards to be set.

Referral protocols should be utilised as appropriate to identify the most effective referral options for patients and the most effective use of both primary and secondary care resources.

The number of referrals received from primary care is the initial indication of demand for services within secondary care. The referral process should be actively managed and the number of referrals received should form a basis for calculating the level of services to be provided.

Management of the Queue

  • A waiting list is simply a queue of patients waiting for treatment. Every patient waiting in this queue has a valid expectation of treatment within a reasonable period of time. Waiting lists should be regularly reviewed to ensure they are accurate and it should be possible at any time to access up-to-date information on any individual patient on the list.
  • Patients should be called from a waiting list in order of clinical priority and within agreed waiting time standards. Patients with similar clinical priority should be admitted predominately in the order of the longest waiting patients first.

Management of Capacity

  • Waiting time standards should be delivered on the basis of a clear capacity plan. Referrals indicate the level of demand and the waiting list shows clearly how many patients are waiting and how long they are waiting. It should therefore be possible at any time to assess the level of capacity required to maintain a waiting time standard. Clinical activity plans should be set to take account of the assessed capacity required to maintain acceptable waiting times.
  • Potential pressures on waiting time standards should be identified at an early stage, for instance an increase in the number of outpatient referrals, additions to the waiting list, emergency admissions or reduced capacity. Regular and effective performance review will identify requirements for management action which should be taken to ensure waiting time standards are maintained.
  • The number of patients treated is related to the efficiency of services. The effective utilisation of resources, for instance beds or theatre time, should be ensured through regular management against agreed efficiency targets.

Leadership

  • There should be clear leadership and accountability within NHS Boards for the delivery of improved waiting times. It is recommended that a Board director leads a multi-disciplinary team drawn broadly from the local health care system, to provide leadership and direction in the reduction of waiting times.
  • Each NHS Board should have a detailed and comprehensive plan setting out the manner by which waiting time standards will be achieved and maintained. This plan should address the requirements of all patient groups who wait for treatment and address services from primary care through assessment and investigation to discharge from the treatment process.
  • Waiting Time improvement should not be seen as the responsibility of a narrow group of “experts” within a health care system. All of those involved in the care of patients who wait for treatment have a responsibility to ensure that patients are well informed, supported and wait as short a time as possible.
  • It is important to build a positive culture around the improvement of waiting times. Local standards should be set following discussion with clinicians, patient representatives and the general public. The benefits of improving waiting times should be understood by all, including the benefits to patients and to the efficiency of the NHS. No interested groups should be excluded from the process of improving waiting times.

1.4 WAITING LIST INITIATIVES

Increasing clinical activity to improve waiting times

Additional activity to improve waiting times may be provided for two purposes:

  1. The short-term requirement to treat a “backlog” of patients on a waiting list and achieve an improved waiting time.
  2. The long-term requirement to close any ongoing gap between the number of patients joining a waiting list and the number of patients leaving a waiting list.

Treating a backlog of patients from the waiting list

A “backlog” of patients to be seen from an outpatient or inpatient waiting list may take two forms:

  1. The number of patients waiting longer than the waiting time standard which is to come into force.
  2. The extent to which the current waiting list is too large to allow the maintenance of the waiting time standard. Whilst a waiting list size is not an objective in itself, a specific maximum waiting time will only be maintained if the waiting list is not over a manageable size.

It may be possible to admit a backlog of patients through improved efficiency and improved queue management. If this is not possible, then a one-off waiting list initiative may be required to see additional patients.

Waiting list initiatives may be used effectively to reduce the number of patients waiting and ensure a waiting time standard is achieved at a point in time. A waiting list initiative, however, will not necessarily ensure a waiting time standard is maintained.

The inappropriate use of waiting list initiatives will undermine the maintenance of waiting time standards. Waiting list initiatives should not be employed in isolation as a short-term means of attempting to solve long-standing problems resulting from poor demand management, poor waiting list management or insufficient capacity to treat patients.

Closing the gap between demand and capacity

Closing a recurrent gap between demand and capacity requires a different approach from treating a non-recurrent backlog of patients from the waiting list. It is necessary to project the expected recurrent

difference between the number of patients joining the waiting list and the number of patients leaving the waiting list. Efficiency measures and additional resources should be agreed as appropriate to bring

into balance the number of additions to, and removals from, the waiting list.

It should always be understood that the nonrecurrent requirement to treat a backlog of patients on the waiting list is not the same as the recurrent requirement to close any gap between demand and capacity. The first approach may ensure that a waiting time standard is achieved, the second approach is designed to ensure that the standard is maintained.

1.5 THE TEN ‘GOLDEN RULES’ FOR WAITING TIME MANAGEMENT

  1. The patients’ interests are paramount.
  2. Referrals for health care services should be clinically appropriate and directed towards the most suitable service.
  3. Adequate services should be available to meet appropriate referrals for assessment and treatment.
  4. Patients should be offered care according to clinical priority and within agreed waiting time standards.
  5. Patients should be advised of any waiting time standard that applies to their treatment and kept up-to-date on their expected waiting time.
  6. Health care services should maintain accurate and complete information on patients waiting for treatment and provide patients with clear guidance to be followed when notifying any changes in contact details or availability for treatment.
  7. Patients should be clearly advised of the action that will be taken if they fail to attend for an appointment and failures to attend should be minimised.
  8. Improvements in waiting times should be delivered through an effective partnership between Primary and Secondary Care, with appropriate protocols and documentation in place for referral and discharge.
  9. The factors which influence waiting times, such as changes in referral patterns, should be regularly monitored and management action taken in sufficient time to ensure waiting time standards are maintained.
  10. Leadership and accountability for the improvement of waiting times should be explicit within each NHS Board area and staff should be adequately trained to ensure waiting times are managed and administered effectively.

1.6 DEVELOPING LOCAL PLANS TO DELIVER WAITING TIME STANDARDS

The Health White Paper, “Partnership for Care”, requires NHS Boards to have in place local plans to deliver a three-tier approach to improving waiting times by:

  1. Ensuring national targets will be met.
  2. Ensuring that condition specific targets set by NHS Quality Improvement Scotland are delivered.
  3. Setting and delivering challenging local targets which reach and then exceed national targets.

The requirement for each NHS Board to develop and implement local programmes for waiting time reductions has been set out in the 2002/03 and 2003/04 guidance for the completion of Local Health Plans.

NHS Boards are required to:

  • Set challenging local targets for their inpatient, day case, and outpatient services. They will demonstrate the progress which each Board is expected to make in reaching and then exceeding our national guarantees.
  • NHS Boards should ensure that the whole patient journey is addressed, including waiting times for outpatients, inpatients/day cases and diagnostic tests.
  • In setting local waiting times standards and laying the foundation to achieve the National Waiting Time standards, NHS Boards should consider the relevant risks/opportunities within their own local system (e.g. winter pressures, junior doctors, hours of work, service redesign projects and organisational development).
  • Waiting time improvement plans should set out clearly any manpower or other resource implications necessary for the successful attainment of national and local standards.
  • NHS Boards should consider how they consult with appropriate bodies to ensure that patients’ views are reflected in the selection of local standards.
  • NHS Boards and Trusts are encouraged to consider how best to link across existing organisational boundaries both internally and within NHS and externally with other organisations.
  • NHS Boards Local Health Plans will be supported by implementation plans for waiting times which are both specific and detailed.

HOSPITAL SERVICES

2.1 MANAGING THE AVAILABILITY OF PATIENTS FOR TREATMENT

  • Once a patient has been placed on a waiting list a commitment has been given to provide treatment within a reasonable period of time.
  • It is not acceptable to allow patients to remain on a waiting list as an alternative to assessment or treatment.
  • It is sometimes the case that a patient is correctly placed on a waiting list but will not be available for treatment for a period of time.

The NHS in Scotland has managed such patients by utilising a deferred waiting list where patients have, at some point in time, been unavailable for treatment, and availability status codes which describe the reasons for a patient’s unavailability for treatment.

Availability Status Codes may also be used to describe particular circumstances relating to the patient’s treatment, specifically if the procedure the patient is waiting for is judged to be of low clinical priority or to be of a highly specialised nature.

The process of managing patients who are unavailable for treatment is being modernised by NHSScotland. The deferred waiting list was abolished from 1st April 2003 and a revised process for managing periods of unavailability and applying status codes will be introduced from 1st April 2004.

2.1 MANAGING THE AVAILABILITY OF PATIENTS FOR TREATMENT

When managing patients who are, or have at some time been unavailable for treatment, or have an Availability Status Code attached to their treatment, then a number of fundamental principles should be adhered to:

  • The original date of placing the patient on the waiting list, whether this is an outpatient, operative or diagnostic list, should always be retained.
  • NHS Boards should set a clear audit standard for the maximum length of time allowed for a period of unavailability or application of status code before patients circumstances and clinical status are reviewed.
  • Hospitals and NHS Boards should ensure that the codes are being interpreted accurately and should monitor the application of all Availability Status Codes.

The following recommendations are provided for the application of Availability Status Codes

Code 2 - where the patient has asked to delay admission for personal reasons or has refused a reasonable offer of admission.

Once the period of unavailability ends and the patient is able to attend for treatment, then the patient should be admitted as soon as possible, taking account of their original date placed on the waiting list and according to clinical priority.

Code 3 - in individual cases where, after discussion with the patient, the treatment has been judged of low clinical priority.

The application of the code for low clinical priority should only be applied after full discussion with the patient. The patient should be advised of the likely timescale for their treatment and be advised of any changes to this timescale.

Code 4 - with highly specialised treatments identified at the time of placing the patient on the waiting list.

This code is intended for treatments which are clearly of a highly specialised nature and should therefore be identified and applied at the time the patient is added to the waiting list. The consequences of the application of this code should be fully discussed and explained to the patient and the patient should be advised of the likely timescale for treatment and updated of any changes to this timescale.

Code 8 - where the patient did not attend or give any prior warning.

This code should always be applied when a decision is taken to retain a patient on a waiting list following a failure to attend. Local protocols should be in place to determine if the patient is given another opportunity to attend or if the patient should be returned for care to general practice and removed from the waiting list.

Code 9 - in circumstances of exceptional strain on NHS such as a major disaster, major epidemic or outbreak of infection, or service disruption caused by industrial action.

This code must only be applied following agreement by the Scottish Executive Health Department and 10 MANAGING WAITING TIMES the code may only apply to patients for an agreed and limited period of time.

Code A - patients under medical constraints (conditions other than that requiring treatment) which affect their ability to accept an admission date if offered.

These circumstances should be fully discussed with the patient at the time of placing on the waiting list and the likely consequences for their waiting time outlined. Once the patient is medically available they should be admitted as soon as possible, taking account of their original date placed on the waiting list and according to clinical priority.

Code X - temporary code valid until September 2003 for patients transferred from the deferred waiting list where the original reason for placing on the deferred list is not known.

By September 2003 all patients who have had this code applied must either be covered by a valid availability status code, be removed from the waiting list because they are no longer waiting, or have been admitted to hospital.

Identifying the start and end point of a waiting time period

A waiting time exists for a patient from the point in time the patient requests, or has a request made on their behalf, for access to a particular healthcare service. Typical examples of a healthcare service are an appointment with your General Practitioner, attendance at a hospital outpatient clinic for diagnosis or advice or admission to hospital for investigation or an operation. The waiting time period normally begins when:

a. the patient requests to see a member of the primary care team;

b. the general practitioner refers the patient for a hospital outpatient appointment. In most cases measurement is from the date the referral is received at the hospital;

c. the hospital doctor agrees with the patient that an appropriate investigation or treatment should take place.

The waiting time period normally ends when the date is reached for:

a. the appointment with general practice;

b. the hospital out-patient appointment;

c. admission to hospital for investigation or treatment.

The waiting time period does not end if the general practitioner or hospital cancels a patient’s appointment or if following admission the patient is sent home before treatment commences.

Sometimes the time it takes for a patient’s period of care to be completed includes one or more diagnostic investigations for which the patient is required to wait. These investigations may relate to serious conditions such as heart disease or cancer. NHSScotland has therefore set specific waiting times for investigation for coronary heart disease and a total waiting time standard from referral to commencement of treatment for cancer (Appendix A).

2.2 ADDING AND REMOVING PATIENTS FROM THE WAITING LIST

Audit Scotland has recommended that all patients waiting for services should be entered onto a waiting list to allow monitoring of waiting times and early warning of pressures in service areas. The level of information recorded for a patient placed on a waiting list should be proportional to the requirements for appropriate clinical management and the delivery of waiting time standards.

Patients should only be placed on a waiting list if:

  1. There is a clear clinical indication that the proposed assessment or treatment is required and will be beneficial. A patient is not to be placed on a waiting list as a holding device until the patient’s condition reaches an appropriate stage or the patient reaches a certain age.
  2. Services are available within the hospital to provide the planned assessment or treatment.
  3. There is a valid expectation that the assessment or treatment will be carried out within the agreed waiting time standard. If this is not the case then the hospital in partnership with the NHS Board and primary care should make arrangements for the provision of care at an alternative facility or through an alternative and appropriate method of treatment.

A patient should only be removed from a waiting list when:

  1. The patient has been seen or admitted and the planned episode of care has commenced.
  2. Within agreed protocols if the patient has failed to attend or repeatedly asked for appointments to be rearranged.
  3. There is another valid reason for removal; for instance the patient no longer wishes treatment, has moved out of the area or has received treatment at another provider.

Patients should not be removed from the waiting list:

  1. If, after being added to the waiting list at one hospital, it is agreed that their care will be provided at another hospital. In such an instance the patient’s waiting time continues to be counted from the original date on the waiting list.
  2. If the hospital cancels an appointment or admission or if the hospital sends a patient home after admission prior to the commencement of treatment.

Removing patients from the waiting list for reasons other than treatment

Hospitals should set targets for the maximum number of removals from a waiting list for reasons other than attendance or admission.

These targets should, where appropriate, be subdivided by reason for removal, speciality of care, condition and proposed procedure. The hospital should calculate the removals for reasons other than admission as a rate against the total number of patients coming off the waiting list. Hospitals should benchmark the rates for removal for reasons other than admission against hospitals with similar services.

High levels of removal for reasons other than admission are indicative of problems in the policy and practice of adding patients to a waiting list, whether for outpatient or inpatient/day case care. Hospitals should ensure removals are at an acceptable level.

2.3 MANAGING INPATIENT/DAY CASE WAITING LISTS AND WAITING TIMES

Patients should be ranked in order of clinical priority in a consistent, equitable and auditable manner. This should normally be the responsibility of a senior clinician.

Assignment of a patient’s clinical priority should be in keeping with NHS Quality Improvement Scotland guidelines, including SIGN guidelines.

A hospital waiting list is an amalgamation of a number of separate waiting lists. The hospital waiting list can be broken down into waiting lists for individual specialities, individual procedures and for individual consultants. Waiting lists should be managed at an appropriate level of detail. It is recommended that a senior clinician with management responsibility should provide leadership to ensure that each sub-division of the hospital’s total waiting list is managed to deliver the agreed waiting time standards. If appropriate this may involve the pooling of waiting lists for designated procedures or for routine referrals across a group of consultants.

In keeping with any national definitions, hospital services should agree with NHS Boards and primary care the criteria which constitute a reasonable offer of admission to a patient. It is recommended that a reasonable offer for attendance or admission should be notified to the patient no later than 3 weeks prior to the planned appointment or admission.

Failure to offer patients reasonable notice to attend may result in prioritising patients who are available at short notice. This may have the progressive effect of significantly admitting numbers of patients out-of-date order and therefore allowing some patients to wait excessively long times. Short notice booking also has a potential to disrupt good theatre planning.

The original date of placing the patient on a waiting list should always be retained. This date should be retained irrespective of the number of occasions the patient has asked for appointments to be rearranged, has become unavailable for treatment or has failed to attend. This date is required to ensure that patients do not remain on a waiting list when there is no prospect of admission, and to ensure that patients are not “lost” on a waiting list when their clinical condition may be deteriorating.

The majority of patients on a speciality waiting list are often waiting for the most common procedures.

These patients may also have the longest waiting times. Hospitals should put in place plans to manage the waiting times for the most common elective procedures, making best use of resources available and promoting the greatest co-operation between consultant teams through the pooling of workload where appropriate.

Hospitals should monitor and review the cancellation of theatre sessions and operations. Targets should be set to reduce cancellations where these are at an unacceptable level. It is recommended that a theatre session should only be cancelled following consultation with a designated director, and specific protocols should be in place for action following the cancellation of a theatre session by a hospital.

The requirement to review the status of all patients after a stipulated period of waiting should ensure that patients on a waiting list are actively waiting for treatment or their reason for unavailability is understood and managed. There should, however, be a formal written policy for the validation and review of both inpatient/day case and outpatient waiting lists.

Pre-assessment clinics should be considered, where appropriate as a means of reducing failures to attend and improving waiting times.

Performance benchmarking against comparable services should be employed as a means of assessing the efficiency of services in delivering waiting time standards. Typical performance benchmarks are; bed utilisation, theatre utilisation, length of stay in hospital and the number of operations carried out as day cases.

2.4 MANAGING OUTPATIENT WAITING LISTS AND WAITING TIMES

Hospitals should take action to identify referrals considered to be inappropriate and, for selected services, work with primary care and NHS Board’s public health departments to produce joint referral protocols.

The prioritisation and management of outpatient referrals should be reviewed by consultant staff in partnership with primary care.

This process should be of mutual benefit to general practitioners and consultants in improving the entire referral process, and consideration should be given to the involvement of primary care referral advisers.

There should be the opportunity for general practitioners to refer directly the most urgent patients with the minimum of waiting time.

The management of follow-up outpatient appointments should be as systematic and thorough as the management of new outpatient appointments.

Hospitals should consider setting a standard for the number and type of referral from primary care which may receive a notification of receipt of referral. This may be particularly valuable where waiting times are particularly long and may have the benefit of reducing patient anxiety.

The recording of certain outpatient procedures is now mandatory. The information available should be utilised to set standards for the actual waiting times for these procedures.

The Information and Statistics Division (Scotland) have a data development programme in place to record an increased range of outpatient services that are not consultant-led. Hospitals should ensure that they are effectively managing the waiting times and services for all outpatient clinics regardless of the designation of the health care professional.

Hospitals should monitor and review the cancellations of outpatient clinics and set targets and reduce cancellations where these are at an unacceptable level. It is recommended that a clinic should only be cancelled following consultation with a designated director, and specific protocols should be in place for action following the cancellation of a clinic by a hospital.

Outpatient services should be managed in accordance with the clinic template, also known as the clinic rules or clinic profile. It is recommended that the clinic template should contain as a minimum the following information for each clinic:

  1. Clinic location and start and end time for the clinic.
  2. Lead clinician for the service being provided.
  3. Clinician holding the clinic.
  4. Number and duration of urgent new outpatient slots.
  5. Number and duration of routine new outpatient slots.
  6. Number and duration of return slots.

Hospitals, in conjunction with primary care, should consider the introduction of booking systems which give patients early notification of their appointment time. This approach is convenient for the patient, promotes efficient use of services and assists in reducing failures to attend.

2.5 MANAGING FAILURES TO ATTEND FOR AN APPOINTMENT OR FOR ADMISSION TO HOSPITAL

There should be a written policy for the management of patients who fail to attend for appointment or admission. This policy should be agreed between the NHS Board, hospital services, and primary care. It is recommended that the policy on failure to attend should contain the following elements:

  1. A senior member of staff should be identified as responsible for implementing and auditing the failure to attend policy. A senior doctor should be responsible for ensuring the clinical appropriateness and effectiveness of the failure to attend policy.
  2. Specific action should be stipulated to follow a patient’s failure to attend.
  3. Action following a failure to attend should take account of the patient’s provisional diagnosis and proposed procedure. Patient notes should be updated with details covering the failure to attend.
  4. The general practitioner should be formally notified of the patient’s failure to attend.
  5. Hospitals should normally contact patients who have failed to attend and explain the actions which follow from this event. General practitioners should normally discuss with patients the consequences and options following their failure to attend.
  6. Hospitals should promptly remove patients from the waiting list where the decision has been taken to return the care of the patient to primary care.
  7. The decision to retain a patient on a waiting list following a failure to attend should always be an explicit decision in keeping with local guidance.
  8. Following a failure to attend, the patient’s status against waiting time standards should be updated in keeping with national and local guidance.
  9. The patient’s original date of joining the waiting list should always be retained if the patient remains on the list following a failure(s) to attend. This is to ensure that patients are not retained on the waiting list for inappropriately long periods, and to identify the possibility of a deteriorating clinical condition.
  10. The management of failures to attend should be supported by regular audit of the accuracy of patient contact details.
  11. The local health system should develop and improve their means of contacting patients in an efficient and cost effective manner. For instance through the utilisation of mobile phones and e-mail in addition to conventional methods.

The policy on failures to attend should be developed to cover patients who repeatedly ask for appointments to be re-arranged.

Hospitals should set target rates for failures to attend as a percentage of total attempted appointments or admissions. This is known as the Did Not Attend (DNA) Rate. The hospital should benchmark their rate against similar services and aim to improve performance in this area. Targets for cancellation/failure to attend rates should be subdivided into Specialty or condition specific targets to take account of clinical circumstances.

A high failure to attend rate is generally an indicator of:

  1. Long waiting times.
  2. Poor communication with patients and management of patient contact details.
  3. Inappropriate referral levels from primary care
  4. A poorly managed hospital outpatient service.

Overbooking available outpatient appointment slots is not good practice and is a compensation approach to the management of outpatient services. Failure to attend rates should be managed and outpatient slots provided to meet the projected demand for services.

2.6 MEETING THE NEEDS AND EXPECTATIONS OF PATIENTS

Hospitals should work to ensure that patients are as fully involved as possible in their treatment process. Patients should normally have one clear contact point to go to for advice or to notify if their situation changes.

Hospitals should set targets for the quality of contact information held on patient records, for example targets covering:

  1. Percentage of patient records holding a telephone number.
  2. Percentage of patient records holding a mobile telephone number.
  3. Percentage of patient records holding an e-mail address.

It may at times not be possible to offer all patients treatment at the first choice hospital or with the consultant who received the original referral. Where there is a particularly high level of demand for certain services, consideration should be given to asking the patient at the time of being placed on the waiting list if they would be agreeable to receiving treatment by another appropriate consultant or at another suitable hospital.

Hospitals should aim to provide the patient with a simple list of rights and responsibilities when they are placed on either an outpatient or inpatient/day case waiting list. It is recommended that this information should include the following:

  1. The service for which the patient is waiting
  2. The doctor or other clinician responsible for the patient’s care.
  3. The expected time the patient will have to wait.
  4. Any waiting time standard which applies to the patient.
  5. Confirmation if the patient is available at short notice.
  6. The amount of notice the patient will be given prior to their proposed attendance or admission date.
  7. How the patient will be contacted by the hospital, for example by letter or by phone.
  8. The actions required of the patient when notified of their appointment or admission date.
  9. One contact point at the hospital in case of any queries.
  10. The action the patient should take if they wish to re-arrange an appointment, notify a change in their circumstances or if they no longer wish to take up the offer of an appointment or admission.
  11. The consequences for the patient if they fail to attend for an appointment or admission.
  12. The action the hospital will take if it is necessary to cancel an agreed appointment or admission date.
  13. Confirmation that the patient will be informed if they are not likely to be admitted within their expected waiting time.
  14. Confirmation if the patient has agreed to treatment with an alternative consultant or at another hospital in order to provide quicker treatment within national or local standards.

2.7 SUPPORTING ACTIONS TO REDUCE WAITING TIMES

Actions to improve waiting times should be supported by actions to maintain service standards in other areas, such as emergency care and the discharge of patients following a stay in hospital.

Hospitals should aim to develop programmes for integrated care through a “whole systems approach” which take account of the entire patient pathway from referral by General Practitioner through consultation and investigation to treatment and discharge home. This approach will help avoid a fragmented care process where work may be duplicated and the focus on the patient may be lost.

Written protocols should be in place for the management of waiting times which are in keeping with required practice and guidance. The effectiveness of written protocols should be regularly audited. Specifically there should be a written policy and procedure for training staff in the management of waiting lists and waiting times. There should be the opportunity for refresher training for key staff.

A consistent approach should be applied to the management of waiting lists and waiting times across all hospital services, in keeping with the specific requirements of individual specialities.

There should be adequate leave and sickness cover for key staff involved in the management of waiting lists and waiting times.

Access to details of individual patients on waiting lists should be entirely within current guidance on confidentiality.AR

PRIMARY CARE

The Audit Scotland report, “Mind the Gap”, covering management information for outpatient services stated, “clinicians need high quality timely information about patients referred in order to determine the appropriateness of the referral, the appropriate provision of services for each patient and the urgency with which they should be seen”.

The Scottish Intercollegiate Guidelines Network (SIGN) report No. 31 “recommended referral document”, identifies good practice regarding the content of referral documents. Primary Care should take account of the substance of this guideline when agreeing and managing the content of referral letters.

General Practitioners are central to the waiting time experience of their patients and should be provided with sufficient information to support their patients through their period of waiting, including the opportunity to influence the actual waiting time, the choice of clinic and arrangements for the clinic visit.

To support an effective partnership between Primary and Secondary Care on waiting time improvements, the following actions are recommended:

  • It is often the case that general practice has more up-to-date and detailed information on a patient’s circumstances than secondary care and hospitals should aim to link with general practice in the validation and updating of waiting lists.
  • NHS Boards should take a lead in promoting the integration of waiting time information between general practice and secondary care. Where possible general practices should be provided with regular updates on outpatient and inpatient/day case waiting lists for their patients.

Waiting List information may be complemented by the practice referral rates to the corresponding services. General practices will therefore be able to assess their referral rates in relation to waiting times, possibly in comparison with other practices.

General practices should consider having a written policy for patients who fail to attend for appointments, both at the practice and at secondary care. Such a policy should aim to support patients and minimise the level of failures to attend.

General practices may consider monitoring and if appropriate setting standards for the time between the decision to refer a patient to secondary care and the dispatch of the referral notification.

The planning process and local target setting to improve waiting times should have continuing and meaningful clinical involvement from both primary and secondary care. There should be clear clinical managerial leadership in ensuring that waiting time standards are delivered in a manner that does not distort clinical priorities and ensures that the patient’s best interests are served.

THE NHS BOARD

Low treatment rates or a high level of demand may be contributory factors to lengthy waiting times. In order to manage demand in relation to need and deliver care of an appropriate level and case-mix, Health Boards should consider the following actions:

  • The appropriateness of referral rates for specific specialities should be assessed by NHS Boards in partnership with primary and secondary care and benchmarked against comparative populations. Intervention rates for selected procedures should also be benchmarked against comparative populations.
  • Where appropriate, referral practice and intervention rates should be protocol driven, taking account of local health needs assessment and existing guidelines from NHS Quality Improvement Scotland, including SIGN guidelines.
  • NHS Boards, in partnership with general practice, should review significant variations in referral levels between different general practices, or groups of general practices, with a view to benchmarking expected referral levels.
  • Access to outpatient and consultative services for those from deprived communities, and those from the most vulnerable groups in society, should be reviewed and where access is perceived to be inadequate, targets should be set for improvement. Rates for patient failure to attend for appointment or admission should be audited in relation to deprivation.

The public health contribution to improving waiting times should support the best balance between meeting need, managing demand and providing appropriate healthcare resources.

It is recommended that when agreeing activity levels to deliver waiting time standards, the following factors should be taken into consideration:

  1. It should be determined if activity levels are appropriate to deliver the agreed waiting time standards. “Roll-over agreements” should not be employed in a manner that activity levels of the previous year are simply confirmed as activity levels for the following year.
  2. Where appropriate, it should be determined at speciality or sub-speciality level if activity levels are appropriate to deliver a specific waiting time standard. The process of “bottom line agreements” should not be employed where increases in activity in one area are simply offset against decreases in activity in another area. An example of this would be off-setting an increase in emergency activity against a decrease in elective activity. Similarly, increases in activity in one speciality should not be off-set against decreases in activity in another speciality unless it is clear this is appropriate and waiting time standards will be maintained.
  3. Where appropriate, annual activity targets should be phased to take account of seasonal variations in demand and capacity. Elective activity for most specialities should generally be lower in the winter period while emergency activity is generally higher in the winter period. Some specialities however, do not suffer from large seasonal fluctuations and this is particularly the case for day case services.
  4. Outpatient appointments should not be utilised as a proxy for demand or for need. Outpatient referrals may be significantly higher than appointments leading to increasing waiting times. In addition, low appointment rates may mask unmet need which has not resulted in referral to hospital.

Planning to maintain waiting time standards should be part of an overall integrated and linked planning process. Action to deliver waiting time standards should complement and not detract from action to deliver other targets, for instance around the management of emergency care and chronic conditions.

The NHS Board should provide leadership in analysing and in managing the entire waiting time pathway from referral to completion of treatment. The aim should be to ensure that patient care does not become fragmented with the patient subjected to a series of consecutive waiting times which are poorly understood and reported.

In completing service strategies and reviews, NHS Boards should take full account of the requirement to improve waiting times. Strategic plans should underpin the delivery of agreed national and local waiting time standards.

Each NHS Board should have an executive director with specific responsibility for waiting times and the Board should receive regular reports covering progress towards national and local standards.

THE PATIENT

Patients should be consulted, informed and appropriately involved during their waiting time period and treatment.

It is usually the case that if the NHS takes the time and has a commitment to communicate with patients positively, patients will then respond positively.

Patients should be clearly informed of the actions that are expected of them, for instance in updating their contact details or informing their general practitioner and hospital of any change in their circumstances.

Following the guidance within the Hospital Services section of this document on “meeting the needs and expectations of patients”, will support patient involvement in their own care.

Patients themselves have a responsibility in:

  • providing accurate information to healthcare professionals;
  • updating general practice and hospital services of any changes in circumstances, and in particular changes in contact details;
  • attending appointments as arranged and avoiding cancelling appointments at short notice.

APPENDIX A

WAITING TIMES, GUARANTEES AND TARGETS

Hospital Inpatient and Day Case Treatment

  • No patient with a guarantee should wait longer than 12 months for inpatient or day case treatment. This will be reduced to 9 months from 31 December 2003 and to 6 months from 31 December 2005.

These targets are firm guarantees. If a patient’s host NHS Board is unable to provide treatment within the target time, the patient will be offered treatment elsewhere in the NHS, in the private sector in Scotland, or England, or overseas.

Coronary Heart Disease

  • From 31 December 2002, the maximum wait from angiography to surgery or angioplasty will be 24 weeks. This will be reduced to 18 weeks by 31 December 2004.

These targets are firm guarantees. If a patient’s host NHS Board is unable to provide treatment within the target time, the patient will be offered treatment elsewhere in the NHS, in the private sector in Scotland, or England, or overseas.

Cancer

  • By 31 October 2001, women who have breast cancer and need urgent treatment will get it within one month where appropriate.
  • By 31 October 2001, the maximum wait from urgent referral to treatment for children’s cancer and acute leukaemia will be one month.
  • By 31 December 2005, no patient urgently referred for cancer treatment should wait more than 2 months.

Coronary Heart Disease

  • From 31 December 2002, the maximum wait for angiography will be 12 weeks from seeing a specialist. This will be reduced to 8 weeks from 31 December 2004.

Outpatients

  • By 31 December 2005, no patient should wait more than 6 months for a first outpatient appointment with a Consultant, following referral by GMP/GDP.

Primary Care

  • From 31 March 2004, everyone should get access to an appropriate member of a primary care team within 48 hours.

APPENDIX B

CONTACT DETAILS

THE GOOD PRACTICE GUIDE
Mike Lyon
Manager of the National Waiting Times Unit
Room 1E:09
Scottish Executive Health Department,
St Andrew’s House,
Regent Road,
Edinburgh EH1 3DU
Phone number: 0131 244 2662
Fax number: 0131 244 4015
E-mail: mike.lyon@scotland.gsi.gov.uk

THE NATIONAL WAITING TIMES UNIT
National Waiting Times Unit
Room 1E:13
Scottish Executive Health Department,
St Andrew’s House,
Regent Road,
Edinburgh EH1 3DU
Phone number: 0131 244 2480
Fax number: 0131 244 4015

APPENDIX C
SOURCES

Designed to Care – Scottish Office Health Department – March 1998
Our National Health, A Plan for Action, A Plan for Change – Scottish Executive Health Department – December 2000
Partnership for Care – Scottish Executive Health Department – February 2003
Audit Scotland Review of the Management of Waiting Lists in Scotland – June 2002
Audit Scotland Mind the Gap Management Information for Outpatient Services – September 2001
Audit Scotland Managing Outpatient Services Self Assessment Handbook – February 2002
Cancer in Scotland: Action for Change – Scottish Executive Health Department – June 2002
Coronary Heart Disease and Stroke – Strategy for Scotland – Scottish Executive Health Department – 2002
The Framework for Mental Health Services in Scotland – the Scottish Office – 1997
Clinical Standards Board for Scotland Standards:
Breast Cancer – January 2001
Colonic Cancer – January 2001
Lung Cancer – January 2001
Gynaecological Cancer – January 2001
Diabetes – October 2002
Generic Standards – March 2002
Scottish Intercollegiate Guidelines Network – Report on a Recommended Referral Document– November 1998
Scottish Intercollegiate Guidelines Network – The Immediate Discharge Document – January 2003
Definitions and Codes in the NHS in Scotland – Information and Statistics Division of NHSScotland – Updated April 2002
COPPISH SMR Data Manual – Information and Statistics Division of NHSScotland – 2000
Local Health Plan Guidance – Scottish Executive Health Department – November 2001 and November 2002
Health Department Letter (2002)70 – Scottish Executive Health Department – October 2002
NHS Board Local Health Plans – March 2002
The NHS Plan A Plan for Investment, A Plan for Reform – Department of Health – 2002
Your Guide to the NHS – Getting the most from your National Health Service – Department of Health
Getting Patients Treated – The Waiting List Action Team Handbook – Department of Health – August 1999
NHS Waiting Times Good Practice Guide – the NHS Executive – January 1996
NHS Waiting Times Guidelines for Good Administrative Practice – NHS Executive – January 1996
Inpatient and Outpatient Waiting in the NHS – report by the Comptroller and Auditor General, National Audit Office – July 2001
NHS Wales Improving Access for Patients – Expected Standards for Waiting List Management in Wales – November 2000
Guidelines for the Management of Surgical Waiting Lists – Royal College of Surgeons England – 1991
Council of Europe Committee of Ministers – Recommendations No R(99)21 on Criteria for the Management of Waiting Lists and Waiting Times in Health care – 1999

© Crown copyright 2003
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INDEPENDENT SECTOR PRICE COMPARISONS

The prices quoted by Dr Woods relate to the first draft Scottish tariff price for the procedures as shown below.  These prices have now been revised and published as at 31 March 2006 and are shown alongside those quoted by Dr Woods.  (Please refer to guidance note below).

Procedure Example Scotland spot purchasing price  2003/4 (+ inflation of 3% for 04/05 and 3% for 05/06) Example Scotland spot purchasing price  2004/5 (+ 3% inflation for 05/06) Average Scottish Independent Hospital price obtained 2005/6 Scottish Ref Cost Elective In-Patient(03/04) First DraftScottish Tariff Published Scottish Tariff
Hip replacement £9,222 * £8,549 * £6,733 £6,761 £6,759 £6,378
Knee replacement £10,282 * £9,579 * £7,425 £7,547 £7,545 £7,095
Cataract £2,388 * £2,112 * £1,600 £1,644 £1,087 £1,071

* based on Glasgow Nuffield guide prices

The table shows an example of an indicative price obtained from an independent sector provider in 2003/4 and 2004/5 for hip and knee replacements and cataracts.  As a comparison, the prices obtained by NWTU in 05/06 for hip and knee replacements were approximately 22% less than in 2004/5 and 27% less than in 2003/4 (after adding inflation of 3% per year).*  Similarly, the prices obtained in 05/06 for cataracts have reduced by 24% since 04/05 and 33% since 03/04. 

NOTE ON CHANGE IN TARIFF PRICES BETWEEN NOVEMBER 05 AND PUBLICATION OF THE TARIFF PRICE LIST IN MARCH 06

The tariff data used in the original note and quoted by Dr Woods reflected the draft tariffs as at November 2005. At that time the Department along with ISD was involved in consulting with the Service over the tariff prices. This consultation led to a number of queries from NHS Boards, particularly around activity data and the calculation of tariffs.  Many of these queries raised concerns around the coding and robustness of activity data and how this impacts on the calculation of the tariff. Each of the issues could impact on the financial flows associated with tariffs and Boards were keen to have them resolved.

As a result the tariff list was revised to address the following issues:

NSS funded cardiac surgery at Yorkhill.  The original calculation of the tariff included costs and activity in respect of Yorkhill (and other) NSS funded activity.  Yorkhill NSS funded cardiac surgery activity and costs were removed from the calculation.

Golden Jubilee.  Although Golden Jubilee activity was excluded from the cross border flow costings, the costs were included in the production of the tariff pricelist.  Both activity and costs were removed from the revised tariff.

Private patients.  Private patients and hospitals were identified and removed from the activity and associated costs for the revised tariff calculation.

Pre-assessment day cases.  NHS Fife raised an issue over the recoding of pre-assessment day cases in orthopaedics and ENT specialties.  These cases were identified and removed from the re-calculation.

High Dependency Unit (HDU) activity.  HDU was introduced as a significant facility in April 2003 and as a result was included in the tariff methodology and calculations.  However, the three-year average activity figures (for calendar years 2002 to 2004) were recalculated based on the April 2003 to December 2004 period.

The effect of these changes has meant that the tariff prices published on 31 March 2006 differ from the draft prices issued in November 2005. Any future comparison of 2005/06 data should use the published version of the tariff.

However, it is important to note that the tariffs should be treated as a ‘work in development’, and that apart from HRGs which were relevant to the 2005/06 specialities, any analysis should be treated with caution.

SCOTTISH NATIONAL TARIFFS

The Scottish National Tariffs are being developed over a three year period starting from 2005/06.  The purpose of the National Tariffs is to create a set of standard prices that Health Boards will charge each other for cross-boundary flow inpatient and day case acute activity. The policy objectives for the Scottish National Tariff are set out in Delivering for Health and are as follows:-

  • create a set of standard prices for most procedures to simplify the process for Service Level Agreements between Boards;
  • create a system that is transparent and fair, and takes into account both volume and case-mix complexity;
  • create an incentive for efficiency by encouraging benchmarking among Boards; and
  • improve the accuracy of financial data by ensuring better recording of both cost and activity data.

In the first year (2005/06), although a full list of tariff prices were calculated for acute procedures, their application to only two specialties was fully assessed – Orthopaedics and Cardiac Surgery.  This represented approximately 25% of cross boundary activity.  The plan is to extend this by a further six specialities for 2006/07, and then to extend it to all acute activity in 2007/08.

The main points to note about the National tariffs are as follows:-

  • The Scottish Tariffs apply to cross-boundary flows between Boards, rather than to activity within Boards.  This is different to the Payment by Results system in England where the Health Service is split at the local level into commissioners and providers.  Thus in England, tariffs are used to set prices for a market based approach to providing services within (as well as between) local areas.
  • Certain activities have been excluded from the scope of the Scottish tariff including specialised services such as those funded by the National Services Division (NSD), outpatients (including drugs), mental health and maternity services.
  • The Scottish National Tariff applies to individual episodes of care while a patient is being treated rather than to continuous spells as in England.
  • Activity is valued using a combined rate for elective inpatients and day cases and a separate rate for non-elective inpatients.

Further details of the methodology behind the National Tariffs along with the list of tariff prices can be found on ISD Scotland’s website via the following link:- 
http://www.isdscotland.org/isd/collect2.jsp?pContentID=3553&p_applic=CCC&p_service=Content.show& 


Footnotes:

1 Tackling waiting times in the NHS in Scotland (AGS/2006/2), Page 12, Para 36

2 Tackling waiting times in the NHS in Scotland (AGS/2006/2), Page 10, Para 30

3 Tackling waiting times in the NHS in Scotland (AGS/2006/2), Page 34

4 National Waiting Times Centre Annual Report to Board Members, PriceWaterhouseCoopers, July 2005, Page 7

5 Tackling waiting times in the NHS in Scotland (AGS/2006/2), Page 32, Exhibit 19

6 Tackling waiting times in the NHS in Scotland (AGS/2006/2)

7 (The Committee notes the slight revisions to the draft tariffs quoted in evidence to the Committee and the final tariffs published subsequently. The final tariff for a hip replacement in the NHS is £6,378 compared to the figures given in evidence of £6,759 in the NHS and £6,733 in the Scottish independent sector. The final tariff for a knee replacement in the NHS is £7,095 compared to the figures given in evidence of £7,545 in the NHS and £7,425 in the Scottish independent sector. Cols 1514-1515).

8 Tackling waiting times in the NHS in Scotland (AGS/2006/2), Page 35, Para 126

9 Tackling waiting times in the NHS in Scotland (AGS/2006/2), Page 35, Para 126

10 Tackling waiting times in the NHS in Scotland (AGS/2006/2), Page 35, para 130

11 Preparing for new ways – interim guidance, provided by SEHD to guide Boards in managing waiting lists.

12 Tackling waiting times in the NHS in Scotland (AGS/2006/2), Page 25, para 82

13 Delivering for Health – Scottish Executive, 2005

14 Tackling waiting times in the NHS in Scotland (AGS/2006/2), Page 30

15 Tackling waiting times in the NHS in Scotland (AGS/2006/2), Page 28, para 101