Agenda item 4 is the Audit Scotland report "Tackling waiting times in the NHS in Scotland". Members have received copies of the report. I invite the Auditor General and his deputy to brief the committee.
Waiting times were examined for three main reasons: they are important to patients; they are one of the Scottish Executive's top priorities; and waiting times targets have been set for most major areas of health service activity. We reviewed NHS performance against most of the targets that now exist: the targets for new out-patient appointments, for in-patient and day-case treatment and for cardiac procedures. Cancer waiting times were excluded because they were examined as part of our report on bowel cancer last year. Performance against the cancer targets in general was reported in our recent overview report. We also examined how the NHS brought down waiting times for patients with guarantees about how long they will have to wait.
Thank you for that informative and helpful report.
Exhibit 20 in the report shows a significant increase in the use of the Golden Jubilee national hospital by the NHS boards in the south and west of Scotland—the proportion of patients from those boards has gone from 64 to 92 per cent—and a significant reduction in the figure for the health boards in the north and east, which suggests an imbalance in the use of the hospital by boards in the north and east. Is there an indication that the situation will be addressed to ensure that patients in those areas are not disadvantaged by a delay in treatment?
That is one of the changes that we think needs to happen as a result of the report. It is clear that, in the past three years, patients from the north and east have been making less use of the Golden Jubilee. Several reasons appear to underlie that, including the fact that boards often do not ask patients for their preferences, which is why we conducted the survey that I mentioned. Barbara Hurst will say more about what needs to happen to address the situation.
The survey that we did was interesting because it threw up the fact that people are willing to travel if that will reduce their waiting time. Quite a lot of people told us that consultants do not like referring their patients because of the follow-up issues, such as uncertainty about when patients will come back under their care. The consultants and managers in the boards concerned must consider how they use the Golden Jubilee. They should consider using the hospital not only for patients whose waiting time is about to tip over six months—the resource is available for the whole health service.
I am aware of that, but the missing link is the patient's view and whether they are given the opportunity to go to the Golden Jubilee. In the Ayrshire and Arran NHS Board area, I know of individuals who have been offered an operation or a visit to a consultant at the Golden Jubilee. Those patients do not care too much, as long as they get the operation and their health is improved. The Health Department may need to consider that issue more closely.
In a special exercise that it carried out for us, the Golden Jubilee found that the late cancellations occurred for a mix of reasons. Sometimes, appointments were cancelled by the referring hospitals; sometimes they were cancelled by the Golden Jubilee, if the patients were judged not fit to be treated; and sometimes they were cancelled by the patients themselves. We flagged up the matter because it has emerged clearly and, given that the hospital does not take emergency cases, one would think that it should be able to plan its work more effectively.
That takes me nicely on to the question whether sufficient work is being done on the procedures that are required to reduce the number of did-not-attend cases in the health service. Should checks be introduced to ensure that, if an individual does not attend a specialist appointment, the matter is referred back to the general practitioner for them to pursue?
We did not carry out a lot of work about DNA cases. However, interestingly, the abolition of availability status codes means that patients who do not attend their appointments will be referred back to their GP. That system is fairer all round.
Common sense suggests that if someone does not attend a consultant appointment, the matter should be referred back to the GP because, nine times out of 10, they will know why the individual did not attend. However, it appears that that has not been picked up.
I have to say that that might give rise to massive problems.
I realise that the phrase is somewhat jargonistic. We are simply trying to say that patients who wait a long time are a symptom of a problem, not the problem itself. If hospital resources such as theatre capacity were used more efficiently and if we considered alternatives to bringing people into hospital in the first place, we could get more people through the system. For example, with one-stop clinics, people can now be tested when they are seen. The whole-system approach also refers to the whole health service in Scotland, in which the Golden Jubilee national hospital plays its part.
Exhibit 1, which shows the various stages of a patient's treatment, appears to set out a series of hurdles that adds to treatment time. That might have something to do with the structure of treatment, but it could also have something to do with content and process. Because such a diagnosis-based approach to patient treatment is very linear and hierarchical, delay is in-built. Does the real problem lie in achieving the correct level of diagnosis between nurse and consultant, or is it one of treatment and delay in reaching the correct level of action?
In some ways, that illustrates Barbara Hurst's comment about the need to take a whole-system approach. At the moment, patients have to go through a number of stages and they might have to wait between each stage. However, we found some good local examples of people looking again at this matter. Later in the report, we highlight how NHS Grampian, in its approach to orthopaedic patients, has put together a team of specialist GPs and physiotherapists who have extended roles and make shorter—and perhaps better—work of the stages up to therapy, test or diagnostic procedure. The board estimates that when it rolls out the scheme fully, it will avoid putting 4,000 patients on to the orthopaedic waiting list. Instead of seeking to treat those patients once they are on a waiting list and heading towards their guarantee times, Grampian is providing them with better assessment and upfront treatment without putting them through all the hurdles that are highlighted in exhibit 1.
The problems are systemic, which means that the solutions can also be systemic. As a total amateur in this area, it strikes me as a form of triage, in the original French meaning of the word—namely, that the right train should get to the right place at the right time. Is the real problem one of ensuring allocation either to diagnosis or to action at the appropriate level—in other words, relating patient needs and problems to the appropriate level of analysis and action, as opposed to the present six-stage linear approach?
In many ways, it is. The problem is that it is not simple to get that right. The solution will vary for each patient, because of their particular needs and history. It will also vary for each clinical specialty and the services within which that specialty is working. Exhibit 2 on page 6 gives a sense of the key stages of what needs to happen. Alternatives that can lead to better outcomes for patients and better use of the health service's resources in particular cases, where they are tailored properly, are listed on the right-hand side of the exhibit.
I take the point that you make about complexity, but is the problem intractable?
It is difficult, but not intractable. There are examples of approaches that work very well at local level.
So the good news is that existing practice points in the correct direction.
I have a long list of questions in a very random order. I will begin with one that follows on from the issue that Andrew Welsh raised. We have been talking about the patient journey. It is easy to define that, because it can be set out diagrammatically, and it is tempting to assess it in terms of the length of each step on the journey. Is there any way of looking at the patient's experience—how it was for them—rather than just how long the journey took? I accept the comments that others have made about people from throughout Scotland having the opportunity to be seen more quickly at another facility, such as the Golden Jubilee national hospital. However, I would be concerned if coercion were involved in the case of someone from the north-east, for example, who might find it difficult to use the Golden Jubilee national hospital because of personal circumstances. I was concerned by Forth Valley NHS Board's criteria. If someone turned down an offer of treatment at the Golden Jubilee national hospital, would that be seen as unreasonable? Would they lose their waiting time guarantee as a result?
Forth Valley NHS Board is included as an interesting case study because we thought that it was making more attempts than other boards to engage with patients on the choices that are available. Most of the patients who responded to the survey that we commissioned did not feel that they had been involved in discussions about their treatment in general and whether there might be the option of going somewhere else to reduce their waiting times. We accept absolutely the point that you make. This is about the patient and the options that are made available to him or her in discussion with his or her consultant.
The other point about the Forth Valley case study that struck me is that patients often have pre-operative assessments well in advance of treatment, so that a group of patients are ready to go when there is a space. If assessments take place so far in advance that a patient's clinical condition has changed by the time that a space becomes available, is there not a risk that that could be a source of late cancellations?
It could be. However, we heard from both Forth Valley NHS Board and the Golden Jubilee national hospital that Forth Valley is one of the boards that responds effectively when it is offered late allocations. It does not sound as if assessments taking place well in advance of treatment is the source of the problem.
Have the professional bodies expressed any concern about the separation of elective and emergency treatment? I refer, for example, to the training of people who may find themselves dealing with a specialty but never see an emergency in that specialty.
This is an on-going debate. The professional journals indicate that there are definitely two schools of thought about whether it is best to split elective and emergency treatment. Managers and clinicians should discuss the issue actively.
Most of the clinical staff at the Golden Jubilee national hospital have NHS boards as their main employers and are doing extra shifts at the hospital, so at the moment the issue does not arise. If the hospital were to be integrated more into the NHS system as a whole, the point would need to be taken into account.
How does one monitor the effectiveness and value for money of bodies such as the national waiting times unit and the centre for change and innovation? The budget for the unit suggests that it spends quite a lot on itself.
We cannot say much about that; we tried to show how much was spent on specific waiting time initiatives. The report makes the point that most of the work that is undertaken on patients who are on waiting lists is part of mainstream clinical expenditure. You may want to ask the Executive's Health Department that question. The total amount of expenditure on the initiatives is very small in comparison with what is spent on elective surgery as a whole.
Most of the money that goes through the waiting times unit is spent on treatments. The unit allocates that money to boards.
That was not clear from the budget.
Waiting times are important to the individual patient, so they are of course important. The waiting list is important to managing the flow of patients through the system. Someone who manages the system cannot look at one type of information without considering the other.
Members have no more questions. We will discuss our reaction to this report and others from Audit Scotland under item 8. I thank Caroline Gardner and Barbara Hurst for their briefing and for answering questions.