Waiting Times Audit Report
Good afternoon. The first item of business this afternoon is a statement by Alex Neil on the waiting times audit report. The cabinet secretary will take questions at the end of his statement, so there should be no interventions or interruptions.
This statement relates to the internal audits that the Scottish Government requested health boards to undertake following the external review by PricewaterhouseCoopers of NHS Lothian’s waiting times. As members will recall, that report detailed practices that were completely unacceptable.
Since 2007, when the Government took power, we have abolished hidden waiting lists, on which there were a total of 30,000 patients; slashed waiting times for routine operations to no more than 12 weeks—that is now a legal right; and delivered a referral-to-treatment journey of no more than 18 weeks for 90 per cent of patients. It is in that context that I wish to advise members of the results of the 15 audits into waiting times practices.
The investigation is the largest into waiting times management practices that has ever been carried out in NHS Scotland. Every single episode relating to every patient who was on a waiting list between January and June this year was analysed by specialists to identify specific trends or patterns that required further investigation. That involved around 2.5 million transactions for the six-month period that the internal auditors investigated.
Earlier this afternoon, all the boards published their internal audits on their websites. That meets our commitment to ensure that all the reports would be in the public domain. The reports will be scrutinised at public board meetings in the new year.
I will set out the findings of the internal audits.
First, the reports provide no evidence of dishonest or wide-scale manipulation of waiting times across the national health service in Scotland.
Secondly, overall, the waiting times that are published by boards are reliable and accurate.
Thirdly, the principal shortcomings relate mostly to the capability to record on some information technology systems, the consistent interpretation of guidance, and staff training.
Finally, there are specific, localised issues in board areas that need to be addressed.
The reports identify a number of areas for improvement in the management of waiting times. Some of the improvements have already been implemented.
First, we have, as of 1 October, already replaced “social unavailability” with “patient-advised unavailability”. Previously, boards themselves could interpret the patient’s unavailability, but it is now up to patients to agree to a period of unavailability. That should ensure that the service is tailored to patients and should give them control over their availability for appointments and treatment.
Secondly, as of August 2012, we have tightened the monitoring and recording of waiting times. The reasons for unavailability have to be recorded as part of the treatment time guarantee.
Thirdly, the implementation of the legal 12-week treatment time guarantee came into effect on 1 October 2012. If a patient wishes to go to a specific location or goes on holiday, they must, having requested unavailability, receive a letter from the health board that confirms their request and explains any impact on their treatment time guarantee. That ensures complete transparency between patients and the health service.
I am pleased to report that a number of the other audit proposals have already been implemented or will be by the end of this month, and I expect boards to have implemented all the proposals by 31 March 2013. Any extension beyond that date will require approval by my officials and me, and will relate only to external factors—for example, where systems developments are required.
The audit reports show that more still needs to be done to improve the consistency of recording and the quality of waiting times information. Therefore, I am implementing an action plan on waiting times that relates, first, to recording, systems, procedures and training, and, secondly, to reporting and governance.
Seventy per cent of the auditors’ recommendations relate to the first category: recording, systems, procedures and training. Unavailability provides positive flexibility for patients in most instances. However, it should never be used without the patient’s knowledge to avoid a breach of targets, as was the case in Lothian. That was one of the principal reasons why we asked for a national audit into all national health service boards’ practices. We needed to know whether there was any other evidence of deliberate manipulation.
The key recommendations in respect of recording and systems from the reports are: review of the recording of the reasons for the use of unavailability codes; recording of details of offers of appointments made by telephone in local systems; review and monitoring of user access; strengthening of systems controls; and implementation of standard operating procedures, consistent with national guidance and supported by adequately trained staff.
The main recommendations for reporting and governance are: improvements in reporting of waiting times information to provide greater clarity; clarity of governance arrangements and escalation processes; and review of team structures in some boards in relation to waiting times teams and management. All those recommendations will be fully implemented.
I will refer in more detail to three boards in particular, starting with NHS Greater Glasgow and Clyde. The key quote from the report on that board says:
“our sample testing did not identify any evidence of inappropriate amendments or contraventions of NHS Greater Glasgow and Clyde’s waiting times policy.”
On Tayside, with regard to the two members of staff who were suspended, I can confirm that NHS Tayside has issued a statement today, saying:
“On the matter of the media reports surrounding the suspension of two members of NHS Tayside staff, we can confirm that, following a full investigation, those precautionary suspensions, which were non-disciplinary acts from the outset, were lifted on 19 December 2012 and the members of staff have returned to work.
Our investigation found there was no evidence of any deliberate instructions being given to any member of staff regarding the inappropriate use of waiting times codes in the sample which was looked at in the audit.”
Since the NHS Lothian report, there has been substantial progress on reducing the backlog and on the level of unavailability. NHS Lothian has a number of recommendations to implement from its internal audit, and I expect them to be fully implemented on time.
As part of my action plan, accountable officers and the chief executives will, of course, be held personally responsible for maintaining sound internal control systems in relation to waiting times.
I expect a letter of assurance from the chair of each board’s audit committee to be sent to the Scottish Government health and wellbeing audit and risk committee by the end of April 2013. Those letters will provide assurance that all their action plans have been completed.
I am also insisting that boards undertake a follow-up audit on the management of waiting times within the next 18 months, to ensure that the planned improvements have been made and are working effectively.
I remind the Parliament that Audit Scotland is currently undertaking a separate investigation into waiting times across the NHS in Scotland. I look forward to receiving its report, and will take appropriate action as a result of any recommendations that arise from it.
Although all waiting times guidance has been updated and reissued to take account of the treatment time guarantee, we will further review our guidance and make any required amendments in the light of the publication of the 15 audit reports.
With thousands of staff, hundreds of locations and millions of transactions, this is an area of massive complexity. In taking forward the action plan, I want to ensure that we adopt a philosophy that pursues service excellence. Indeed, the Scottish in-patient survey that was published this year indicated that 88 per cent of patients were happy with their waiting time. I want to ensure that that level of satisfaction is maintained and improved upon.
To help me to manage and monitor the waiting times action plan, I am setting up a parallel stream of work to ensure consistency, quality and robustness in waiting times reporting and management. The professor of six sigma and process excellence at the University of Strathclyde, Professor Jiju Antony, will also provide additional strategic-level oversight as part of that work, with regular reporting to me.
Our staff are acting with integrity and in the best interests of patients. It is to our 155,000 staff working together that we owe a debt of gratitude for reducing our waiting times to the current all-time low. However, as the audits have shown, boards need to give their staff a system that is easy to work with and which has rules that are clearly understood and are transparent to patients and their carers. That is why the audit recommendations will be followed up and fully implemented swiftly. I will hold the chief executives and chairs of boards to account for that timetable and will challenge them to show the necessary leadership in pursuit of better services for patients.
The cabinet secretary will now take questions on the issues raised in his statement. I intend to allow around 20 minutes for questions, after which we will move on to the next item of business. It would be helpful if members who want to ask a question were to press their request-to-speak button now.
I thank the cabinet secretary for an advance copy of his statement but regret that its contents demonstrate beyond any doubt that the Scottish National Party waiting times scandal has just deepened. His statement is a whitewash full of assertions that are patently not true—he would have had evidence of that if he had bothered to read the internal audit reports. For an area in which there are apparently no problems, an awful lot of action is now being taken.
First, NHS Lothian was caught fiddling the waiting times figures. At the time, Nicola Sturgeon assured the chamber that she had spoken to all health boards and that there was a problem only in NHS Lothian. Then came NHS Tayside, with evidence revealed today of blatant waiting times manipulation and serious allegations of bullying and pressure being applied to staff. The problem is wider. Other health boards have retrospectively adjusted their figures: social unavailability was at an all-time high of almost 21,000 in June 2011 but dropped to 9,500 as of September 2012, which is nothing short of a miracle. The one thing that is clear is that the manipulation of waiting times is rife.
In NHS Greater Glasgow and Clyde, auditors have been unable to interrogate data, there was no audit trail and, where they sampled, they found that 60 per cent of patients had their waiting time guarantee suspended.
You need to come to a question, Ms Baillie.
Can the cabinet secretary tell me why the internal audits cover the period from January to June 2012, when Audit Scotland is looking at April to December 2011? Were health boards being given time to cover up after NHS Lothian was exposed? Will the cabinet secretary now confirm that Nicola Sturgeon misled Parliament when she said that there was a problem only in NHS Lothian? Is it not the case that, today, the SNP has shown that, instead of leading the NHS, it is misleading Scotland and the thousands of patients who have been affected by this scandal?
I have never heard such an hysterical and outrageous attack on the national health service of Scotland. If Jackie Baillie thinks that it is becoming to launch such an unfounded attack, she is not fit to be a spokesperson, never mind a minister.
I remind members of what Jackie Baillie said on 27 September in The Herald:
“This is astonishing and shows the scandal of waiting time fiddling in Lothian wasn’t a one off.”
PricewaterhouseCoopers and all the other auditors have shown that it was a one-off. Will she not have the grace to admit that her scaremongering was totally unfounded and that her allegations are totally without foundation?
The attack that we have just heard—in effect, an attack on NHS staff—was totally outrageous. Jackie Baillie’s representation of the position in NHS Tayside is wholly inaccurate and misleading.
Let me say a word or two about Glasgow. Under “Overall Statement”, the PricewaterhouseCoopers report on Greater Glasgow and Clyde NHS Board says:
“On the basis of the work performed we found that overall, the waiting times processes and procedures within NHS GGC were operating in a controlled manner with no material deficiencies identified.”
It is there in the report.
I am reading from the report right now.
“In addition, our sample testing did not identify any evidence of inappropriate amendments or contraventions of NHS GGC Waiting Times Policy.”
That is the conclusion of the independent auditor. I know that that does not fit the script that Jackie Baillie obviously wrote before she read the reports, but nothing that she said is reflected in them.
I thank the cabinet secretary for early sight of his statement. The scandal began because, as we accepted at the time, the cabinet secretary Nicola Sturgeon was serially misled by Lothian NHS Board. The investigation was undertaken because of the allegation thereafter that there was a widespread systemic collapse across Scotland, so I think that patients across Scotland will be relieved to find that that suggestion is not borne out by the detailed investigation that has taken place.
However, I want to return to a point that the cabinet secretary made yesterday about the responsibility of NHS boards. In so far as the various reports have a common theme, it is that some people may believe that appointments to NHS boards are something of a sinecure rather than a fundamental responsibility. The inconsistency that the cabinet secretary referred to at the end of his statement in relation to rules being not clearly understood by or made transparent for patients and their carers is the responsibility of NHS boards, so I would like him to give me an assurance that he will rigorously enforce that area with the boards. Many of the actions that have been recommended are actions that the boards ought to have ensured were in place without the necessity for detailed reviews to have taken place. In that sense, the reports provide a wake-up call, which I hope the cabinet secretary will act on.
I thank Jackson Carlaw for his objective and fair comments on the reports. Clearly, unlike Jackie Baillie, Jackson Carlaw has read them.
I accept that, as Jackson Carlaw says, it is the responsibility of the boards to manage waiting times just as it is their responsibility to manage all aspects of the running of the board. However, the boards must be held to account, particularly through the chairs and the non-executive directors. That is why, starting with Ayrshire and Arran on Monday, as part of the annual review process I have instituted a particular and separate meeting with the non-executive directors on each board to encourage them to question, to probe and to play their role—as would non-executive directors in any company—in ensuring that the executive is held to account within the board. I have also encouraged the non-executive directors not just to take as read the information that they are given but to check it for themselves by going to the front line, talking to staff and finding out what is actually going on in their board area.
Having been a very successful businessman, Jackson Carlaw will no doubt understand the importance of the critical role that non-executive directors must play on any board and the importance of being aware of and knowledgeable about what happens on the front line.
A number of members want to ask questions on this important subject, so I ask members to confine themselves to a question and the cabinet secretary to be as brief as possible.
I thank the cabinet secretary for his statement. Given that the chief executive of the NHS recently said that this year our health service has had its best ever performance, does the cabinet secretary share my conviction that our hard-working doctors, nurses and administrators will be more than up to the task of implementing the recommendations of the audit reports?
I totally agree with the sentiment that Aileen McLeod has expressed. In fact, I can confirm that I have announced today to the staff of the entire health service, as a gesture of good will and as a measure of thanks in difficult times, that I have agreed that the national health service will pay the £59 fee for the protecting vulnerable groups disclosure arrangements that all staff are required to register under. That gesture, which will go to every member of NHS staff who is covered by the PVG requirements, is a clear indication of the thanks not just of the Government but, I hope, of the entire Parliament. It is a gesture, at this time of year, to thank all staff for their tremendous efforts in the national health service.
As a consultant, I had my PVG disclosure paid for by the board, so that last statement, although welcome, is irrelevant and has nothing to do with what we are discussing.
I ask the cabinet secretary to re-examine the audits. First, will he acknowledge that the detailed scrutiny was not of every record but of a sample, and that the audit trail was flawed in many boards? Secondly, why did he order the review of records from January to June 2012 when the Lothian scandal was exposed in the late summer of 2011? It is clear that the board’s practice began to change—
You need to bring your remarks to a close, Dr Simpson. Please respond, cabinet secretary.
I have two things to say. First, to start now questioning the professionalism of the auditors is beyond belief. The Labour Party’s message is: “If you don’t like the message, shoot the messenger.”
Secondly, the fact is that in every case independent auditors of world-class standing have said that there is no fiddling. The only people left in Scotland who believe that there is any fiddling outside Lothian are Jackie Baillie and Richard Simpson.
I welcome the fact that there was no material evidence of manipulation or abuse of waiting times policies in Glasgow. However, there were concerns about how information was recorded on IT systems. What action is being taken in Glasgow to improve the IT systems to ensure that my constituents get the best and most reliable service possible?
When the Government took over in 2007, there were 11 different IT systems operating in Glasgow. By the end of next year, there will be one IT system that manages waiting times. The difference between this Government and the previous Administration is that the previous Administration ran a shambles that ended up in waiting times of six months. We are putting that situation into order, which is why our patients have record low waiting times.
Will the cabinet secretary accept that there was systemic underfunding at the heart of the scandal in NHS Lothian and that significant improvements are still required? Will he admit that his £10 million loan needs to be direct funding for new staff and clinical facilities to tackle the waiting times backlog?
Sarah Boyack is slightly behind the times. NHS Lothian has announced that it has recruited new staff. According to the chief executive, it has the money required to sort the problem.
In relation to Sarah Boyack’s earlier question to the First Minister, the underlying reason why there has been a short-term bed problem in Lothian for a couple of days is because the Edinburgh royal infirmary was designed to be under capacity to the tune of 20 per cent. There are 20 per cent fewer beds than are needed because the Labour Party got it wrong and messed it up. It is to blame, not us.
The cabinet secretary will be aware that the audit of NHS Fife identified no inappropriate behaviour or pressure on staff to hide breaches or manipulate data, although it recognised that there are areas for improvement in practice. Does he agree that that indication of hard work in NHS Fife compares favourably with the discredited hidden waiting lists of the previous Administration?
In the interests of brevity, and to let more back benchers in, I say that I totally agree with that statement.
The cabinet secretary read out a statement from NHS Tayside that absolved it of wrongdoing, but he chose to ignore the audit, which spoke of “bullying”, “inappropriate behaviour”,
“potential breaches of NHS Tayside's regulations”,
and evidence that 17 per cent of cases experienced the systematic application of unavailability to prevent a waiting time breach. Does he agree that the patients of NHS Tayside deserve better? What personal contact will he have with its officials to address that unacceptable performance?
The member must make a distinction between allegations and what has been found to be true or not true.
I have made it absolutely clear that our policy is—I repeat it—one of zero tolerance towards bullying of any member of staff. I have made it abundantly clear to chairs and chief executives that I expect appropriate disciplinary action to be taken if any member of staff is found guilty of bullying another member of staff in the national health service. To try to blame such a situation on the Scottish National Party Government and ministers is a total absurdity. It is an operational matter for the boards.
On 3 December, Jackie Baillie said that the suspension of two NHS Tayside employees was
“the beginning of a national scandal of health boards fiddling waiting times”,
and claimed that SNP members owed her an apology.
As the two staff members have been fully investigated and, this week, reinstated—
Can we get a question, Mr McDonald?
Today’s reports demonstrate Ms Baillie’s claims to be false. Does the cabinet secretary agree that the only apology owed is one by Jackie Baillie to the hard-working staff of our NHS?
I totally agree. If Jackie Baillie had any grace at all, she would now apologise for and retract her unwarranted and unfounded allegations in relation to Tayside and the wider national health service in Scotland.
The cabinet secretary referred to two reports. I will quote briefly from the Glasgow report, which says:
“often little or no detail is recorded in the waiting times system due to systems limitations in the character fields and there is therefore little or no evidence to support the:
contact being made with the patient;
content of the conversation and the ‘offer(s)’ made; or
‘offer(s)’ being made in the spirit of New Ways Guidance.”
Can we get the question, Mr Smith?
The quotation continues:
“As such, there is no way of formally verifying the validity of any subsequent application of ‘unavailability’ without contacting or asking patients.”
Can we get a question?
Yesterday, at health questions, the cabinet secretary was asked for a guarantee that there was no fiddling of the figures in my city, which is also the city of the previous health secretary. Based on that report, can or will he give that guarantee?
I will read the conclusion resulting from that part of the report:
“Whilst our testing of the process within South Glasgow did identify a number of issues and areas for improvement, the testing did not identify any evidence of inappropriate amendments or contraventions of … Waiting Times Policy.”
The Labour Party reminds me of a Victorian undertaker looking for a hard winter and a full churchyard.
Does the cabinet secretary agree that when failings are identified within the health service—as they clearly were in NHS Lothian—swift and decisive action is essential to restore trust and public confidence? Is not the lesson of today that the failings that were identified in Lothian are not typical of the wider management culture in our national health service?
Absolutely. The reports clearly show major areas for improvement, as I said. However, there is a big difference between saying that there are areas for improvement and saying that there is dishonesty and that deliberate manipulation and fiddling are going on. Every report undertaken by the independent, world-renowned auditors makes it absolutely clear that, outside Lothian, there is no fiddling in the national health service in Scotland.
I refer to what the cabinet secretary said about hospital bed provision in Edinburgh in particular. It was obvious that the Royal infirmary was too small. What plans are there to increase the number of beds in Lothian?
Cabinet secretary, this is about waiting times.
Presiding Officer, I am happy to answer.
Can you make it very brief?
It will be one sentence.
We have already reopened the Royal Victoria hospital to take account of the necessary capacity requirement.
That ends the statement from the cabinet secretary.