Waiting Times (NHS Lothian)
The next item of business is a statement by Nicola Sturgeon on NHS Lothian waiting times. The cabinet secretary will take questions at the end of her statement, so there should be no interventions or interruptions.
14:04
My statement today relates to the report of the external review, conducted by PricewaterhouseCoopers, of NHS Lothian’s waiting times management. I was briefed on the key findings of the review at the end of last week and I received the full report yesterday. I have made the report available to NHS Lothian and I placed it in the Scottish Parliament information centre this morning.
The report details practices that are completely unacceptable and I thought it important to make a statement to Parliament at the earliest opportunity. In my statement I will remind members of the background to the report, summarise its key findings and set out my reaction to it and the instructions that I have given as a result.
Members will recall reports in October about NHS Lothian patients being offered treatment in England at short notice, in some cases with only one appointment date being offered. When patients subsequently and understandably refused to travel to England, they were recorded as being unavailable. As a result, they did not appear in NHS Lothian’s published waiting time figures as breaching waiting time guarantees.
I was clear that the situation did not comply with the new ways waiting times guidance. At my request, the chief executive of NHS Lothian initiated an investigation and the subsequent report by the board’s waiting times management group was submitted to me and shared with Parliament on 9 January. The board’s initial investigation concluded that the practice had not been used intentionally to manipulate waiting times. NHS Lothian also provided assurances that patients were no longer being offered treatment in England and that arrangements had been put in place to ensure that all patients would be treated swiftly.
However, the report also made reference to administrative practices in the management of waiting times that I considered needed further investigation. On 6 January, my officials, on my behalf, asked that the board carry out an audit of its waiting times practices and management. In response, the chair of NHS Lothian decided to commission an external audit and, on 31 January, appointed PWC to conduct it.
After further reflection, and mindful of the potential seriousness of the issues involved, I decided that it was appropriate for the review to be instructed completely independently of NHS Lothian. The chair was advised on 25 February that, in the interests of appropriate corporate governance and to ensure the independence of the findings, my officials would commission the report, which would come to me in the first instance.
The key finding of the PWC report, which examined the period from April to December 2011, is that NHS Lothian has been applying periods of unavailability to some patients inappropriately, to reduce artificially the number of patients who would otherwise have been reported as breaching waiting time guarantees. That has been done, in the main, by retrospectively adjusting the patient’s waiting time record.
Let me say at this stage that the vast majority of the almost 1 million episodes of patient care that NHS Lothian deals with in a year proceed through the system quickly, smoothly and without undue delay. Furthermore, not all NHS Lothian patients who have had a period of unavailability applied will have been inappropriately recorded in that way. It is also the case that in NHS Lothian, as in Scotland as a whole, the clear majority of patients are treated within waiting time targets, irrespective of whether they are unavailable for a period of time.
However, the report makes it clear that the NHS Lothian practices that were under review will have masked the numbers of patients who were breaching guarantees and will have resulted in certain patient journeys being longer than they should have been. It is not possible to quantify exactly the number of patients who were wrongly coded as being unavailable without a detailed examination of every single patient record, but I am very clear that any instance of a patient being inappropriately coded as being unavailable—or indeed any practice that seeks to manipulate waiting times—is completely and utterly unacceptable.
My reaction to the report is one of disappointment and considerable anger. Waiting time guarantees matter. Patients value them and staff work hard to deliver them. I will not tolerate the manipulation of them.
Let me make clear what will happen now. First, it is clear that the practices that have been identified in the report could constitute serious misconduct on the part of certain staff members. NHS Lothian has already instigated disciplinary proceedings. Members will appreciate that it would not be appropriate for me to comment further on that at this stage.
However, the chair and the non-executive members of Lothian NHS Board are appointed by me to provide scrutiny and appropriate governance. Therefore, a central question that I required the report to address was whether the board could reasonably have identified the problem earlier and acted to put it right. The report finds that the board was not presented with a sufficiently comprehensive picture of waiting times to have identified that an issue existed.
It is to the credit of the board’s chair that, when concerns began to surface, he decided to commission an external audit. However, as well as instructing the chair to urgently consider and respond to all the findings in the report, I have today asked him to review the scope of the information that the board receives at its meetings, to learn from good practice in other boards and to report to me within a fortnight on how he intends to ensure the highest standards of governance in the future.
The other significant issue that is of very serious concern is the suggestion in the report that the management culture in NHS Lothian contributed to the situation. The report states that staff were under pressure to find tactical solutions to waiting times rather than to tackle the root causes of the delays. It says that the culture actively discouraged people from accurately recording the facts and prevented full disclosure of waiting times from progressing up through the NHS Lothian management chain and governance framework to the board. That is completely unacceptable.
There is no place in any part of the national health service for such a management culture. The NHS in Scotland has a proud and unique record of working in partnership with staff and is internationally recognised for that.
The report notes the view of some staff that recent changes in the structure and attitudes of senior management have resulted in an improvement. However, I want and need to be assured that any problems of culture in any part of the organisation of NHS Lothian will be identified and rooted out. I have therefore instructed the chair to commission an investigation into the extent of such a culture in NHS Lothian that will identify the reasons for it and what needs to be done about it. As members will appreciate, it is important that the outcome of that investigation is not pre-empted, but I have made it clear that it must include scrutiny of the conduct and behaviour of senior management. I expect to see the outcome of that work by the end of April.
It is important to make it clear that the unacceptable practices have now ended in Lothian. The ending of them has resulted in the surfacing of a significant number of patients whose waiting time guarantees have been breached. The board has put arrangements in place to ensure that those patients are treated as quickly as possible. I have sent in an expert Scottish Government team to work with the board to address longer-term sustainability issues. I expect the board to work constructively with that team to develop and agree a sustainable operational plan that guarantees that patients will be seen and treated within the legal treatment time guarantees.
Since concerns about NHS Lothian came to light, I have taken steps to assure myself that all other boards are acting in line with the new ways guidance. I have received assurances from all chief executives that that is the case. Members will note from appendix B of the report that the pattern of retrospective adjustments to waiting times in NHS Lothian is not seen anywhere else in Scotland. However, as an added assurance, I have asked for the rigour of a specific and detailed audit of local waiting time management and processes, as part of each board’s internal audit programme over 2012-13. The results of that process will be made public in each board’s meeting papers.
I conclude by making clear my commitment and that of the Government to shorter waiting times and to complete transparency in the reporting of waiting times. The situation in Lothian is serious, but it should not detract from the efforts of the thousands of NHS staff, including the majority of staff in Lothian, who have worked hard and diligently to deliver the shortest waiting times in Scotland on record.
I want people to have confidence in NHS Lothian and in the NHS in every part of Scotland. Patients expect and deserve that the rules that we set to ensure speedy access to treatment are complied with, and I intend to ensure that they are.
That ends the cabinet secretary’s statement. She will now take questions on the issues raised. I intend to allow about 20 minutes for questions, then we will move on to the next item of business. It would be helpful if members who wish to ask a question of the cabinet secretary would press their request-to-speak buttons now
I thank the cabinet secretary for an early copy of her statement to Parliament and for sight of the PWC report on waiting times management in NHS Lothian. Someone who is much more cynical than I am might suggest that the timing of the statement has more to do with the fact that it is budget day and therefore a good day on which to bury bad news.
The findings that the cabinet secretary has outlined are quite shocking. I share her disappointment and anger, and I associate myself with her remarks about the efforts of staff. We have discovered that periods of patient unavailability have rocketed, and that that was achieved by retrospective manual adjustments. In other words, the figures were fiddled. In one hour alone, more than 100 people were removed from the waiting list at the click of a button, and in one five-day period, almost 2,000 people were removed. Staff were under pressure to conform. No bad news about waiting times was allowed. Although we all recognise the importance of waiting time guarantees, we must acknowledge that increasing demand and reducing staff numbers mean that our hospitals are unable to cope, as the Royal College of Nursing highlighted this week.
In October last year, we asked the Government for a Scotland-wide inquiry and we repeat that call today. We do so on the basis that the figures for patients who are unavailable for treatment for social reasons, and who are therefore dropped from waiting lists, have risen dramatically. In March 2008, for in-patient and day cases, it was 4,967. By December 2011, it had risen to 15,824, which is more than three times higher. There is a similar story for out-patient cases. It would therefore appear that the problem of creative reporting is not to be found in NHS Lothian alone.
What advice was received by NHS Lothian from the Information Services Division about the recording of waiting times? Is the guidance completely clear? Does it leave no room for dubiety? I am sure that the cabinet secretary will agree that the people of Scotland should be able to trust the Scottish Government statistics on waiting times. Unfortunately, the report suggests that they might not be worth the paper that they are written on. Some might even suggest that this is the Scottish National Party’s hidden waiting list. To dispel any such notion, rather than allowing health boards to undertake internal audits, I ask the cabinet secretary to request that Audit Scotland undertakes a full and thorough review of each and every territorial health board in Scotland to restore confidence in the system.
I will try to be as brief as possible while addressing all the points that Jackie Baillie made. On the issue of timing, I suspect that this is one of those occasions on which, whatever I decided to do, Jackie Baillie would have said that it was wrong. I have lost count of the number of times that Jackie Baillie has stood up in the chamber and wrongly but vigorously accused me of not bringing information to members timeously. I received the report yesterday and I took the view—and I hold to that view—that, notwithstanding an important event happening in another Parliament, it would be right to inform this Parliament as quickly as possible.
The practices outlined in the report are shocking and I do not think that I can be accused of trying to gloss over that in my statement. I am shocked and extremely angry at the report that is before members today. However, as I said earlier, it should not take away from the fact that Scotland has the shortest waiting times on record.
Contrary to what Jackie Baillie said, if she looks at the recent quarterly figures for in-patients and out-patients, she will see that they are falling across Scotland. I am sure that she will be happy to look at those figures and reflect upon them.
It is also important to recognise that, in many cases, patients have genuine reasons for being unavailable. The figures for unavailability across Scotland show that 75 per cent of all patients who have a period of unavailability are unavailable for less than three weeks. In other words, they have a genuine reason. I take the issue very seriously and am absolutely clear that patients have a right to expect low waiting times and speedy treatment, and that everyone in Scotland has the right to expect the reporting of those waiting times to be completely transparent.
As for the rest of Scotland, I made it clear in my statement that I expect all boards to carry out a rigorous audit. That information will be published in board papers and I have no objection to Audit Scotland or anybody else looking at it. It is not for me to tell Audit Scotland what to do, but I want and demand transparency on waiting times.
Finally, I will not indulge much in party politics today because, in my view, that is not worthy of the issue, but I shall take no lectures from a representative of the previous Administration on hidden waiting lists. The previous Administration stripped patients of their waiting time guarantee, had a hidden waiting list that peaked at 35,000, with thousands waiting for more than two years, and spent months, if not years, denying its very existence. We have brought transparency to the system. I am dismayed and furious that NHS Lothian has compromised that, but my job is to put it right and to ensure that it stays right.
Like Jackie Baillie, I thank the cabinet secretary for providing an advance copy of her statement. As a Lothian member of this Parliament, I, too, am appalled at the content of the report and the practices that it has unearthed. I share the anger evident in the cabinet secretary’s statement. There is no getting away from the fact that at certain levels of NHS Lothian there has been more concern about the doctoring of statistics than about the treatment of patients, and that the manipulation of information extends to the information conveyed to its board.
Equally appalling is the finding that clerical supervisory staff were under unacceptable pressure to find tactical or paper solutions to waiting list issues. That unacceptable pressure could only have come from more senior management levels within the organisation and the decision on what information to present to the board from time to time on waiting lists was, equally, made at a senior management level.
The cabinet secretary has said that she has instructed the chair of NHS Lothian to commission an investigation into the extent to which the management culture focused on cover-up rather than cure. If, in the interests of appropriate corporate governance, it has taken an external audit reporting to her to uncover the problem, why not have an independent investigation under her direction to resolve it? To what extent will this investigation be independently supervised? Let me put it bluntly: can we have any confidence that the heads that should roll will roll?
I thank David McLetchie for that serious and legitimate question. I have given a great deal of thought to that issue. When the concerns about NHS Lothian began to surface, they were potentially so serious and I lacked so much knowledge about where things were known and about what the chain might have been that I felt that the review had to be taken out of the hands of NHS Lothian and instructed by my officials. At that time, I did not know that the practices at NHS Lothian about which I was beginning to hear were not known by the board, the chair or senior management. I needed an independent piece of work to answer the question in my mind whether I still had confidence in the chair and the board. This piece of work has answered that question and I retain confidence in the chair.
It is now appropriate to allow the chair to carry out the investigation and I have asked him to report to me by the end of April, such is the priority that I attach to this matter. If further action needs to be taken based on the findings of that report, David McLetchie and this Parliament have my assurance that further action will be taken. I do not want to pre-empt what the investigation might find, but I deliberately said in my statement that it had to include the conduct and behaviour of senior management. Without pre-empting anything, I will say that the culture of an organisation is not created by junior members of staff; it comes from much further up. If there is such a culture, I want to know the reasons for it and, more than that, I want to know that it will be rooted out. That is what this work is intended to achieve.
I thank the cabinet secretary for the decisive action that she has taken and for the clear assurance that problems of culture in any part of NHS Lothian will be rooted out. Bearing it in mind that the culture of any organisation comes from the top, how can we be sure, and what assurances can the cabinet secretary give, that junior and middle-ranking staff in NHS Lothian will not be made to carry the can for the behaviour of others?
That is another extremely legitimate question. As I said in my statement, I understand that disciplinary action has already been instigated in NHS Lothian. It is important that I do not comment further on that, for reasons that will be obvious to members. Any member of staff in NHS Lothian, or in any organisation, who is found to be guilty of misconduct must be subject to the appropriate action. I think that all members would agree with that. As I said to David McLetchie, what troubles me most about the report—although I must say that literally every line of it troubles me—is what it says about the culture of the organisation. As I said to David McLetchie, culture in any organisation is not created by staff in junior positions. That is why the work that I have instructed must look at the senior management. I expect it to do so and to result in the rooting out of any behaviour that is inconsistent with the way in which I expect the NHS to be managed.
In 2008, I asked a question about quality control, as I was concerned about some of the exclusion reasons at that time. Since then, the annualised rate for out-patient exclusions has multiplied by three, with the annual figure going from about 60,000 to about 200,000. When I raised the issue in 2008, I was assured that the Information Services Division would carry out an evaluation, including of the patient experience, as part of quality assurance. Last year, I warned that games might be being played, and that has proved to be the case.
Does the cabinet secretary agree that the data in the appendices to the report show an alarming variation not only between boards, but within boards? Many boards show a true exceptional use of retrospective changes, with single digits being reported, whereas the figures for NHS Borders range from 10 to 143; for NHS Greater Glasgow and Clyde they range from 130 to 545; and for NHS Grampian they range from zero to 421. Does the cabinet secretary agree that a fuller independent inquiry covering all boards is required to restore public confidence in the new ways waiting time system? A Lothian internal report did not unmask the manipulation that we now see laid bare by the PWC report. Will the cabinet secretary invite Audit Scotland to carry out a further review of the new ways waiting time system, particularly all aspects of the removal of patients from waiting lists, and with particular attention to the vulnerable patients whom I have warned about repeatedly: those with sensory problems, learning difficulties and literacy problems and immigrants and refugees?
I have already responded to Jackie Baillie on the point about Audit Scotland. I am perfectly happy for Audit Scotland to conduct an investigation into any aspect of the national health service, and Audit Scotland is perfectly free to do so.
I pay tribute to Richard Simpson, because, over a period of time, he has asked questions about the new ways system and he has done so from a position of considerable knowledge and understanding of the system. I will not repeat all the things that I have said about the importance that I attach to ensuring that we have complete transparency. Whenever there is any way in which we can improve transparency, I am not only open to that, but keen that we do it. As Richard Simpson knows, the system is complicated because of the volume and complexity of the data with which it deals. We should always be looking at ways in which to improve that, and ISD always is.
Richard Simpson’s point about the appendices is interesting. As he would expect, I have looked carefully at the figures. As the report makes clear, there are many circumstances in which it is perfectly legitimate to change a record retrospectively if a mistake has been made or if there have been changes in a computer system. Some of the figures that are footnoted in the report clearly relate to where a board has changed a patient management system, which has led to changes in the records. I am looking, in particular, at the figures for NHS Greater Glasgow and Clyde, which show a reduction in the number.
Nobody can look at the figures and not see that NHS Lothian sticks out like a sore thumb—it has made more retrospective adjustments than the rest of the health boards in the country put together. NHS Lothian has clearly been misusing the practice of retrospective adjustment, as we do not see that quantity or pattern in the figures for any other board.
Richard Simpson has my assurance that we will continue to look carefully at all of this to assure me, the Government, the Parliament and the wider public of the integrity of our waiting time system. I am proud of the NHS’s record on waiting times, which is a huge success story. What angers me about NHS Lothian’s behaviour is not just that it is a betrayal of its own patients—which it is—but that it undermines the reputation of thousands of NHS staff members across the country who have worked hard to reduce waiting times. I am not prepared to allow that to happen.
I share the cabinet secretary’s anger at the report and, in particular, the exposure of a scandalous and unacceptable management culture. Given that the chair is accountable to ministers for the good governance of the board, after this audit does the cabinet secretary still have confidence in the chair of NHS Lothian?
I touched on that in my response to David McLetchie. It is an issue that I had to assure myself on and that I wanted the report to address. I had to be sure that the board had neither known about the problem nor should have known about it had it been looking properly at the information that was available to it. The report has satisfied me that the information that would have been required to identify the problem was not getting to the board. Also, as I said in my statement, it is to the credit of the chair that he was the one to commission the audit that we are discussing today. Yes, I do have confidence in the chair, which is why I have charged him with further work to ensure that any issues and problems in NHS Lothian are completely rectified.
There is little point in waiting time guarantees if patients can be cheated in this way. NHS Lothian’s comprehensive manipulation of the system is pretty disgraceful. If patients had a right to access information about their individual pathways all along the way, perhaps this would not have happened—they would have been able to challenge it if they had been marked down as unavailable. What steps could the cabinet secretary take to improve communication and openness with patients about their individual pathways?
That is a very good question, and it is something to which I am happy to give consideration. Members should remember that the Government has introduced the 12-week legally binding waiting time guarantee, which will come into force later this year. We discussed the regulations that will introduce that at the Health and Sport Committee just yesterday. As well as introducing a legally binding guarantee, the regulations place duties on health boards in terms of the information that they must provide and the communication that they must have with their patients.
In the interests of transparency, it is legitimate to ask whether we could do more to ensure not just that there is overall public transparency, but that individuals have as much information as they need to have about their waiting times. I am more than happy to give that further consideration.
Given the importance of the statement and the concern among members—particularly Lothian members—I intend to let the questions on the statement run on. That means that time will be extremely tight in the debates that follow. I would be grateful if members could keep their questions as short as possible, but I intend to get through everybody who has requested to ask a question.
The massaging of the waiting time figures and the massive pressure on staff in NHS Lothian have been laid bare today. Given the loss of more than 300 nurses in the past year, the 20 per cent increase in demand for elective surgery, the fact that NHS Lothian is still below parity in NHS Scotland resource allocation committee funding and the inescapable fact that more capacity is needed to treat patients, what will the cabinet secretary do to ensure not only that the process of waiting list places is sorted, but that NHS Lothian patients get the treatments that they need and deserve?
What I am not going to do—I will be perfectly frank about this—is make excuses for NHS Lothian. It has always been the case, and it is particularly the case in the environment in which we are living, that health boards face difficulties and challenges in meeting the demands that we place on them to deliver quality access for patients as quickly as possible. All boards face those challenges, but no board other than NHS Lothian has been comprehensively manipulating its waiting time figures, so I am not going to make excuses for NHS Lothian.
The Scottish Government is working closely with the board to do two things. The first is to ensure that it treats as quickly as possible all those patients that we now know have breached their waiting time guarantee. The Scottish Government has made additional funding available to NHS Lothian in order to speed up that process. Secondly, as I said in my statement, I have sent in a team to work with NHS Lothian on the sustainable operational plan that it needs to have in place to assure its patients that they will all be treated within the legal treatment time guarantee, as patients in every other part of Scotland can expect.
I assure Sarah Boyack that we will work closely with the board to ensure that patients come first. Patients should always come first. Sadly, not all patients have come first in NHS Lothian in recent times, but we are going to put that right.
Although there cannot be any exact numbers, can we have an assurance that large numbers of patients have not been waiting an inordinate amount of time? How are those patients who have been waiting and are still looking to receive treatment best advised to ensure that they receive the treatment that they need, following the Scottish Government’s intervention?
I said in my statement—I hope that members will understand this—that without doing a detailed review of every single patient record, it is not possible to quantify the number of patients who have been inappropriately categorised as unavailable.
As I said in my statement, NHS Lothian deals with almost 1 million patient episodes in a year and, in the vast majority of them, patients are treated through the system quickly and effectively without undue delay. If we look at the quarter ending June 2011, even in NHS Lothian, at a time when these practices were at their peak, two thirds of patients never had any period of unavailability applied, and three quarters of patients had periods of unavailability of less than three weeks. That gives me confidence—and it should give members confidence—that the vast majority of patients go through the system in NHS Lothian quickly, as they do in the rest of Scotland.
I have already talked about patients who had breached their waiting time guarantee who surfaced once the practices ceased. We saw 1,500 in-patients and 3,500 out-patients surfacing who had breached their waiting time guarantee. NHS Lothian is now working on that backlog of patients.
On Marco Biagi’s point about what he can say to his constituents, I assure him, so that he can assure them, that the board is focused on ensuring that all those patients are treated as quickly as possible.
I welcome the cabinet secretary’s statement and the expert team that will address long-term sustainability, but I have questions on the two issues on which she will receive reports. First, on information to boards, does she have a national standard against which she will judge the proposals of the chair of NHS Lothian? Secondly, what action will she be prepared to take in relation to management culture if the problems are as serious as they appear to be?
First, I have asked the chair to look at best practice, and I can tell Malcolm Chisholm that I and my officials will also look at best practice in the scope, content and nature of the information that boards get, with a view to standardising that, as a result of what happened.
Malcolm Chisholm’s second question is perfectly legitimate and I hope that he will accept that I am not trying to avoid answering it, but I think that it is important not to pre-empt the outcome of that work, in the interests of due process and natural justice. I have made it clear that the board has to look at senior management behaviour, and it will be for the board to decide, as a result of that, whether it wishes to take any further action in that context.
As a former health minister, Malcolm Chisholm knows that although I appoint the chair of the board, senior managers are employees of the board. That is an important distinction, but nothing is off the table. I am determined that any culture that is inconsistent with the way in which we work in the health service will be rooted out in NHS Lothian.
I commend the cabinet secretary for her actions. Can she assure patients in Lothian that they will continue to receive their waiting time guarantee in an identical way to every other health board in Scotland?
Yes. As I have done before, I want to draw a distinction involving patients who have already breached their waiting time guarantee. It is clear that I think that that is extremely regrettable and that NHS Lothian has let down those patients. They must be treated as quickly as possible and that process is already under way.
In the longer term, the work that I have referred to and the expert team that I have sent in will ensure that Lothian has an operational plan in place that allows it to guarantee that every patient is treated within the waiting time guarantee, which applies in not just Lothian, but the rest of the country. I do not care where people in Scotland live: they have a right to be treated within the maximum time that we set. My job is to ensure that NHS boards have the right plans in place to ensure that that is the case.
Does the cabinet secretary accept that we have witnessed a board that is unable or unwilling to challenge what has gone on and senior management who are either hopelessly incompetent or outrageously manipulative? At what stage does the cabinet secretary step in and say, “Enough is enough,” and clear the whole lot out so that we can start again with people the public have confidence in? If they are doing this on waiting lists, what might they be getting up to in other areas of their responsibility?
I am clearly saying today that enough is more than enough and that this behaviour will not be tolerated. I have already covered the position in relation to the chair and the board. I hope that members will appreciate that that was something that I gave deep and serious consideration to. The view that I have come to is based on a close analysis of what I consider to be the messages in the report.
As I have already said in response to Malcolm Chisholm, senior management are employees of the board. Due process would have to be undertaken before any action was taken against a senior manager in any NHS board, but Neil Findlay made a point that I agree with. We are talking about waiting times, but the reason that the cultural problem troubles me so much is that if there is a culture in any organisation that leads to problems being covered up, then that can occur in any part of the organisation and that is what I am not prepared to accept. Members should be in no doubt about how determined and serious I am about ensuring that whatever needs to be done to root out that culture is done. It is important that the investigation that I have asked to be commissioned is allowed to take its course. The chair will then come to me and I will come to the Parliament with a very clear explanation of how we can be sure that such a culture no longer exists in NHS Lothian.
Patients want assurances that the inappropriate and unacceptable practices in Lothian have not been replicated elsewhere in the country. Will specific guidance be given on how health boards manage their internal audits of waiting times and will those audits provide reassurance to my constituents in Glasgow and constituents elsewhere that they will not be affected by the same culture as in Lothian?
Obviously, audits must meet certain standards. I should say that all chief executives of boards will be sent today a copy of the report and very clear guidance from my senior official on what they are required to do in their audit as a result. Guidance is already in place for boards on how to manage their waiting times. Coincidentally, not because of this situation but because of the introduction of the 12-week legally binding waiting time guarantee, that guidance will go through a process of refinement. I can assure Bob Doris that as we do that work, which we would have been doing anyway, we will ensure that any lessons from this episode are fully applied.