Management and scrutiny of NHS waiting lists have to improve

21 February 2013

Audit Scotland has published the findings of its audit of the management of patients on waiting lists at NHS boards. This was carried out following the discovery of manipulation of waiting lists and misreporting of performance by NHS Lothian during 2011. Inappropriate use of waiting list codes has been reported at NHS Tayside.

Audit Scotland’s review covered April to December 2011, the period during which lists were known to be manipulated at NHS Lothian. It follows a report in 2010 in which Audit Scotland raised concerns about inconsistent application of waiting lists guidance and the need for better information to enable boards to show they were managing patients properly.

Auditor General for Scotland, Caroline Gardner, said:

"Waiting times are very important to patients and are a major performance target for the health service. The management and scrutiny of the waiting list systems have not been good enough. NHS boards and the Scottish Government must improve the monitoring of boards’ use of waiting list codes if they are to retain public trust and assure patients they are being treated fairly.

"During the period we reviewed, the Scottish Government and boards were focussed on making sure waiting times targets were being met but not giving enough attention to how this was being done. Better scrutiny of the increasing use of social unavailability codes could have highlighted concerns earlier. It also could have identified where waiting times pressures were building in the system."

The report says the waiting list systems have inadequate controls and audit trails, and limited information is recorded in patient records. This means it is not possible to trace all the changes made to the records of patients waiting for treatment, or to identify the reasons for amendments and verify that codes have been applied appropriately. Recently updated guidance from the Scottish Government on managing waiting lists should improve monitoring and reporting, but does not address all the risks.

The report highlights the widespread use across Scotland of the social unavailability code during the period covered by the audit. This code was intended to give patients more flexibility; periods of time that patients are unavailable for treatment are not counted as part of their overall waiting time.

As national waiting times targets shortened over recent years the use of this code rose, from 11 per cent of patients in 2008 to more than 30 per cent in mid-2011. It then started dropping from the end of 2011, around the time manipulation of waiting lists was found in NHS Lothian. The reasons for this are unclear, due to the limitations of waiting list management systems and the lack of evidence in patient records.

Audit Scotland found a small number of instances where unavailability codes were used inappropriately. Due to the poor information, it was not possible to determine whether these were due to human error, inconsistent interpretation of guidance, or deliberate manipulation.