Cabinet Secretary for Health and Wellbeing
Nicola Sturgeon
Scottish Parliament
September 19, 2007
Presiding Officer, I am very pleased to have this opportunity to bring Members up to date with important changes in the way that patients' waiting times will be measured in the NHS in Scotland. These changes will enable the abolition of hidden waiting lists for people waiting for routine outpatient appointments and hospital treatment.
To some of us, so-called Availability Status Codes have always been synonymous with hidden waiting lists - difficult to understand, impossible to explain, and deeply unfair to patients. Abolishing them will bring real benefit to many patients. I want to make sure that the changes are explained clearly and that the implications are understood widely. That is why I have arranged to make this Statement here today, and why I will be making information on the new system available to GPs, hospitals and patients.
In this statement, I will summarise how waiting has been defined and measured in the NHS up to now. I will then describe in some detail the new approach to measuring waiting times that will apply from January 1 next year and the steps we are taking to ensure that patients are aware of the changes and what the implications are for them. Finally, I will outline what we will do to ensure that the new system is fully transparent and open to scrutiny.
In short, presiding officer, I will make it clear how this new SNP government will do in our first year what the last government failed to do in 8 years - ensure that hidden waiting lists in our NHS are a thing of the past.
First, let me explain the current approach to measuring waiting for routine NHS appointments and treatment. It goes back, I am told, for around 15 years to the days of the patient charter. Under this system, many patients were given Guarantee Exception Codes, which meant that they were placed outside the waiting time guarantee and placed on a deferred waiting list.
By 2001, there were almost 26,000 patients on the deferred list.
In 2003, the then Health Minister abolished Guarantee Exception Codes and the deferred waiting list and replaced them with Availability Status Codes.
But it was little more than a cosmetic change.
The circumstances under which Health Boards apply Availability Status Codes to patients are remarkably similar to those that had previously led to a patient being given a Guarantee Exception Code or placed on the deferred list.
And a patient given an Availability Status Code is, just as before, stripped of their waiting time guarantee.
Once a Code is applied, there is no requirement on the NHS ever to take it off again. Patients are outside the scope of the guarantee. As a result, patients with ASCs continue to wait long periods - in many cases, several years - for treatment. And that is simply because a hospital decides that their treatment is low clinical priority; or because at some stage they have been unable - often through no fault of their own - to attend an appointment; or because at some point in the past they have not been fit enough for treatment.
Not only is the system unfair to patients, it is designed to keep them in the dark. No regular statistics are published on the length of waits experienced by people with Availability Status Codes.
To make matters worse, individual patients are often not properly informed, or even informed at all, that a Code has been applied to them; this despite the fact that as a result they might have to wait a very long time for routine treatment. In my view that is simply unacceptable. It fails to treat patients as partners in their own care with a right to know about their treatment. And it undermines confidence in the NHS.
In December 2004, a different Health Minister conceded that ASCs did not work in the interests of patients and announced that a new approach to defining and measuring waiting would be introduced.
The plan was to introduce new arrangements from the end of 2007. In the meantime NHS Boards were to get ahead to treat as many as possible of their patients who had had a Code applied in the past.
Unfortunately, that intention was not matched by action.
The number of people on these hidden waiting lists continued to rise.
By March 2006, around 35,000 patients had an ASC and, therefore, no waiting time guarantee.
And yet the previous Administration persisted in claiming that all patients were being treated within maximum waiting time targets even though they - and the public - knew that was not the case; serving only to undermine confidence in the NHS.
I do not think that anyone will disagree, then, that the current system needs to change.
So, let me now describe the new system that will replace Availability Codes from 1 January 2008.
The first change is that all patients who need to see a specialist at an outpatient clinic, or who need hospital treatment, will receive treatment within the maximum waiting times limits. There will no longer be any exclusions because a hospital decides treatment is of low clinical priority or too highly specialised.
The second change is that where patients waiting for treatment become unavailable for any reason - medical or social - they will no longer lose their waiting time guarantee completely, as is the case with ASCs.
Instead, any periods of unavailability will be taken account of when measuring the total waiting time.
The best way of thinking about the new approach is that each patient will have a personal waiting time clock. The clock starts when the GP's referral is received by the hospital or when a decision is made to provide treatment. The patient must be seen or treated before the clock shows the maximum waiting time. Where a patient is unavailable for treatment, the clock will stop and be restarted when the period of unavailability ends.
For example, if a patient needs admission to hospital for treatment but has a 6 week period when they cannot accept an appointment for social reasons - work or family commitments - the hospital's obligation will be to treat them within 24 weeks from the start date, rather than 18 weeks.
Another example would be if a patient has a temporary medical condition such as raised blood pressure or a chest infection. This would make it clinically inappropriate to undertake treatment. The patient is therefore unavailable. The hospital will keep that patient on the list and under review until the issue has been resolved. The waiting time clock will be stopped until the patient is fit again and available for treatment.
Patients who become unavailable and have their clock stopped will be kept under regular review. These regular reviews will pick up when a patient has become available for treatment again and make absolutely sure that waiting time clocks are not stopped for any longer than necessary.
Of course, there will be cases where a medical condition may render a patient unavailable for treatment for an indefinite period of time. In these circumstances, a hospital may, in the patient's own interests, remove them from the waiting list and refer them back to the active care of their GP.
Presiding Officer, the third key change will be a hospital appointments system that is more flexible for patients.
In future, a patient will be offered a choice of at least two appointment dates, with at least 3 weeks notice.
Now, under the current system, if a patient, having accepted an appointment, then asks to rearrange it, they could be given an ASC, lose their waiting time guarantee and end up waiting 2 years or more for treatment.
I don't believe that this strikes the right balance between the interests of the NHS and those of patients. A patient may well need to postpone an appointment, indeed more than once, for good reasons. However it is also clear that repeated rearrangement of appointments will cause additional work for the NHS and may divert resources or even waste part of a scheduled session that another patient could have used.
I have therefore decided that a patient will be able to postpone and rearrange an appointment or admission, if necessary, not once but twice.
In these circumstances, the hospital will reset the waiting time clock to zero from the date of cancellation. The hospital will then offer a least two further appointment dates with at least 21 days notice - these dates must be within the maximum waiting time.
I believe that this strikes the right balance between patient flexibility, and avoiding wasting NHS time through repeatedly cancelling and rearranging appointments.
Presiding Officer, this new system will ensure much greater protection and more flexibility for patients.
The other side of the coin will be an obligation on patients to treat the NHS with respect.
A patient who accepts an appointment and then fails to attend for no good reason and without giving the hospital notice, can expect to be removed from the waiting list and referred back to their GP.
Presiding Officer, I have described the new approach in some detail. I now want to go on to explain the steps we are taking to ensure that patients know about the changes and how they might be affected.
First, general practitioners and hospitals are being supplied with copies of a leaflet for patients explaining the new approach. GPs will be expected to give these to patients when they refer them to a specialist for investigation or diagnosis. And hospitals will be expected to provide the leaflet to patients when a decision is made that they need to be admitted for hospital treatment.
I have arranged for copies of the leaflet, along with other relevant material, to be provided to Members for their information. The packs have been delivered to Members today along with a copy of this statement.
Guidance has been drawn up for GPs and their staff on how the new approach works. And more detailed guidance has been provided for hospital staff explaining in detail what I have just described. Posters will be provided for display in GP surgeries and in hospital outpatient departments. All of this will help get the message across that there is a new approach to waiting times and how they are defined and measured.
As the patient leaflet makes clear, patients with questions about the new approach can call NHS 24 on the number given in the leaflet. Staff there have been trained to answer a wide range of questions about the new approach and will do their best to satisfy patients' queries.
Members may find constituents coming to them with questions about the new arrangements. I hope that the information being distributed to them today will help you to answer these questions or to pass constituents to the best source of advice.
It is essential in my view that patients and their representatives have as much information as possible about the changes being made - both in general and in terms of how they affect individuals.
It is also essential that the new system is completely transparent.
We know from experience that simply changing the system of recording waiting times cannot be guaranteed to get rid of hidden waiting lists.
Any system that is not fully transparent will potentially be open to abuse.
So let me now outline the steps I am taking to ensure that this new system will be subject to full scrutiny.
First, hospitals will be obliged to tell patients when their clock has been stopped, and explain the implications. They will also explain how the regular reviews work and what will happen once the period of unavailability is over.
In addition, patients will be able to ask, at any time, to see information held by their local NHS Board about them and if necessary to have that information corrected - for example, if they believe that a period of unavailability has not been recorded accurately. This will help to ensure that patients are well-informed about their diagnosis and treatment, and that all patients can benefit from the maximum waiting times targets now in place.
Second, we are arranging for information about waiting times, including information about unavailable patients, to be published regularly on the statistics website maintained by NHS National Services Scotland. The first quarterly publication following the launch of the new approach will cover the quarter from January to March 2008 and will appear in May 2008. This is in line with the convention for these publications.
The web site will show how many patients at the quarter end were recorded as being unavailable. It will also show how many of the patients treated during each quarter had periods of unavailability recorded, the length of these periods, and how many patients were removed from the waiting list and returned to the care of their GP. This information will be provided by NHS Board area. As time moves on, trend information will build up and it will be clear whether more or fewer patients are unavailable, and whether different Boards have larger or smaller proportions of unavailable patients than the average.
This information will enable the Health Directorates to keep track of Boards' performance. It will also enable Members here and the news media to track what is happening in terms of patients' experience in different parts of Scotland. This is in sharp contrast to the opaque arrangements surrounding Availability Status Codes.
I have also asked for further measures to be put in place to ensure that NHS Boards operate the new arrangements fairly and consistently and in the interests of patients. Information Services Division of NHS National Services Scotland operates a quality assurance function in respect of published NHS information. It will allocate resources throughout 2008 to help ensure that Boards apply the new guidance consistently and accurately. This will include undertaking cross checks on samples of patients' details. The aim will be to ensure that details are accurate and that recorded periods of unavailability are supported by evidence. I have asked for an initial report on any issues relating to the use of the new approach in the first half of 2008 to be with me as soon as practicable. I will publish that report.
In addition, I have invited the Auditor General for Scotland to undertake a review of how the NHS applies the new approach. Clearly the details and the timing of any such review would be for Audit Scotland to decide. But I believe there is a strong public interest in satisfying this Parliament and the public at large that Boards are applying the new guidance consistently and fairly.
In addition of course I expect that Boards themselves will do all they can to ensure they apply the guidance correctly and continue to meet the 18 week maximum waiting times targets under the new arrangements.
And patients themselves have a key role in ensuring that they and the NHS follow the new arrangements. I remind Members that the NHS is under an obligation to treat all patients quickly, within the maximum waiting times targets. In return, patients are under an obligation to accept a reasonable offer of treatment, to attend at the time they have agreed, and to alert the hospital as soon as possible if they have to change their plans for any reason.
I believe that is a fair and reasonable balance. I want the NHS to deliver on its side of the bargain. I expect that patients will deliver on theirs.
The new system will no doubt take a little time to bed down, and there may be teething problems. I urge Members to alert me to any problems so that they can be thoroughly investigated.
I hope that today's statement and the opportunity for questions that now follows will help promote awareness of the new arrangements and ensure that they operate to the benefit of patients throughout Scotland.
Above all else, I hope it assures the chamber of this government's determination to ensure that there will be no more hidden waiting lists for NHS patients in Scotland.