NHS gooroo blog

Posts Tagged ‘Scotland’

Some of the differences between Scottish and English waiting times are pretty obvious. England has three 18-week referral-to-treatment targets and a 6-week diagnostic wait (pp.38 & 58), whereas Scotland has one 18-week referral-to-treatment target, a 6-week diagnostic wait, a 12 week inpatient/daycase Treatment Time Guarantee, and a non-legally-binding 12 week outpatient wait (p.5). Already we can see that it’s quite complicated in England, but even more complicated in Scotland.

If you dig into these targets you find the rules are different too. The differences are pretty big, and many patients who would have a right to short waiting times in England, enjoy no such guarantees in Scotland.

For instance, if you are referred to an English hospital then they have to accept the referral and treat you (unless they don’t provide that kind of care, or you agree to be treated elsewhere) (pp.7-8). But in Scotland the hospital can routinely send its patients just about anywhere it likes (p.16), even if the destination is way outside the boundaries of its Health Board; any patient who refuses can be taken off the waiting list or have their ‘clock’ reset to zero (p.17). In case you think that such long-distance transfers might be a rare event, Scottish Health Boards have regular arrangements to send increasingly large numbers of waiting list patients to the Golden Jubilee National Hospital west of Glasgow, even from as far away as Orkney (p.5).

You have to be ready at short notice in Scotland too, because the NHS considers seven days’ notice to be a “reasonable offer” (p.15), compared with three weeks in England (pp.34-35). (To protect urgent patients, hospitals can offer shorter-notice appointments in both nations, and patients are free to accept or reject them without penalty.)

And you should avoid changing your appointment in Scotland, even if you give them plenty of notice, because the hospital can use that as an opportunity to reset your clock to zero; if you change your appointment three times, they are normally expected to send you back to your GP (p.19). There are no such sanctions for changing appointments in England even if you give only short notice (p.28). In both nations, though, you can be taken off the list and sent back to your GP if you fail to attend your first outpatient appointment without giving notice (i.e. you ‘DNA’) (p.20, p.28).

If you are ever unavailable for treatment, either for medical or social reasons, then in Scotland your ‘clock’ is paused (p.22-25). This rule was very heavily applied (pp.10, 19) until a recent clampdown. In England the new main target (based on incomplete pathways: p.58) does not allow clock pausing at all, although clock pauses were certainly allowed and used against the previous main target.

Then there are patients who are completely excluded from the targets. For obvious reasons, both England and Scotland exclude obstetrics from their waiting time guarantees. If you are waiting for an organ transplant, then the wait for the organ itself is excluded in both nations. And if you want to become pregnant then assisted reproduction is covered in England, but not in Scotland. (p.13-4)

Both nations have short-wait guarantees for cancer outpatient appointments and initial treatment, but the English guarantee covers all cancers (pp.38-40) while in Scotland there are exclusions covering several cancer types (pp.15, 25-26). If you are having a course of cancer treatment then, in England, you are guaranteed your subsequent treatment within time limits, whether it’s surgery, chemotherapy or radiotherapy (pp.39-40); but there are no such guarantees in Scotland (p.5).

There are different exclusions in diagnostics as well. Scotland applies the 6-week guarantee only to eight key diagnostic tests (p.14), which means that English (but not Scottish) patients are guaranteed a 6-week wait for DEXA and various kinds of physiological measurement (p.8). However in both nations the diagnostic wait is part of the 18-week referral to treatment wait, so this may not make a massive difference in practice.

Why are the English rules apparently so much more patient-friendly and inclusive than the Scottish ones? I think the answer was right at the start: the nature of the waiting times targets.

In England, the overall targets have a tolerance, for instance that 92 per cent of patients on the waiting list must be within 18 weeks. That leaves an 8 per cent margin for the odd exceptions (and there will always be exceptions).

In Scotland, though, the legally-binding 12 week Treatment Time Guarantee is a 100 per cent target. There will still always be exceptions, so they must be allowed for in the rules; which means you need lots of rules.

Personally, I think the English approach is the better one. (And in case anyone north of the border is starting to suspect a national bias, I should say that I am Scottish and was born and brought up in Scotland.) Hard cases make bad law, and trying to define all the reasonable exceptions in the rules is inevitably going to be complex and imperfect. Better simply to allow a tolerance in the target and let the rules include everybody.

Scotland is getting results from its new legally-binding Treatment Time Guarantee (TTG), which guarantees that eligible inpatients and daycases will start treatment within 12 weeks of being added to the waiting list. The number of over-12-week-waiters on the list fell, for the first quarter in nearly 2 years, to levels not seen since December 2011.

However over-12-week waiters on the outpatient waiting list, which are subject only to a non-legally-binding target, continue to rise rapidly.

All data in this post comes from ISD Scotland, and I have excluded Lothian Health Board throughout (they would totally dominate the picture otherwise: they were caught with terrible long-waits but have been turning things around since).

If you do look up the original data tables you should be aware that the inpatient & daycase data is rather confusing at the moment. The TTG only applies to those patients added to the list after 1 October 2012 (and there are exclusions), so in the following chart I have added together the pre- and post-October data series in the hope of getting (reasonably) consistent data.

Patient treatment target met
(Scottish Government)

Sigh. Yes, the target was met, again. No, this doesn’t mean that waiting times have improved in Scotland.

The Scottish referral-to-treatment (RTT) figures only tell us about those patients who were lucky enough to be treated. If you look at the poor souls who are still waiting for weeks on end, you can see that their numbers continue to rise.

Excluding the exceptional waiting times meltdown in Lothian, this is what is happening to long-waiters who are still on the waiting list in Scotland (source: ISD):

Scotland doesn’t yet collect RTT data for incomplete patient journeys (the data is far from perfect for completed patient journeys, so there are good reasons for not taking that more-difficult next step). But we do have this stage-of-treatment data for the waiting list itself and, yes, this is subject to targets: a 12 week target wait for outpatients, and a legal requirement (the Treatment Time Guarantee, or TTG) to treat inpatients and daycases within 12 weeks from 1 October.

Long-waiting outpatients and inpatients have actually eased back slightly in September from their peak at the end of August (not shown in this quarterly chart). This may mark the start of an improvement, or it could be a seasonal effect. You might expect the inpatient/daycase waits to improve as the TTG takes effect (even though, strictly, it only applies to patients added after 1 October). We shall see.

Scotland met its referral-to-treatment (RTT) target again at the end of June: a perfect record of achievement since the target came into force in December 2011. Sounds great. But is it?

A target has been met, but that doesn’t mean waiting times have improved.

If you look at the long-waiting backlog still on the waiting list, you can see (even if you omit scandal-hit Lothian) that it is growing instead of shrinking: the outpatient backlog is lurching upwards in seasonal jumps while the inpatient/daycase backlog rises more steadily. (Scotland does not collect RTT data for incomplete patient journeys, which is why we have to look at stage-of-wait data to estimate what is happening to the backlog.)

Meanwhile, the RTT figures for completed patient journeys show (as we noted before) that the number of long-waiters being treated is continuing to decline, despite the rising backlog. That is the manner in which the target (that 90 per cent of patients must have waited less than 18 weeks RTT when they are brought in for treatment), is being met.

The number of long-waiters being treated is falling, but is still high enough overall to allow Health Boards to treat these long-waiters on their waiting lists. Even Ayrshire & Arran, the only Health Board with sharply rising inpatient/daycase long-waits and falling RTT longwaits being treated, is still able to tackle its overall longwait backlog within the RTT target (dark blue lines in the chart below; the inpatient/daycase backlog uses the right-hand scale).

Forth Valley (red lines in the chart) failed the RTT target while clearing long-waiters from the backlog, and were criticised in the media for it. It would be fair enough to criticise them for having long-waiters in the first place, but it surely makes little sense to complain when they treat them. (This has been a pitfall of treatment-based targets in England too.)

Among all this detail, an interesting story is unfolding; a story quite different from the development of waiting times policy in England:

The Scottish RTT target came into force in December 2011, and this has been the top priority for hospitals when it comes to waiting times. Backlogs have been allowed to grow in some places, not necessarily as a ruse to achieve the RTT target, but perhaps more because eyes were taken off that particular ball.

But priorities are changing in October, when the legally-binding Treatment Time Guarantee (TTG) comes into force. This requires inpatients and daycases to start treatment within 12 weeks of agreeing to it. This target is more stringent than the 18-week RTT target, and those Health Boards that have built up backlogs will need to clear them, even if that means failing the RTT target while they do so.

If Health Boards are successful in clearing their backlogs, then things could settle down nicely. However Scotland’s target regime has quite a few holes in it which financially-squeezed Health Boards might feel they are being pushed into:

1) Backlogs can still build up in outpatients, either in follow-up loops or on the outpatient waiting list itself. Those patients fall outside the TTG because that only covers the inpatient and daycase stage of wait. They also escape being counted under the RTT target until the day they are eventually brought in for treatment. So a delay at outpatients is a way of postponing the expense of admission and, once a backlog has built up, the RTT target actively discourages Health Boards from clearing it.

2) In common with Scottish waiting times targets down the years, there are still far too many opportunities to pause the clock on patients, both in the TTG and RTT targets. These opportunities are taken up very widely: 25 per cent of inpatients/daycases on the Scottish waiting list are declared “unavailable” (and some 43 per cent in NHS Grampian).

3) There is also a temporary issue that patients added to the inpatient/daycase list before October are not covered by the TTG. Will Health Boards seek a little short-term relief by neglecting those patients on the waiting list? From a patient care standpoint, that would be most unfair. From the Health Board’s point of view, the extra complexity of managing and planning against two parallel target regimes is not to be sneezed at. And they can’t neglect those patients forever, so I hope Health Boards do the right thing and treat patients equitably (even if strictly the TTG does not apply to them all).

The best longer-term solution for waiting times policy would be to set an incomplete journeys target (with no adjustment for clock pauses), like the target being introduced gradually in England. However Scotland’s data systems are probably not quite ready for that challenge yet (even England, which is some years ahead of Scotland on RTT measures, is still far from perfect when it comes to stitching incomplete pathway waits together).

The caveats aside, Scotland’s new target regime is an interesting case study because the waiting-list-based target (the TTG) is more stringent than the as-they-are-treated RTT target which runs alongside it. This is a step ahead of England, where the as-they-are-treated targets are still more stringent. The TTG prevents Health Boards from building up backlogs for expensive admitted procedures, and the economics of the RTT target (which lumps admitted and non-admitted patients together) encourage them to treat inexpensive patients quickly in clinic instead of building up a backlog.

It’s messy, yes, but Scotland’s target regime does have its pragmatic points. Will it work out nicely, or will the loopholes undermine it? We’ll just have to wait and see. (Personally, I fear the loopholes.)

(All data from ISD)

The first Gooroo user group is being set up for the East Midlands and surrounding areas, where we have a growing cluster of NHS organisations using Gooroo’s planning and scheduling software.

Meetings will be held three times a year, and attendance is free of charge. The first will be on Monday 1st October from 2pm to 4:30pm in Teaching Room 5 of the Education Centre at Derby Hospital. If you’re a current or potential Gooroo user and would like to come along, then you are very welcome, and should email info@nhsgooroo.co.uk to add your name to the mailing list.

The second user group is already being set up in Scotland, and again if you’d like to come then please email us. The first meeting will probably be in late October in Stirling.

If you are a Gooroo user somewhere else in the country, and would like a user group to be established in your area, then please let us know and we’ll see what we can do.

Usually when Celtic nations borrow ideas from the English, they pick the best bits and leave the not-so-good stuff behind. Not this time. Scotland has just “achieved” its first 18-weeks referral-to-treatment (RTT) target, but this success is an illusion. Behind a distorting target, long-waits are shooting up at an astonishing rate.

As if that isn’t bad enough, the NHS in Scotland is also enduring a torrent of headlines about the Lothian waiting times scandal, with lurid tales of inappropriate offers, staff suspensions, fiddles, and bullying. Anyone outside Scotland, wanting to see from a safe distance just how nasty a waiting list scandal can get, should take a look (before checking out the antidote here).

How did it go so wrong?

Fundamentally, Scotland picked the wrong target. It copied the headline English target (that 90 per cent of completed patient journeys must be within 18 weeks RTT, adjusted for periods of patient unavailability). As in England, any Health Board can achieve the target simply by refusing to treat patients who have already passed the 18-week mark. And that, it seems, is exactly what has happened.

The Scottish Government wanted the 90 per cent target met by December 2011, and right on cue the NHS achieved 92 per cent. But they achieved it by suppressing the number of long-waiters being treated to a record low (figures from Table 1 here):

This would be fine, if it were genuinely the result of having fewer long-waiters still on the waiting list. But the opposite is true. We cannot make a direct comparison on a RTT basis because (unlike England) Scotland does not publish RTT figures about the waiting list itself. But there is data available for the separate outpatient and inpatient/daycase stages of the patient journey, and the official charts (reproduced below) could hardly show more starkly how the number of long-waiting patients still on the list is going up like a rocket.

It doesn’t look any prettier in raw numbers. Year on year, the number of patients still on the waiting list over 12 weeks went up from 1,769 to 6,141 for new outpatients, and from 210 to 2,019 for inpatients and daycases. The big numbers are concentrated in Lothian (as patients wrongly declared “unavailable” are returned to the waiting list), but there are sharp increases in other Health Boards too, showing that this is not a Lothian-specific phenomenon.

It is such a pity. These outpatient and inpatient/daycase targets, which apply to patients who are still on the waiting list, were meant to be the magic bullet that would stop backlogs building up, and stop the Scottish referral-to-treatment target from distorting waiting times as they did in England. But the backstop has failed. The distorting target won, it prevents Health Boards from treating enough long-waiters, and so the number of long-waiters still on the waiting list is going up.

Are there any plans to sort this out? The Scottish Government will take half a step in the right direction, with a 12 week legal guarantee covering some inpatients and daycases due to start in the autumn. But putting a small patch on a weakened backstop will not fix the underlying problem.

Instead, Scotland should look across the border and learn again from England’s mistakes. The new English target is the one to copy: that 92 per cent of patients still waiting must be below 18 weeks, on a referral-to-treatment basis and without adjustment for patient unavailability.

Even better, Scotland could do it first. Although English Health Ministers have accepted the logic of a waiting list based target, and gone to all the trouble of creating one, they have bizarrely delayed its full implementation until at least April 2013. Scottish Ministers could switch targets now, and rapidly achieve and sustain the genuine short-waits that they wanted in the first place.