AUDIT SCOTLAND REPORT MANAGEMENT OF PATIENTS ON WAITING LISTS, FEBRUARY 2013 AND USE OF UNAVAILABILITY WITHIN NHS HIGHLAND.

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1 Highland NHS Board 9 April 2013 Item 5.5 AUDIT SCOTLAND REPORT MANAGEMENT OF PATIENTS ON WAITING LISTS, FEBRUARY 2013 AND USE OF UNAVAILABILITY WITHIN NHS HIGHLAND. Report by Margaret Brown, Head of Service Planning on behalf of Elaine Mead, Chief Executive The Board is asked to: Note the Key Messages and s of the Audit Scotland report. Be assured of the within against the key recommendations. Note the planned actions and those already underway against the full list of recommendation. Identify any additional performance reports required by the Board. 1 Background and Summary Audit Scotland published its report Management of patients on NHS waiting lists on Thursday 21 February This report followed evidence of manipulation of reported waiting times in NHS Lothian during 2011 and an Internal Audit report on the inappropriate use of unavailability codes in NHS Tayside during The Internal Audit report undertaken in Tayside was one of the Internal Audit reports that were undertaken across all NHS Boards during Our local Internal Audit report was presented to the Board and the Audit Committee in December A summary of this paper was considered by the Improvement Committee on 5 March to give assurance regarding the report findings in relation to The Audit Scotland report aimed to identify whether the issues identified in NHS Lothian and NHS Tayside were isolated incidents or an indication of widespread problems across the NHS in Scotland. To do this, a detailed audit was undertaken of each Board s electronic patient management systems, and an analysis of the application of unavailability during the period April to December Key Messages and s The key messages of the published report for NHS Scotland are detailed below. The NHS Highland is provided the against each of these Key message 1 for NHS Scotland The systems used to manage the waiting lists have inadequate controls and audit trails, with limited information recorded in patient s records. This meant it was not possible to trace all amendments to records and the reasons for them. The limitations of the current patient administration system in the management of waiting lists are acknowledged by. The Board agreed at its December 2012 meeting to formally adopt TrakCare as its new patient management system which would provide the required audit trails and control. This will be fully implemented by October 2013.

2 Key message 2 for NHS Scotland Most patients records reviewed did not include enough information to verify appropriate application of unavailability codes, after discussion with the GP or patient. The % of patients on the admissions waiting lists with social unavailability applied rose from 11% in 2008 to just over 30% in With Ophthalmology and Orthopaedics having the highest percentage applied. The use of the code started to reduce in most NHS Boards in late 2011 and at the same time the % of patients waiting longer than 12 weeks started to rise. The existing PAS does not have provision for the required information to be recorded. A standard operating procedure is in place to make best use of the current system until the new PMS is in place in October does not follow the national picture described above for the use of unavailability for patients waiting for admission. The graphs below show that we have kept a consistent level of unavailability. The Scottish average has gradually reduced to the level that we have maintained. Equally our percentage of patients waiting over 12 weeks for treatment has not risen in line with national trends. 2

3 Key message 3 for NHS Scotland The sampling found a small number of instances in which unavailability was applied inappropriately. The limitations of the systems meant that it was not possible for them to determine whether this was due to human error, inconsistent interpretation of the guidelines or deliberate manipulation of the waiting lists. For, the report identified 6 records out of a sample of 23 where unavailability had been initially applied without an end date. This means patients could have remained unavailable indefinitely if they were not reviewed. We immediately corrected this and developed a standard operating procedure for all staff to prevent this from happening again. We also introduced a new daily monitoring report which identifies any record where an end date has been missed so that this can be rectified immediately. None of the 6 patients had been disadvantaged as a consequence of the omission identified. Key Message 4 for NHS Scotland There was not enough scrutiny of the increasing number of patients recorded as unavailable by the Scottish Government. Better use of the available information could have helped identify concerns about its use and the wider capacity pressures building up within the system. For a number of years we have produced a weekly report which identifies the number of patients currently on the waiting lists for outpatients and admissions with unavailability applied. This is detailed by speciality and Operational Unit and is available to managers across. This regular monitoring has helped ensure that we did not have the increase in patients with unavailability that was evidenced across other NHS Boards. Key Message 5 for NHS Scotland It is important to have effective whistle-blowing policies and an environment where people can raise concerns safely and with confidence that they will be acted on. The policy Implementing and Reviewing Whistleblowing arrangements was introduced in November The full set of recommendations of the report is detailed in Appendix 1, together with the. The key recommendations of the published report are detailed below Scottish Government and NHS Boards should Monitor and report the use of unavailability and ensure its appropriate application in line with national guidance. Use this information to Identify where staff may be incorrectly applying codes Help plan and manage capacity required to deliver waiting times targets. As stated above a weekly report is produced by and is available to managers across the Board. This allows us to monitor the number and percentage of patients with applied unavailability. In addition to this we are monitoring patients who have been on our admissions waiting list for more than 6 months. These are mainly patients who have advised us of extended periods of unavailability, either as a single period or frequent shorter periods. The service is then asked to review the appropriateness of these patients remaining on the waiting list and to encourage them to accept a date for admission or refer them back to their GP until the patient is willing and available for admission. 3

4 NHS Boards should Ensure that electronic systems have an audit trail to enable scrutiny of waiting list, and controls and safeguards to provide assurance that waiting lists are being managed properly. Ensure that information is recorded within patient records identifying the reason for the application of unavailability. Communicate clearly with patients about their rights and responsibilities under waiting time guidance and legislation. Ensure effective whistle-blowing policies and procedures are in place and published. The new PMS will be implemented by October 2013 with capability to provide the required audit trails and controls. Standard operating procedures are in place to maximise the facilities of the current PAS to record reasons for application of the unavailability. Full implementation of the written communication detailed within the new guidance introduced in October 2012 has not yet been achieved due to the in ability of the current systems to produce and store the required range and volume of letters. E-health is currently investigating options to achieve this. However in line with legislation, patients are being notified in writing if we have failed to achieve to deliver the 12 weeks Treatment Time Guarantee (TTG) or if we think that we may not be able to, and they are offered the opportunity to travel outwith to access treatment within the independent sector. To date 20 patients have accepted this offer. Patients who do not wish to accept this offer are not made unavailable nor do they have their waiting time adjusted in any way. The Whistleblowing policy was introduced in November Non-Executive Directors of NHS Boards should Ensure they have the full range of information available to scrutinise how their Board is applying unavailability and planning and managing capacity to deliver targets. There is regular scrutiny of waiting times performance through the Improvement Committee. Periodically detailed reports of the application of unavailability have also been presented. As reported earlier these are readily available and can be presented on a more frequent basis if required. The Scottish Government and ISD Scotland should Clarify the role of each organisation in monitoring the application of unavailability and performance against waiting times targets. Clarify the process for raising concerns about issues within individual NHS Boards. The full Audit Scotland report can be accessed at 3 Contribution to Board Objectives The efficient and effective management of waiting times contributes to the delivery of the HEAT access targets for elective patient activity. Reduced waiting times and support of those patients with additional needs also improves the quality of service we provide our patients. 4

5 4 Governance Implications Staff Governance Staff will continue to be trained to ensure accurate recording and management of patients waiting times. Patient and Public Involvement Patients will have increased formal communication regarding their waiting times and the impact of their actions and availability for treatment. Patients with additional support needs should have these taken into account when booking attendance at hospital and accommodated when attending hospital and receiving treatment. Clinical Governance Accurate recording of patients waiting times ensures patients are treated as soon as possible, in accordance with clinical need and in turn. Financial Impact Accurate recording and effective management of waiting lists may reduce the need for additional work to be undertaken locally at enhanced payment rates. However in circumstances where we cannot meet the TTG locally, patients wishing to accept the offer of treatment outside will incur additional costs for. 5 Risk Assessment Waiting Times are identified in the Corporate Risk Register under the following items 4: Difficulty in measuring effectiveness and quality of interventions and services (Medium risk) 14: Failure to meet HEAT targets (Medium Risk) Waiting Times have been part of the Internal Audit plan for the last 2 years and is included again for 2013/14. It is expected that the remit for this will again be set nationally for all Boards to address. This paper can only provide assurance on the performance for health facilities; it does not cover management of residents on waiting lists in other NHS Scotland Boards. In particular residents of Argyll and Bute on waiting lists in NHS Greater Glasgow & Clyde, or any residents on waiting lists for specialist assessment or treatment in the main tertiary centres in Scotland. We have attempted to get regular waiting times information from other NHS Boards as part of our SLA agreements but have been unable to enforce this. 6 Impact Assessment No impact assessment has been undertaken. Margaret Brown Head of Service Planning 28 March

6 Appendix 1 Full list of s for Boards Ensure that information is recorded within patient records about the reasons for applying waiting list codes. Make sure that electronic systems have an audit trail to enable scrutiny of waiting list systems and that good control and safeguards are in place, as described in Exhibit 4 on page 15, to provide assurance that waiting lists are being managed properly. The new PMS will be implemented by October 2013 with capability to appropriately record reasons for unavailability and provide the required audit trails and controls. Share good practice on enhanced performance reporting to monitor patients on waiting lists. Operational and senior managers within regularly participate in national meetings and events focussing on waiting times management, which provide the opportunity to share good practice. Identify and take into account patients' individual circumstances, such as access to transport, mobility and additional support needs, before offering them treatment at a location outside the board area. Ensure patients with additional support needs, such as a disability or requiring a translator, are identified and provided with the support they require. We recognise that there are aspects of this that we still need to address and to build on those elements already in place. We need to ensure we are able to Electronically capture patients additional support needs within primary care Communicate these effectively in referral to specialist care Take account of these in booking patients Provide the necessary support when patients attend hospital. This major piece of work will be managed through the Highland Quality Approach framework, during the next year and will interface with a few major change projects planned or already underway. Monitor offers made to patients for treatment outside the board area as part of wider monitoring of local capacity. All patients who are likely to breach their Treatment Time Guarantee, introduced on 1 st October 2012, are formally written to offering them the option for us to seek an alternative provider for them who may be able to offer an earlier date. All of this is stored on a local data base. To date 20 patients have accepted this offer and have been treated in the independent sector. Monitor use of social unavailability codes, including high numbers of changes, retrospective changes, and changes that affect waiting time performance, to ensure staff are applying the codes appropriately. Monitor the use of patient choice codes introduced under the updated guidance to ensure this is kept to minimum. We have a robust set of performance reports in place to monitor the application of unavailability. 6

7 The exception to this is that the current patient administration system does not allow us to identify when this has been done retrospectively, but this will be addressed by the new PMS implementation. It should be noted that it is acceptable and standard practice to apply unavailability retrospectively in some instances e.g. patients who do not respond to the initial invitation to contact the patient booking office and require a reminder. Take action to reduce unavailability in specialties where use of these codes is particularly high and may indicate capacity problems. Our performance reports for unavailability provide application at speciality level. In addition to this we are monitoring patients who have been on our admissions waiting list for more than 6 months. These are mainly patients who have advised us of extended periods of unavailability, either as a single period or frequent shorter periods. The service is then asked to review the appropriateness of these patients remaining on the waiting list and to encourage them to accept a date for admission or refer them back to their GP until the patient is willing and available for admission Ensure adequate systems are in place so there is no delay in the hospital receiving referrals or delays in the patient being added to the waiting list. Performance reports are in place to identify any delay in patients whose referral has been received but not added to the outpatients waiting list within 7 days, and patients who have had a recorded clinic outcome decision to add to the admissions waiting list but not been added within 7 days. However there is no process that we can implement to give this assurance for manual referrals. Work is underway to encourage all NHS Highland GPs to refer using SCI gateway, and we actively manage the completion of clinic outcomes. s regarding consultant to consultant referrals will be presented to the Board as part of the review of the Local Access Policy later this year. Communicate clearly with patients about their rights and responsibilities under waiting time guidance and legislation. Full implementation of the written communication detailed within the new guidance introduced in October 2012 has not yet been achieved due to the inability of the current systems to produce and store the required range and volume of letters. E-health is currently investigating options to achieve this. However in line with legislation, patients are being notified in writing if we have failed to achieve to deliver the 12 weeks Treatment Time Guarantee (TTG) or if we think that we may not be able to, and they are offered the opportunity to travel outwith to access treatment within the independent sector. To date 20 patients have accepted this offer. Patients who do not wish to accept this offer are not made unavailable nor do they have their waiting time adjusted in any way. Ensure effective whistle-blowing policies and procedures are in place and publicised. The Whistleblowing policy was introduced in November