NHS HDL (2002)70 abcdefghijklm Health Department St Andrew s House Regent Road Edinburgh EH1 3DG Dear Colleague, THE MANAGEMENT OF WAITING LISTS IN NHSSCOTLAND Summary 1. This HDL sets out an action plan for the implementation of the recommendations in the Audit Scotland report "Review of the Management of Waiting Lists in Scotland". The plan includes actions for the Health Department, NHS Scotland Boards and Trusts, and for Information and Statistics Division, and reflects consultation with the NHS. It has been approved by the Minister for Health and Community Care. Background 2. At the request of the First Minister, Audit Scotland conducted a review of the management of waiting lists in NHSScotland, and published its report on 25 June 2002. A copy of the report can be found at http://www.auditscotland.gov.uk/publications/pdf/02pf03ag.pdf 3. The report made a number of recommendations to improve the management of waiting. The Department sought views on the recommendations from NHS Board and Trust Chief Executives and from ISD Scotland. An action plan has now been agreed which addresses all of the recommendations. The timescales for implementation are included in the Plan. It is very important that timescales are adhered to. 3 October 2002 Addresses For action Chief Executives, NHS Boards Chief Executives, NHS Trusts Director, ISD Scotland For information: Chief Executive, Health Education Board For Scotland Chief Executive, Scottish Ambulance Service Chief Executive, State Hospital Chief Executive, Common Services Agency Chief Executive, NHS Education for Scotland Chief Executive, Clinical Standards Board for Scotland Chief Executive, Health Technology Board for Scotland Director, Scottish Health Advisory Service Enquiries to: Margaret Duncan Performance Management Division St Andrew s House EDINBURGH EH1 3DG Tel: 0131-244 2291 Fax: 0131-244 2051
Action 4. NHS Boards, NHS Trusts and ISD Scotland should implement the action plan and the guidance in Annexes A and B as soon as possible. Yours sincerely TREVOR JONES Chief Executive, NHSScotland
ANNEX A Recommendations In The Audit Scotland Report (set out in Action Plan at the end of this document). Recommendations Numbers 1-5 Acute Trusts should implement these recommendations with immediate effect. Recommendation Number 6 It is essential that NHS Trusts ensure that all patients requiring treatment, whether on an inpatient, day case or outpatient basis, are entered on an appropriate waiting list as soon as the decision is made that treatment is required. In particular, all patients requiring inpatient or day case treatment, including those for whom treatment is provided very quickly, should be included on an appropriate waiting list. This will enable better and more accurate monitoring and recording of waiting times, and ensure that, where appropriate, such patients are recorded in the quarterly SMR3 census. Recommendationa Numbers 7 and 20 On 27 August 2002, the Minister for Health and Community Care announced his intention to abolish the deferred waiting list as soon as possible. He has asked ISD Scotland to provide him by the end of September 2002 with a report covering the implications for NHS computer systems and hospital administrative arrangements, the definitional changes which may be necessary and a timetable for implementation. Meantime, NHS Trusts should commence reviewing the cases on their deferred waiting lists to ensure that they know the reason why each patient has been classified as deferred, that patients who no longer require treatment are removed, and that for those patients who are now available for treatment, that this is scheduled as soon as possible. Recommendations Numbers 8 and 9 ISD Scotland s existing guidance on waiting applies to all NHS Trusts. All Primary Care Trusts should liaise with ISD Scotland to ensure that they are applying current guidance fully and correctly. They should also ensure that written protocols and procedures are in place. Information on waiting times and waiting lists for services provided by professions other than consultants i.e. nurse-led clinics, Allied Health Professionals, etc is not currently collected centrally. ISD Scotland has a major project underway the Data Development Project to address these and other issues.
Recommendation Number 10 NHS Trusts should implement this recommendation with immediate effect. Good communications with patients are essential. When it is decided that a patient requires treatment, they should be informed of how long they will have to wait for this treatment and whether they have a waiting times guarantee. They should also be informed of any subsequent change(s). Recommendation Number 11 NHS Trusts should implement this recommendation as soon as possible. A short-life working group led by Peter Gabbitas, Chief Executive, West Lothian Healthcare NHS Trust, is currently undertaking work on DNAs, identifying reasons for variation across Trusts, collating examples of good practice and considering the best approach to help drive down DNA rates. Recommendation Number 12 NHS Trusts should implement this recommendation as soon as possible. Recommendation Number 13 NHS Trusts should implement this recommendation as soon as possible. The National Waiting TimesUnit will also require regular, up-to-date information on waiting times for all services from all NHS Trusts, in order to develop the National Waiting Times database. Recommendation Number 14 NHS Boards should implement this recommendation with immediate effect. NHS Boards have a key role to play in monitoring waiting lists and waiting times for their residents, and must therefore ensure that appropriate arrangements are in place to monitor performance and management in their local NHS Trusts. Recommendation Number 15 This recommendation is being considered by the Performance Assessment Framework (PAF) Steering Group, set up to consider changes to the PAF for next year. Recommendation Number 16 The Chief Medical Officer is raising this issue at his meetings with professional bodies including the SJCC, SMASAC, the Academy of Medical Royal Colleges and his Specialty Advisers. NHS Trust management should work with their clinicians to develop agreed protocols.
Recommendation Number 17 It is clearly important that accurate information is available on the recent trend of the number of procedures moving from hospital day cases to outpatient settings. NHS Boards and Trusts should note that mandatory recording of outpatient procedures will be introduced shortly. Initially, information will be required and will be mandatory from 1 April 2003. ISD will issue guidance on the required list shortly. This however is only the beginning and ISD will continue to identify with the Service a comprehensive range of procedures carried out in outpatient for mandatory reporting on SMR00. NHS Trusts are encouraged to make an early start to recording all procedures carried out in outpatient settings. ISD's Data Development Project will take forward work in this area, including the development of new and additional definitions. Recommendation Number 18 Work undertaken by ISD Scotland indicates that a number of Trusts have not been implementing current guidance on CNAs appropriately, and a large number of such patients are currently included, inappropriately, on deferred waiting lists. Patients who CNA should be given a guarantee exception code 2, but retained on the true inpatient/day case waiting list. ISD Scotland will issue clarified guidance on this issue. Recommendation Number 19 Current guidelines apply to all NHS Trusts, including Primary Care Trusts, and should therefore be implemented by all NHS Trusts. ISD Scotland will reissue current guidance to the Service in October 2002. In the longer term, ISD's Data Definitions Project and Waiting Lists Definitions Review will lead to the deveopment of new and additional definitions for all Trusts. Recommendation Number 21 NHS Boards and Trusts should note that mandatory recording of outpatient procedures will be introduced shortly. Initially, information will be required and will be mandatory from 1 April 2003. ISD will issue guidance on the required list shortly. This however is only the beginning and ISD will continue to identify with the Service a comprehensive range of procedures carried out in outpatient for mandatory reporting on SMR00. NHS Trusts are encouraged to make an early start to recording all procedures carried out in outpatient settings. ISD's Data Development Project will take forward work in this area, including the development of new and additional definitions. General The National Waiting Times Unit is preparing good practice guidance on the management of waiting which will be available by the end of this year.
Other Important Issues Relevant To The Effective Management Of Waiting ANNEX B Management Of Waiting It is essential that all NHS Trusts have effective waiting lists and waiting times management in place to ensure that the longest waits are reduced and overall waits minimised. Special tools are available to assist in this regard - for example the "Checklist" computer model. Some NHS Trusts are subscribers to "Checklist", but in most cases its utilisation is at the very early stages. All NHS Trusts should take steps to introduce an effective system for managing waiting lists, or where such a system has already been introduced within the Trust to extend its use so that it is utilised throughout the organisation. Waiting Times Guarantees NHS Boards and Trusts are reminded that the national waiting times guarantee of 12 months (to be reduced to 9 months by the end of 2003 and 6 months by the end of 2005), must be met at all times, and not just on the quarterly waiting list census dates. The decision to place a patient on the inpatient/day case waiting list is a commitment to treat that patient within the guarantee period. ISD Scotland have been asked to review the introduction of a mandatory completion of the guarantee exception code box on the SMR1, to enable a more accurate record of NHSScotland performance against the inpatient and day case waiting time target. Use Of Waiting Times Guarantee Exception Codes Patients considered to be an exception to the waiting time guarantee must be advised immediately of the reasons. All exceptions should be monitored by NHS Trusts and NHS Boards to ensure that the exceptions fall within ISD Definitions and that they are not being interpeted too liberally or to the disadvantage of patients. NHS Boards and Trusts are reminded that the exception Code 9 should only be used in dealing with the circumstances of exceptional strain on the NHS, such as a major disaster, major epidemic or outbreak of infection or service disruption by industrial action, and that the agreement of the Scottish Executive Health Department must be obtained before the use of the exception Code 9. Reclassification Of Patients From Day Cases To Outpatients Advances in clinical practice and changes in patterns of service delivery have resulted in a number of procedures formerly undertaken on a day case basis now being performed in outpatient settings. Audit Scotland found variations in practice among NHS Trusts across the country in the management of patients whose treatment had been so reclassified. Clearly, a consistent approach is essential.
NHS Trusts should also monitor existing and new referrals for reclassified outpatient procedures and maintain the waiting times guarantees that these patients would have held had they been treated as day cases. Patients with a guarantee on the inpatient/day case waiting list who are reclassified from day case treatment to an outpatient setting and consequently removed from the waiting list, should retain their waiting times guarantee and be treated within the guarantee period. Similarly, patients to be treated in an outpatient setting for procedures which were formerly undertaken as day cases should be given a guarantee that they will receive treatment within the national maximum waiting time. This guarantee should apply from the date when the decision was made that such treatment was necessary. Recording of Outpatients ISD Scotland have been asked to undertake a review of the definition and recording of patients who Can Not Attend or Did Not Attend their outpatient appointment. On completion of their review ISD will issue revised guidance to the Service. Collection Of Information On The Treatment Of NHSScotland Patients By The Independent Healthcare Sector NHS Boards and NHS Trusts must ensure that all current and future arrangements with independent healthcare providers for the treatment and care of NHSScotland patients require prompt submission of the standard SMR data to ISD Scotland (NHS HDL (2001) 56 refers). This guidance should be implemented with immediate effect.
AUDIT SCOTLAND REVIEW OF MANAGEMENT OF WAITING LISTS IN SCOTLAND: ACTION/IMPLEMENTATION PLAN NUMBER RECOMMENDATION ACTION BY IMPLEMENTATION ACTION Acute Trusts 1. Ensure consistent application of waiting list policies and procedures across whole Trust Lead: NHS Acute Trusts Acute Trusts will implement this recommendation within the context of current guidance. Specific good practice guidance will be prepared by the National Waiting Times Unit by December 2002 and issued to the Service. 2. Ensure all new staff are trained in applying policies and procedures and refresher training provided for existing staff. Lead: NHS Acute Trusts Acute Trusts will implement this recommendation within the context of current guidance. Specific good practice guidance will be prepared by the National Waiting Times Unit by December 2002 and issued to the Service. 3. Ensure ongoing monitoring of staff applying policies and procedures Lead: NHS Acute Trusts Acute Trusts will implement this recommendation within the context of current guidance. Specific good practice guidance will be prepared by the National Waiting Times Unit by December 2002 and issued to the Service. 4. Ensure adequate administrative cover for sickness and annual leave to ensure no delays in recording patients Lead: NHS Acute Trusts Acute Trusts will implement this recommendation within the context of current guidance. Specific good practice guidance will be prepared by the National Waiting Times Unit by December 2002 and issued to the Service. 1
NUMBER RECOMMENDATION ACTION BY IMPLEMENTATION ACTION Acute Trusts 5. Ensure clear levels of security access to waiting list systems in accordance with current guidance. Lead: NHS Trusts Acute Trusts will implement this recommendation within the context of current guidance. Specific good practice guidance will be prepared by the National Waiting Times Unit by December 2002 and issued to the Service. 6. All patients waiting for services should be entered onto a waiting list to allow monitoring of waiting times and early warning of pressures in service areas Lead: NHS Trusts Immediate: NHS Trusts should ensure that all patients requiring elective inpatient and day case treatment are entered on the waiting list. 7. Waiting Times on deferred waiting list should be monitored routinely Lead: NHS Acute Trusts Immediate This is already in place in most Trusts. See recommendation number 20. Primary Care Trusts 8. All Primary Care Trusts should have written protocols and procedures for waiting lists and waiting times for all services. Lead: NHS Primary Care Trusts Others: SEHD and ISD ISD will ensure that current guidance for Primary Care Trusts on waiting times and waiting lists is applied. Further guidance will be issued as required by ISD and the National Waiting Times Unit. 2
NUMBER RECOMMENDATION ACTION BY IMPLEMENTATION ACTION Primary Care Trusts 9. Should be investment in systems to allow collation and monitoring of waiting list and times for all Primary Care Trust activity Lead: NHS Primary Care Trusts Others: SEHD and ISD Decisions on services to be covered September 2003 Start implementation 1 April 2004 Data Development Project will cover waiting times and waiting lists for services provided by professions other than consultants i.e. nurse-led clinics. Implementation date for such services will be post 2004. Meantime, ISD will ensure that current guidance for Primary Care Trust on waiting lists and waiting times is applied. Further guidance will be issued as required by ISD and the NWTU. All Trusts 10. Patients should be routinely informed about the implication for waiting time guarantees when placed on a deferred waiting list or have an exception Code applied. Lead: NHS Trusts. Others: SEHD and ISD Trusts will implement the recommendation within the context of current guidance. The National Waiting Times Unit will prepare good practice guidance by December 2002 to be issued to the Service. 11. To reduce the DNA rate, patients should be contacted routinely to ensure that circumstances have not changed. Lead: NHS Trusts Others: SEHD and ISD Trusts will implement the recommendation within the context of current guidance. The National Waiting Times Unit will prepare good practice guidance by December 2002 to be issued to the Service. 12. All Trusts should develop formal early warning systems and contingency plans to identify and manage potential waiting list problems. Lead: NHS Trusts Others: SEHD and ISD Trusts will implement the recommendation within the context of current guidance. The National Waiting Times Unit will prepare good practice guidance by December 2002 to be issued to the Service. 3
NUMBER RECOMMENDATION ACTION BY IMPLEMENTATION ACTION All Trust s 13. Trusts should develop and provide regular information for patients, GPs and the public about waiting lists and waiting times for all services. Lead: NHS Trusts Others: SEHD and ISD Trusts will implement the recommendation within the context of current guidance. The National Waiting Times Unit will prepare good practice guidance by December 2002 to be issued to the Service. Unified NHS Boards 14. Review arrangements for monitoring waiting lists and waiting times in all Trusts to ensure appropriate governance arrangements are in place Lead: Unified NHS Boards Other: NHS Trusts. Immediate: NHS Boards should ensure that appropriate arrangements are in place to monitor waiting lists and waiting times performance in all their local Trusts. Health Department 15. Consider amending the PAF to include other waiting times issues, the mean time waiting on deferred lists, as well as times waiting for non-consultant outpatient clinics. Waiting time targets for nonconsultant led outpatient services should also be considered across both Acute and Primary Care Trusts. Lead: SEHD Other: ISD September 2002 These issues will be considered by the PAF Steering Group, set up to consider changes to the PAF for next year. First meeting is in September 2002. Information on waiting times for non-consultant outpatient clinics is not currently collected centrally. ISD has commenced discussions with Allied Health Professionals (AHPs) on tightening the definitions of current recording systems and establishing a multi-disciplinary sub-group to advise on common datasets from which national information, including waiting times, could be collected. 4
NUMBER RECOMMENDATION ACTION BY IMPLEMENTATION ACTION Health Department 16. Guidance for the management of low clinical priority cases should be considered. Lead: SEHD (CMO), NHSScotland and Medical Bodies. From Autumn 2002 Development of protocols are clinical matters and should be developed by relevant clinicians. The Chief Medical Officer will raise this issue at his forthcoming meetings with the professional bodies, including the SJCC, SMASAC, the Academy of Medical Royal Colleges and his Specialty Advisers. Information & Statistics Division 17. ISD s review of waiting list and waiting times definitions should include developing definitions which reflect current medical practice, such as the move from day cases to outpatients procedures, to ensure that perverse incentives do not remain. Lead: ISD Others: NHSScotland and SEHD From October 2002 ISD Scotland will re-state current advice to the Service. In the longer term, the work being undertaken in ISD's Data Development Project and Waiting Lists Definitions Review will result in the development of new and additional definitions. 18. ISD s review of waiting list and waiting times definitions should include strengthening definitions relating to cannot attend and do not attend. Lead: ISD Others: NHSScotland and SEHD ISD Scotland will issue clarification to the Service in September 2002, for implementation from 01 October 2002. 19. ISD s review of waiting list and waiting times definitions should include producing definitions for primary care services. Lead: ISD Others: NHSScotland and SEHD From October 2002. Existing definitions apply to all NHS Trusts, including Primary Care Trusts. ISD will reissue guidance in October 2002. In longer term, work being undertaken in ISD's Data Development Project and Waiting Lists Definitions Review will result in the need for new and additional definitions for all NHS Trusts.. 5
NUMBER RECOMMENDATION ACTION BY IMPLEMENTATION ACTION Information & Statistics Division 20. Review the rationale of a deferred waiting list to ensure that patients are not disadvantaged by being placed on this list. Lead: ISD and SEHD Others: NHSScotland ISD s Waiting List Definitions Review has examined issues relating to the deferred waiting list and Project Board has recommended move to a single waiting list and abolition of deferred waiting list. On 27 August 2002, the Minister for Health and Community Care announced his intention to abolish the deferred waiting list. He has commissioned a report on the implications and a timetable for implementation from ISD Scotland by the end of September 2002. 21. Progress consistent recording of outpatient procedures Lead: ISD and NHSS Other: SEHD From October 2002 for a limited set of procedures. Mandatory coding for all procedures being addressed as part of the Data Development Project. Full implementation by April 2003. In the longer term, all OPCS4 codes need to be captured on SMR00s for outpatients. Data Development Project will address capture of all OPCS4 codes on SMR00s. Introducing mandatory OPCS4 coding for those day case procedures already reclassified to outpatients is a step on the way to this. ISD will write to NHSScotland asking them to commence this for a limited range of procedures with effect from 01 October 2002, and will support the Service to ensure complete coverage by April 2003. 6