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Healthy change in procedure

THE revelation that Lothian Health Board was manipulating waiting lists to meet targets prompted concerns that the practice was rife throughout the NHS in Scotland.

An investigation was launched into all 14 health boards and yesterday Health Secretary Alex Neil announced there was no evidence that similar practices were widespread. Patients can only be partly reassured, however.

The sudden drop in the number of patients unavailable for social reasons from 17,360 in December last year to 9537 by this September may not be due to a miracle, as Labour's health spokesperson Jackie Baillie surmised, but lies suspiciously far outside normal variation. Given the timing, the most plausible explanation would seem to be that, following the furore over the excessive and inappropriate use of social unavailability in Lothian, there was a hasty revision of procedures elsewhere.

This raises questions about transparency for patients, monitoring of the system and consistency of approach to waiting time targets across the country. Despite the finding that there was no general fiddling of the figures to meet targets, the reports on individual health boards reveal a disturbing level of sub-standard practice, particularly when recording patients as unavailable. The worst instances were in Tayside. The audit found that in 17% of the 367 cases tested, unavailability "appeared to have been systematically applied to prevent patients being reported as not meeting their treatment guarantee date". It is difficult to interpret this as anything other than a blatant manipulation of the lists to ensure the targets were met. Taken together with reports from some staff of being bullied into inappropriate listing of patients as unavailable, a disturbing picture emerges of a culture which prioritised meeting targets above the best interests of patients. Although two members of staff who were suspended in Tayside have been reinstated, it is clear that there needs to be a radical reform of practice there.

Other health board have less serious problems. Nevertheless, the many examples of patients wrongly categorised as unavailable, such as when they have agreed to postpone treatment, must dent public confidence that the reductions in waiting times represent the degree of improvement the figures suggest.

The investigation has revealed some problems with IT systems and staff training. In addressing these, the opportunity to achieve greater consistency between boards should be grasped.

Targets are intended to improve performance. In the case of waiting times they ought to provide a simple way of checking each patient's progress through the referral and treatment timescale but it is apparent that in some cases the focus has been switched from the patient to the target. By scrapping "socially unavailable" as a reason for halting the waiting time and requiring patients to confirm their availability, Mr Neil has taken a step towards a clearer system. But it must be recognised that targets are a means to an end (improving the outcome for patients), not an end in themselves.

Contextual targeting label: 
Health

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