WHEN Karen was referred to an NHS physiotherapist for help with painful joint disease, she was told it would take around four weeks to get an appointment.
But the 36-year-old from Glasgow, who did not want to use her real name, ended up waiting for four months, during which time she felt her conditions – osteoarthritis and joint hypermobility syndrome – were getting worse.
She said: “My GP wouldn’t consider altering my medication until I had seen the physiotherapist. In the end they couldn’t do anything for me anyway. I think the service the NHS provides is really good, but waiting times is the biggest issue.”
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She is far from alone – earlier this month it was revealed around 50,000 patients are queuing for NHS physiotherapy in Scotland. Latest figures show only 53.2% of patients are being seen for their initial appointment within four weeks, compared to the expected 90%.
In other areas of the NHS, there is a picture of a service which is increasingly under pressure. The percentage of outpatients who waited less than the target time of 12 weeks for treatment fell from 86.1% in September 2015 to 78.7% in September 2016.
For inpatients undergoing procedures requiring surgery or a hospital stay, 88.9% were seen within 12 weeks in September 2016 – compared to 94.6% at the same time the previous year.
Other targets include 95% of cancer patients urgently referred with suspected cancer waiting a maximum of 62 days for first treatment. The latest figures show this was standing at 87.1% in July to September last year.
But behind the headlines over missed targets and NHS failures, what do waiting times statistics really tell us about the performance of Scotland’s NHS – and what needs to be done to improve it?
Professor David Galloway, president of the Royal College of Physicians and Surgeons of Glasgow, said recent figures indicated a fall in performance in Scotland – and elsewhere in the UK.
He said: “There is no doubt that one conclusion we can draw is we have a significant problem – that has been recognised for the last two or three months or perhaps more. You could argue it is more important perhaps to make sure you get the correct treatment in a reasonably timely fashion and a good outcome, even if having to wait a little bit longer.
“It [waiting times] is nevertheless a bit of proxy for just how efficiently the system is actually working.”
Galloway said there had been a drive over the past couple of decades for greater efficiencies in the health service and for people to spend less time staying in hospital – resulting in cutting of hundreds of hospital beds for specialist care of the elderly for example.
But he said that this, combined with a boom in the elderly population had now led to the NHS being placed under enormous pressure.
“It is inevitable it will get worse if nothing changes,” he said. “Is the health service sustainable for the future? It is creaking right now.”
The issue of NHS performance is inevitably often a political football. Scottish Conservative health spokesman Donald Cameron said waiting time figures painted a picture of an NHS in crisis and called for the SNP to put in place a “long overdue” sustainable workforce strategy.
Alison Johnstone, health spokeswoman for the Scottish Greens, also called for an urgent tackling of recruitment issues and the need to address staffing shortages in social care, nursing, midwifery and consultant specialities.
Scottish Labour health spokesman Anas Sarwar accused the SNP of “short-term gimmicks” on the health service, rather than planning for the long-term.
The image of an NHS in crisis which usually sparks the most headlines is that of the A&E department, with patients queuing for hours or being left on trolleys triggering outrage.
Latest statistics show in December 2016, 92.6% of patients were seen and admitted, transferred or discharged within four hours in emergency departments across Scotland – compared to a target of 95%. The figure has fallen since December 2015, when the figure was 94.9%.
But this compares favourably with elsewhere in the UK – the figure for England in the same month was 86.2%, for Wales 81% and for Northern Ireland 69.9%.
Dr Martin McKechnie, vice-president Scotland for the Royal College of Emergency Medicine, said emergency departments north of the border had been given more resources by the Scottish Government in the past few years, with a significant increase in the number of A&E consultants.
But he said improvements which had been made in A&E were now under pressure because of difficulties stemming from "exit block" – the flow of patient through the hospital – with delays in discharging patients from hospitals leading to fewer beds being available.
“The median time for everything to be done from the most severely traumatised and injured patients to the most minor of cases is two hours 10 minutes,” he said. “If there is no exit block, we can bring that time down even further.
“We need the rest of the system downstream from us to gear up a little bit more to get patients through the ward system and discharged back into social care.”
Theresa Fyffe, director of the Royal College of Nursing Scotland, said providing the right level of care for people in the community – delivered by staff such as district nurses and physiotherapists – was a key area of concern, which would also prevent patients with chronic conditions becoming unwell and having to be admitted to hospital.
While in the past, for example, a patient with a respiratory condition may have been admitted to hospital for antibiotic or oxygen treatment, now they are more likely to be able to stay at home and be visited by a specialist team.
But Fyffe said while there was a clear policy towards providing more care in the community rather than in hospitals, there was a question over whether sufficient funds were being invested in this area – often the first to be targeted by council and NHS bodies when budgets are tight.
“If those resources aren’t there then patients will end up being admitted to hospital, which in turn puts pressure on beds and in turn puts pressure on planned care,” she said.
“One of my frustrations at the moment is ensuring we appropriately fund community and primary care.”
She pointed out other steps were being taken by the Scottish Government to relieve pressures on hospitals, such as plans to set up specialist elective treatment centres to perform only certain types of operations such as hip and cataract surgery. This means these operations will not be cancelled as a result of emergency cases, as can happen in hospitals.
But she added: “We have to make sure we have the right workforce capacity in place for setting up the new centres.”
Dr Peter Bennie, chair of the British Medical Association (BMA) Scotland, said the impact of austerity since 2010 had added a “double shock” to the health service – both because of tightening budgets and the negative impact on the health of the population.
“To some extent I have at least some sympathy with the Scottish Government on that, because the budget is set by the Barnett consequentials," he said. "But I would be looking for more in the way of flexibly in trying to address that and trying to find extra funding.
"My least favourite soundbite from government every time we have this discussion is that we have more doctors and nurses than ever before. The point is we don’t have sufficient staff to do the job properly just now, because the demand is increasing year on year and the population is getting older."
Bennie said waiting time targets were important, but questioned if focusing on them "to the exclusion of everything else” was the best way to assess how the NHS is performing.
“There is no getting away from it, there is quite a political focus on waiting times, especially the four-hour target in A&E,” he said. “You almost boil down the entire performance of the health service as to whether you have got 94% or 96% waiting to be seen within four hours – and that is not the best way of looking at the health service.”
A review of NHS targets was set up by the Scottish Government last year, with an expert group headed by former Chief Medical Officer for Scotland Sir Harry Burns expected to report their findings in the next few months.
Burns said he could not comment on any findings of the review yet, but he believes there is a need to use targets more for “improvement than judgement”.
“If you have a hard-edged target like 95% of people should be out of an A&E department within four hours, then what tends to happen is at three hours and 58 minutes all hell breaks loose,” he said. “The idea of using information for improvement is that if you reach 90% of the target, that means 90% of people are successfully being managed within it – so why don’t you look at what you are doing with them and change the process?”
Health minister Shona Robison said the NHS is performing well – but admitted there is “scope for further improvements”.
She said targets had an important place in the NHS and there were certain standards – such as the four-hour A&E target and timely access to cancer treatment, which patients had the right to expect.
She added: “Our A&Es consistently out-perform those in England, Wales and Northern Ireland, but we want to go further and continue to improve performance in Scotland.
“This year territorial NHS boards are receiving an average increase in funding of 5.5% – an increase of over £475 million in this year alone – and overall health spending is rising to a record of almost £13 billion this year. This investment has ensured that staffing levels in the NHS in Scotland are now at record high levels.
“Our £200 million investment in six new elective treatment centres will allow also people to be treated more quickly for planned surgery and the facilities will help the NHS meet increasing demand from a growing elderly population.”
For patients like Karen, a mother-of-three, the only concern is getting access to treatment when needed. “People like myself are left in chronic pain when you are waiting for an appointment,” she said. “When you are not able to do the stuff of everyday life, you feel like it is affecting your children’s lives as well as your own.”