A clean bill of health?

Hardly. Audit Scotland's report on the management of NHS waiting times is far from a glowing exoneration. Much of the controversy over waiting times over the last year has centred on the use of social unavailability codes, entered onto NHS computers to explain why patients were not available for treatment.

According to Audit Scotland, the percentage of people waiting for in-patient treatment given such a code rose from 11% in 2008 to just over 30% at the end of June 2011, but started to drop in most NHS boards in late 2011; at the same time the percentage of patients waiting longer than 12 weeks started to rise.

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What happened at the end of 2011 that could help explain this change? Only the NHS Lothian waiting times manipulation scandal, when the board was found to have wrongly used the codes to help meet waiting times targets. Could it be that other boards were using the codes wrongly too and hurriedly stopped doing so when the Lothian scandal broke? Audit Scotland was not in a position to deduce as much, thanks to the shortcomings of the waiting list management systems, saying the reasons were unclear, but there are grounds for suspicion.

Anyone reading the report is left with worrying doubts about just how fairly patients are being treated. What is clear is that it is simply not possible for Audit Scotland or anyone else properly to police how waiting lists are being managed.

Against that backdrop, the relentless positivity of the Health Minister Alex Neil is inappropriate. A lack of clear evidence of manipulation does not mean there are no grounds for concern; far from it. Audit Scotland's report demands improvements; to restore public trust, the Scottish Government must ensure enough is being done to reform the system. Yes, some action is being taken, but Audit Scotland makes clear that recently updated guidance from the Scottish Government does not address all the risks. Insisting that all is well will not wash.

This is not merely an issue about administrative systems, but about the culture that exists within the NHS. Westminster Health Secretary Jeremy Hunt spoke last week in the wake of the Mid Staffordshire crisis about "defensiveness" within the NHS in England and the importance of creating an atmosphere in which staff felt able to raise concerns. The NHS in Scotland is not immune to such a culture developing, or one where the pursuit of targets overrides other considerations. In December, an internal audit by NHS Tayside found staff spoke of "inappropriate behaviour including pressure on them to use unavailability to prevent breaches", echoing claims about what had happened at NHS Lothian. This cannot be tolerated.

Clearly it is primarily the responsibility of health boards to provide positive leadership and create an atmosphere in which problems can be raised and quickly addressed without rancour. Patient care must always be paramount. Yet problems such as the NHS Lothian scandal have not arisen in a vacuum; they have developed as a consequence of political pressure on boards to meet waiting times targets and at a time when the NHS budget in Scotland is going down in real terms. It is good news that the Government is to pilot a national confidential phone line for whistleblowers, but that is not enough. Patients need to feel confident the Government is not complacent and the culture which led to the manipulation of waiting times is being reformed, along with the management systems.