WHEN it comes to waiting times in the NHS, the gulf between what happens on paper and what happens in reality has never been wider.
In theory, 95 per cent of people attending an A&E department should be seen, treated and out the door within four hours - whether that means heading home, getting admitted onto a ward, or transferred to another hospital.
The four-hour benchmark is more than just a tick-box exercise; evidence clearly shows that spending too long in A&E prior to admission is fundamentally associated with an increased risk of avoidable harm and death.
In September, however, the target that achieved with just 69% of patients. Prior to Covid (when attendances fell substantially) it was last met in August 2017.
The number waiting over 12 hours has also gone from 43 in August 2017, to a once-unthinkable 5,296 in September.
Similar patterns are seen for diagnostic tests.
In 2009, the Scottish Government introduced a target stipulating that no patient should wait any longer than six weeks for one of eight key tests, such as CT and MRI scans or a colonoscopy.
This was challenging even before the pandemic but, by the end of June this year, 5,400 patients had been waiting over a year for endoscopy and 6,419 had been waiting over six months for a scan.
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All of which has contributed to the steady deterioration in another target: the standard which specifies than at least 95% of cancer patients must begin treatment within 62 days of an initial "urgent referral with a suspicion of cancer".
No patient can start treatment without a diagnosis, of course, and this is where the main bottlenecks lie - worsened now by increased demand on top of pre-existing staffing shortages.
The 62-day target was last achieved at the end of 2012 - a full decade ago - with the most recent statistics for April to June showing that just76.3% of cancer patients went from referral to treatment within two months.
More positively, the 31-day standard - a separate cancer target stipulating that, once a decision to treat is taken, that treatment must begin within 31 days for at least 95% of eligible patients - has been met consistently since autumn 2019 despite the pandemic pressures.
On the downside, if a patient has already waited too long for diagnosis then the risk is that the cancer is at a more advanced, and less treatable, stage.
All this forms the backdrop to the latest row over the time patients can expect to wait for surgery.
The UK's statistics watchdog this week criticised the "potentially misleading" picture presented by Scotland's new NHS Inform dashboard, created in August to provide patients - as Health Secretary Humza Yousaf put it - "with some reassurance on the possible length of their wait".
The problem for clinicians is that, in many cases, patients were being given a false reassurance.
Chloe Scott, a Lothians-based consultant orthopaedic surgeon, described the figures set out in the dashboard as "pure fantasy".
Colin Howie, the former president of the British Orthopaedic Association, branded them "grossly misleading".
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It's not that the NHS Inform portal is inaccurate; it's just that it doesn't tell the whole story. The refrain "lies, damned lies, and statistics" comes to mind.
What the dashboard does allow patients to do is burrow down into the data for the most recent quarter in order to see how many patients in their health board area underwent a particular type of elective procedure - from orthopaedics to heart surgery - and the "median" time to treatment (a way of presenting averages based on the midpoint in a range of numbers).
As doctors have pointed out, what this does is present waiting times based only on those patients who have completed treatment - not those patients still in the queue.
Currently, the NHS is managing backlogs by splitting patients into priority groups based on urgency.
In April to June this year, 11% of patients on waiting lists were P2 ("treatment should be scheduled within four weeks") but accounted for nearly 46% of elective admissions.
By contrast, P4 patients ("treatment may be safely scheduled after 12 weeks") were 53% of those on waiting lists but less than 19% of admissions.
Of course the most urgent patients must be prioritised, but the effect is to imply to patients in Lothian, for example, that the typical wait for a hip or knee replacement in their region is 19 weeks when, as of June 30, there were 2,009 patients who had been waiting over a year already (including 140 more than two years) - equivalent to 29% of all those on the orthopaedics list.
As Chloe Scott put it: "If urgent people keep being added, the reality is some people or patients will never get to the top of the pile. The only way you can get a joint replacement unless you are urgent is if you pay for it.”
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The situation is also said to have "confused patients and created strife between the patients and the doctors".
"When the patient believes the operation is going to be carried out in 19 weeks, they are extremely upset when they are told it is going to take two years,” said Colin Howie.
Some progress has been made on tackling two-year waits for overall inpatient and day case elective procedures, with 7,650 patients still waiting by the end of September - down from 10,066 in June.
However, it is not quite in keeping with the Scottish Government's pledge that two-year waits would be effectively eradicated by the end of September.
The gap between targets and reality is not new.
Take the 12-week treatment time guarantee (TTG): flagship legislation passed in 2011 which placed a legal requirement on Scotland's health boards to carry out all planned inpatient and day case procedures within 12 weeks.
Yet almost since its inception, the TTG has been missed by an ever wider margin year on year. By February 2020, compliance was just 72% and by June this year, less than 62%.
All too often patients wondering how long they might wait for tests and treatment might be as well asking 'how long is a piece of string?'
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