NHS Lothian patients punished for doctors’ delays

NHS Lothian deviates from Scottish Government recommendations by stating that patients should wait for up to the length of an entire clinic to be seen. Picture: Colin Hattersley

NHS Lothian deviates from Scottish Government recommendations by stating that patients should wait for up to the length of an entire clinic to be seen. Picture: Colin Hattersley

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LOTHIAN health bosses are booting patients to the back of the appointments queue – if they are forced to leave late-running clinics before being seen.

The step means outpatients who have waited as long as three months for a consultation could face potentially serious delays to their treatment.

NHS Lothian is believed to be the only health board in Scotland to deviate from national guidance, which states patients should not be punished if they are unable to attend appointments through no fault of their own due to doctors running behind schedule.

The revelations are sure to heap fresh pressure on NHS Lothian over its management of waiting lists – after it was previously slammed for listing patients as “unavailable” to meet government waiting list targets.

Last night Jackson Carlaw, a senior MSP and Scottish Conservative health spokesman, said: “Why do bosses there think they can deviate from Scottish Government policy to make statistics look better?”

The move, revealed in a document obtained by the Evening News under Freedom of Information legislation, could hit parents who are forced to abandon late outpatient appointments because of childcare commitments and workers who need to get back to their jobs.

The regional rules state that patients should wait for up to the length of an entire clinic – several hours – or face being put to the back of the line and another three-month wait for a new slot. If patients are recorded as cancelling themselves, it means they go to the back of the queue and will not be classed as breaching strict targets for another 12 weeks.

The prospect of delays has raised fears that patients could be left to suffer in pain or that life-threatening conditions could go undiagnosed.

The Scottish Government today hit out at the NHS Lothian position, which was introduced in 2012 but is now set to be formally adopted by the health board, saying its own rules should be followed.

The NHS Lothian stance also sparked unease from the British Medical Association (BMA), MSPs and patients’ representatives, although the health board defended itself, saying the Government guidance says “local judgement is necessary”.

Some even went as far as to accuse NHS Lothian of a cynical attempt to improve statistics by changing rules, two years after the health board was found to be deliberately fiddling waiting list figures.

NHS Lothian countered by saying only 49 patients – out of half a million – had been recorded as attending a clinic but “could not wait” since October 2011.

However, senior sources within the health board branded the claim “ridiculous”.

Outraged Mr Carlaw added: “NHS Lothian has just put one waiting list scandal behind it – now it seems intent on creating another.

“Patients will be rightly furious at this revelation. Why should they have to pay the price for a clinic running behind schedule? Even without the previous massaging of waiting lists this would be disgraceful. But bearing the past in mind points to an even more worrying approach.”

In an internal NHS Lothian audit report, which marked the health board “satisfactory” in its waiting times arrangements, it states that the “differences in practice from national guidance require to be documented in the Local Access Policy”, which was last reviewed in May last year.

According to the document, these include that “patients who leave clinics that are running late before attending appointments are deemed to have cancelled”.

A senior medical source at NHS Lothian said that waits of an hour or more beyond appointment times were common across departments and that the move was “an obvious way of attempting to massage the figures”.

They added: “The vast majority of patients accept it and are kept up to date but some do leave. Often young mothers have to pick up children, while at the Royal Infirmary, where you have to pay for parking and the meter’s running up, some feel they have to leave through financial disadvantage. People do get fed up, angry and walk out.

“Clinics can last for up to four hours, so they are defining it as appropriate for patients to be kept up to that time. That’s unreasonable.”

A spokeswoman for the Scottish Government insisted that its guidance, issued to all boards, “should be followed”.

She added: “If clinics do run slightly late, patients should be informed of this on arrival and if possible, the appointment fulfilled. However, if a patient cannot wait as they have to collect children from school or are due at work, then our national guidance is very clear that we would expect the board to agree an alternative appointment with the patient.

“If a clinic is running significantly late then patients should be informed and alternative appointments provided.”

The Scottish Government guidance says that if a patient has arrived for an appointment but cannot wait, handling of the situation should depend on “whether it is a patient or service-induced situation”.

If the delay is “much longer than a patient could reasonably be expected to wait” then the rules say appointments should be defined as “cancelled by service”, with the patients being promptly offered a fresh date.

A patient leaving a clinic should only be put to the back of the queue if they are given information on the delay but are “not willing to wait even a short length of time”, according to the guidelines.

However, Lothian health chiefs have chosen to define the “reasonable” period as the length of the entire clinic, meaning that the patient will be deemed to have cancelled themselves even if they leave after being told they face sitting in a waiting room for several hours.

NHS Lothian sources insisted that local teams were able to apply discretion, if a patient is unable to wait in a late-running clinic for good reasons, however the board’s policy is expected to be updated imminently to set out NHS Lothian differences from the national position.

Labour Lothians MSP and shadow health secretary Neil Findlay said “a bit of give and take” was required. He added: “I’d like to think that common sense will prevail.”

The BMA warned that hitting targets must not be put before patients. A spokeswoman said: “We recognise the need for waiting time targets, but believe that these should always be clinically focused and not politically motivated.”

Jim Crombie, NHS Lothian’s director of scheduled care, said that the national guidance in the area indicated “that local judgement is necessary”.

He added: “In order to ensure consistency across services, we have provided advice to staff that if a patient leaves before the end of the clinic session that this will be considered a patient cancellation.

“Our staff are asked to ensure that patients are kept informed of any delays and given information on how long they might have to wait. If the clinic delay is significant then these individual circumstances will be taken into account.

“As part of our response to the internal audit we have identified that since October 2011, 49 patients have been recorded as being unable to wait. Of these, 41 were considered to have experienced a reasonable delay. Only one patient in the last six months has been recorded as having experienced an unreasonable delay and may have been affected by our lack of clarity in this area.”

Analysis

By Dr Jean Turner Director of the Scotland Patient Association

There are obviously pressures on clinics. Generally, I don’t think there are enough staff to run them. They can run behind schedule for all sorts of reasons, because a patient needs more attention than expected, or because a member of staff is sick.

Some of these people may have waited ages for an appointment, then they may have taken time off work and have limited time before they need to get back. Or they might have a child they need to pick up or an elderly relative

they need to look after.

If you have one of these appointments you’re rarely seen bang on time, and most people are willing to wait. If someone walks out after an hour because they can’t be bothered that’s one thing, but if they have another appointment and desperately need to get away, I think it’s wrong that they’re put to the bottom of the list. They should be given another reasonable appointment before they leave the premises.

No-one should go to the end of the queue unless they’ve been unreasonable.

The truth is you never know what a person will present with, even if they’ve been seen before. The GP will have seen fit to send people for these appointments. You could be putting someone who has cancer or a heart condition back by months.

I would like to know what [health secretary] Alex Neil thinks of this. I think the government guidelines should be followed. It seems that they’re trying to make

their statistics look good.

This type of thing isn’t satisfying for staff who are trying to treat patients. I imagine this is the type of thing management would come up with.

Private teams called in

HITTING a 12-week target for seeing outpatients is among the most challenging targets NHS Lothian faces.

After the waiting times scandal emerged, it was revealed that more than 4000 patients were waiting beyond the period for appointments by April 2012, with the figure rising to over 5000 by July that year.

After substantial investment by NHS Lothian, the figure was brought down to a little over 2000. However issues over a “nightmare” summer, including holiday leave, saw the number waiting beyond the target spiral once again to more than 4500 by August last year.

The latest public figures, from the end of October, show that in NHS Lothian 4335 people had waited too long for an outpatient appointment.

Patients with eye conditions can expect the longest waits, with 704 ophthalmology patients having their target breached.

Health chiefs have admitted that the Princess Alexandra Eye Pavilion has been left struggling to cope and that the facility is no longer fit for purpose. Private teams have been called in to treat patients. The picture is little better in rheumatology, with serious issues also being reported in colorectal and general surgery, gastroenterology, the Dental Institute, clinical neurosciences and pain management.

Health board chief executive Tim Davison admitted recently that progress in the area had been frustratingly slow.

He said: “Generally, we’ve undertaken enormous effort and made really good progress in three of four areas [inpatients, cancer and endoscopy] but outpatients particularly remains a huge challenge.

“It’s like you fix the problem here, and another one pops up over there. It’s relentless.”

NHS Lothian, which has responsibility for 800,000 patients, said it runs approximately 75,000 outpatients clinics every year.

A new health boss, Jim Crombie, was recently hired to solve the issue.