NHS GRAMPIAN
Management of Waiting Times
Aim
1.1 This paper is submitted to the NHS Grampian Board to:
· inform the Board of the outcome of the recent internal audit of waiting times management;
· seek Board approval of the principles that the Executive Team have applied to the management of waiting times[1] and
· seek approval for an investment programme (requiring both capital and revenue funding) to ensure consistent compliance with the requirements of the Patient Rights (Scotland) Act 2011.
Strategic Context
1.2 A forensic review of NHS Lothian’s waiting times management was undertaken by PricewaterhouseCooper (PwC) during January and February 2012. As a result of this review and subsequent report, the then Cabinet Secretary, Nicola Sturgeon provided assurance to the Scottish Parliament and the public that New Ways Guidance (the NHS Scotland waiting times guidance) was being applied appropriately across every other NHS Board in Scotland. This assurance was followed by an obligation that every NHS Board in Scotland would undertake a "rigorous, specific and detailed internal audit of local waiting times management and processes, including reporting mechanisms."
1.3 The review of waiting times arrangements within NHS Grampian, was carried out by our internal auditors in accordance with the Terms of Reference issued by the Scottish Government Health & Social Care Directorate on 3 May 2012. The findings of the internal audit review are included as Appendix I to this paper.
1.4 The Patients Right Act (Scotland) Act 2011, effective from 1 October 2012, has introduced a number of changes to the management of waiting times, including a Treatment Time Guarantee. This means that there is a legally-binding agreement that in all but a very few exceptional cases, patients should be offered treatment within 12 weeks of that treatment being agreed between them and their treating consultant.
Discussion
Findings of the internal audit of Waiting List Management
1.5 The full internal audit report is attached as Appendix 1. The report was presented by PwC to NHS Grampian’s Audit Committee on 13 November 2012. The methodology, findings and action plan were considered in detail and the Committee was assured that NHS Grampian’s waiting list management was fair and consistent with Scottish Government guidance.
1.6 The overall conclusion of the internal audit review as set out within the Executive Summary of the full report was as follows:
“On the basis of the work performed we found that overall, the waiting times processes and procedures within NHS Grampian were operating in a controlled manner.
Similar to all territorial NHS Boards in Scotland, the waiting times supporting systems within NHS Grampian have not been designed to provide a clear and evidenced audit trail across all aspects of the patient journey. This relates in the main, to the administration of the process and recording of “offers to patients”, rather than clinical decision making.
As such, there is no way of formally verifying the validity of the application of “unavailability” without contacting or asking patients. The process is complex with the majority of interaction (including “offers”) with the patient being made by telephone. This requires NHS staff to interact with the patient and ensure flexibility around making the “reasonable offer(s)” as prescribed in the New Ways Guidance.”
1.7 In response to the internal audit review we emphasised that the arrangements implemented by NHS Grampian have required that patients are involved and have an input into all decisions affecting their pathway of care. In relation to reporting and governance, the findings within the internal audit report also highlighted the consistency of waiting times information presented at a governance, strategic and operational level within NHS Grampian and the transparency with which we presented our performance. The report also confirms that appropriate controls were implemented to ensure that access permissions to our patient management system were granted based on the application of strict criteria.
1.8 The review did however highlight a number of areas where improvements could be made to our processes. The Executive Team accept the internal audit recommendations raised in relation to further enhancing our reporting arrangements and improving the level of detail captured within our patient management system, particularly in relation to the recording of patient contacts and the basis on which reasonable offers are made. The actions have all been progressed since the internal audit report was finalised in line with the management action plan set out within Appendix 2 of the internal audit report.
1.9 Subsequent to the reporting of the internal audit findings the Chief Executive (NHS Scotland) has requested that in order to provide the necessary assurance that all action plans have been successfully implemented on time, a letter of assurance requires to be provided by the Chair of the Audit Committee to the Scottish Government Health and Wellbeing Audit and Risk Committee by April 2013.
1.10 Furthermore, Boards are required to undertake a follow-up audit on the management of waiting times within the next 18 months to ensure that the planned improvements have been made and are working effectively.
NHS Grampian’s principles applied to the management of waiting times
1.11 In the application of New Ways Guidance, NHS Grampian has consistently adhered to strict principles:
· patients will be scheduled according to clinical priority;
· within a given clinical priority, all patients will be booked in turn;
· wherever possible and where clinically appropriate, patients will be offered treatment within Grampian;
· children will not be offered treatment outwith Grampian unless they require specialist care that cannot be provided locally;
· where patients wish to wait rather than be treated outwith Grampian, they will be treated in turn and at the earliest available opportunity; and
· waiting list management will ensure best value for the public and fairness for all staff – eg wherever possible, patients will be offered treatment in NHS facilities rather than private facilities and NHS Grampian will not utilise waiting list initiative arrangements (whereby consultants are contractually required to be paid treble time for undertaking waiting list work, whilst other staff groups are paid time plus a third)
1.12 The application of these principles does make it logistically more difficult to manage the waiting list, but this is a consequence that we believe is far outweighed by the benefits of delivering access to patient care on a fair and equitable basis and with reference to each patient’s clinical needs.
Investment in capacity to deliver on the Treatment Time Guarantee
1.13 As mentioned previously, the Patients Right Act (Scotland) Act 2011 introduces a legal requirement to offer patients treatment within 12 weeks. Demand and capacity modelling has demonstrated that there is a mismatch between the demand and current capacity to deliver this. This mismatch is in terms of both clinical teams and operating theatre capacity. Substantial investment in planned care services is therefore required primarily in increasing our surgical operative capacity at Aberdeen Royal Infirmary (ARI) and Woodend Hospital.
1.14 A review of our demand and capacity requirements has been undertaken and confirmed a requirement for an additional three theatres i.e. two at ARI and one at Woodend Hospital.
1.15 The need for this increase in capacity has been accepted by the Scottish Government and prompt action has been taken to develop plans to provide the capacity as soon as is practicable.
Aberdeen Royal Infirmary (ARI) – capital investment
1.16 The proposals for the two new theatres at ARI are set out in the attached Standard Business Case (SBC). This is the result of an appraisal of a range of options involving managers and clinicians. The SBC recommends a preferred option at a total capital cost of £4.968m.
1.17 The new ARI theatres will be located within the existing theatres suite by making use of an existing courtyard together with some internal re-organisation. There have been discussions with UCAN, the urological cancer charity, and the new theatres will be configured to provide robotic surgery should a decision be made by the Scottish Government to permit this new technology at a later date.
1.18 Subject to formal approval it is expected that the ARI theatres will be operational in December 2013. The SBC for the ARI theatres has been approved by the Asset Management Group and is submitted to the Board for approval prior to formal submission to the Scottish Government for final approval.
Woodend Hospital – capital investment
1.19 The plans for the additional theatre at Woodend are being developed rapidly and it is likely that the way forward will be to develop a modular solution in the courtyard adjacent to the existing theatre suite at a capital cost of c£2.85m.
1.20 The benefits of this approach include fast construction and the potential for revenue savings arising from the replacement of an existing leased theatre with a NHS Grampian facility.
1.21 There is a focus on providing this additional capacity as soon as possible to minimise the need to use external providers to treat patients in line with the requirements of the Treatment Time Guarantee. As the cost is within NHS Grampian’s decision making limit of £3m, delegated authority is sought from the Board to permit the Asset Management Group to approve the proposals for implementation as soon as they are finalised. Subject to this approval being granted within the next 2-3 weeks it is expected that the new facilities could be operational by October 2013, with construction being undertaken using an existing framework contract.
Assumptions within our financial plans
1.22 In terms of the capital investment of £7.818m we have secured an additional capital allocation of £4m from the Scottish Government towards the cost of the theatre construction. The construction of the modular theatres at Woodend Theatre will provide a revenue benefit of c£600,000 per annum enabling the discontinuation of the current lease theatre and preventing the requirement for an additional lease theatre to meet capacity requirements.
1.23 In addition to the capital investment, the establishment of additional consultant and nursing capacity and associated services and costs will require the Board to commit up to £8.0m of revenue on a recurring basis. Within our financial plans we have been able to identify £6.5m of revenue to invest in additional capacity, largely from the additional NRAC allocation that the Board will receive in 2013/14. Discussions are ongoing with the Scottish Government regarding support to fund the remaining £1.5m necessary to address aspects of our demand / capacity gap.
1.24 A summary of the revenue investment is presented below:
Aberdeen Royal Infirmary
Consultants / 6wte / £750,000Anaesthetists / 5wte / £625,000
Nursing and ancillary staff / 19.9wte / £621,000
Supply costs / £2,200,000
Clinical support services / £250,000
Facilities and capital charges / £310,000
Recovery beds / £125,000
Other / £100,000
Total / £4,981,000
Woodend Hospital
Consultants (Orthopaedic) / 4wte / £500,000Anaesthetists / 2.5wte / £313,000
Nursing and ancillary staff / £433,000
Supply costs / £1,300,000
Clinical support services / £250,000
Facilities and capital charges / £168,000
Other / £68,000
Total / £3,032,000
Key Risk
1.25 In the absence of investment in planned care demand and capacity, the Board will
not be in a position to implement a sustainable plan to ensure that patients can be treated within the requirements of the Treatment Time Guarantee in accordance with the principles set out in this paper.
Recommendations
1.25 The Grampian NHS Board is asked to:
· Note the internal audit report on waiting list management, the management actions and the requirement for a letter of assurance from the Audit Committee that all actions have been implemented;
· Review and endorse the NHS Grampian principles applied to waiting time management; and
· Approve the investment plan (both capital and revenue) that will allow full compliance with the Treatment Time Guarantee
· Delegate authority to the Asset Management Group to approve the proposals for Woodend theatres up to a value of £3m.
Executive Leads
Pauline Strachan, Chief Operating Officer
Alan Gray, Director of Finance.
Graeme Smith, Director of Modernisation
29 January 2013
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[1] The Board has previously approved the Access Policy at the December 2012 meeting. The policy sets out the framework used to govern the management of waiting times within NHS Grampian