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Robert Black

Theresa Fyffe of RCN Scotland

Theresa Fyffe of RCN Scotland

Nursing leaders have warned that further changes to NHS pensions, on top of a proposed pay freeze and job losses would be “a step too far”.

Speaking as an Audit Scotland report revealed that public sector pensions cost £3 billion per year, RCN Scotland director Theresa Fyffe said that the impact of changes already agreed should be monitored first.

In its report on the cost of public sector pensions in Scotland, published today, Audit Scotland says that the Scottish Government and councils will need to implement changes in Scotland to ensure that pensions are fair and affordable in the future.

Currently, public bodies – or the tax-payer – pay £2.2 billion per year, while employees pay around £810 million towards the cost of providing pensions.
The report looks at Scotland’s six main public pension schemes, which cover around a million people (including those already receiving pensions and those who have yet to retire.

It comes ahead of the report next month of the independent review of public pensions across the UK. Chaired by former Labour minister Lord Hutton, this is expected to suggest options which would lead to employees having to bear more of the brunt of the cost.

On average, employees’ contributions cover around a quarter of total pension costs and vary between 1.5 per cent and 11 per cent of pay. Public sector employers pay the largest share with contribution rates ranging from 11.5 per cent to almost 25 per cent of pay. Although higher contributions tend to reflect higher benefits in some schemes, the Audit Scotland report says there appears to be no clear reason for these variations.

Pensions are earned according to pay and length of service. The average annual pensions (excluding lump sums) range from £4,222 in the civil service scheme to £15,674 in the police scheme.

Ms Fyffe said that the report “explodes the myth about gold-plated public sector pensions” because the average annual pension for people who worked in the NHS in Scotland is £7,057.

“Indeed, most retired nurses receive even less because women who worked in the NHS receive an average of only £5,098. 90% of nurses in NHS Scotland are women,” she added.

“Our members understand the pressures on public sector pensions resulting from our ageing population and we have previously supported changes to the NHS pension. This included an increase in contributions to the scheme, progressive increases for higher earners, an increase in pensionable age for new entrants and protection for the tax-payer against increased liabilities.

“There is no need to make any further changes to the NHS pension at this stage: the impact of the changes already agreed should be monitored instead.

“Pensions reform has featured heavily in UK public debate in recent months, but any further changes to pensions, on top of the proposed pay freeze and increased workloads as staff numbers are cut, would be a step too far.”

But watchdogs suggested action was needed. Robert Black, Scotland’s Auditor General,said: “Pensions are a large and important part of public sector pay – one in five Scottish people have or will get a public sector pension and it costs the Scottish public sector £2.2 billion a year to support the six major public schemes. With major UK-wide pension reforms imminent, the Scottish Government should look at the differences between the country’s schemes, and consider how to implement changes that will be both fair and affordable in the long term.”

John Baillie, the chairman of the Accounts Commission for Scotland, pointed out that councils were facing escalating pension costs.

“Over the past five years employers’ contributions to the scheme have increased by 25 per cent in real terms to £836 million a year. Scotland’s councils should now decide on the extent and pace of further reform to ensure the scheme stays sustainable. This includes considering how to share the increasing costs of pensions most fairly with employees.”

NHS Scotland logoScotland’s NHS is facing the worst financial pressure since devolution, according to watchdogs.

In a report published today, Audit Scotland forecasts trouble ahead, with NHS bodies forced to find significantly more financial savings to deliver the same level of quality provided in previous years.

In its overview of NHS Scotland’s finances for 2009/10, the organisation congratulates health boards for a good financial performance, with all ending the year within budget.

But the Auditor General, Robert Black, added: “They have had to find significant savings to balance their budgets and will need to find even more to continue to do so.

“While the NHS budget will rise in 2011/12, this will be a far smaller increase than in previous years and is likely to be outstripped by rises in demand and cost pressures.”

He said the NHS was taking action to meet the longer term financial challenges, which include increased demand from patients, and rising costs of fuel, drugs and staff pay.

“For [the action] to be successful, it needs good workforce planning, better information on costs, quality and activity, close partnership working and sound leadership.”

Nicola Sturgeon, the health secretary, said the report “recognises the excellent financial performance on the NHS” and pointed out that the health service had exceeded the government’s two per cent efficiency target.

“It is clear the pressure on NHS finances will continue to increase but I am confident that the health service is prepared for the challenges ahead. We will work with health boards to eliminate waste and encourage modernisation programmes to increase productivity and efficiency gains, while enhancing the quality of care.”

Unions and opposition politicians were less impressed, however. Labour, the Lib Dems and Tories all called for savings realised through efficiencies to be directed at frontline services. And Theresa Fyffe, director of RCN Scotland, said the report backed up the union’s own findings on the financial pressures facing boards.

“With demand for health services growing and healthcare costs increasing, the NHS is far from protected from the cuts that the wider public sector is now grappling with,” she said. “This is particularly so as the NHS may end up providing healthcare for the people who need more support as a result of cuts by local authorities. However, if health boards keep cutting away at staff numbers to deal with these pressures, there could be serious and costly repercussions for patient care in the future.”

Brian Keighley, chairman of the BMA in Scotland, said that making indiscriminate cuts was short-sighted and that the government should plan to make savings. “Plans so far have included cutting nursing staff numbers, imposing a recruitment freeze and attempts to undermine the terms and conditions of NHS doctors,” he said. “These may deliver a quick reduction in financial spending but they are not the long term solution. There are areas where there is a genuine need to examine ways of working and service delivery to ensure that they are delivered in the most cost effective manner – without affecting the quality of patient care. Government can only do this if they work in partnership with the profession.”

Audit Scotland points out that funding increases for the NHS in Scotland are slowing compared with recent years. Between 2001/02 and 2009/10 NHS spending rose by 38 per cent in real terms. The increase between 2009/10 and 2010/11 was 2.6 per cent and the proposed 2011/12 budget of £11.4 billion will be up just 1.7 per cent on the current financial year.

Photo by: London Vision Clinic

Photo by: London Vision Clinic

By Stuart Crawford

We’re pretty good at doing ourselves down, we Scots are, so it’s high time we actually acknowledged one of the things we’re pretty good at for a change. And it concerns health too.

The “sick man of Europe” description is, sadly, all too accurate in some areas of healthcare north of the Border, although things are improving. But when it comes to looking after our eyes we’re way ahead of the game. In fact, Scotland has an eye health system which is probably, without exaggeration, a world leader.

How did this come about? How can it be that, in the land where fatties, alkies and smokers reign supreme, we’re pretty good at looking after our eyesight, and more besides?

Politically, we have to thank the Liberal Democrats. Yes, I know, but bear with me. Back in 2003, when the party was drawing up its wish list for another four year term in office in the Scottish Parliament in coalition with the Labour party, it put “free eye tests for all” in its election manifesto. By this it meant that the NHS sight test, which essentially told you whether you needed glasses or not, should be extended as a free benefit to those who paid for it, as well as continuing to be free to those who didn’t.

The Association of Optometrists were quick off the mark to contact the Lib Dems and tell them there were better ways to spend the additional money this would undoubtedly cost. At risk groups, the poor, unemployed, and those with chronic eye health conditions would be better recipients of the additional funding, it argued. With typical Lib Dem sang-froid, the reply was “Why not do both?”

Within the optometric profession the baton then passed to the newly formed umbrella organisation Optometry Scotland which, by dint of its enthusiasm and energetic lobbying of the Scottish Executive, renegotiated the contract between the profession and the NHS in Scotland, resulting in the much more comprehensive eye examination replacing the old sight test.

The new eye examination was introduced in Scotland in April 2006, delivering a universally free and comprehensive community based eye care service. It signified a step change in the delivery of eye care, putting in place a regime which is the envy of many other countries both within and outwith the UK. Scotland could, with some justification, claim to lead the world.

Now, sadly, this is under threat from the public spending squeeze which will, as sure as night follows day, be imposed after the Comprehensive Spending Review is published on October 20th. The Scottish Government’s own review will be published thereafter, and it is likely to make grim reading.

The threat to free universal benefits, including free eye examinations, was first flagged up by Scotland’s Auditor General, Robert Black, in the second half of 2009. It raised its head again in the more recent Independent Budget Review Panel Report – the “Beveridge Report” – which stated very plainly:
“The principle of universality in the delivery of many of our public services, such as concessionary travel, prescription charges, eye examinations, free personal and nursing care and tuition fees is commendable, but simply may no longer be affordable. A debate needs to be had on whether those who can afford to pay might be invited to do so, thus allowing better targeting of those in most need.”

That debate is now under way. However, it’s not at all clear exactly how much money might be saved if some, or all, of these free universal benefits were withdrawn from those who can afford to pay, ie in sweepingly general terms those between the ages of 18-59 in employment without chronic health conditions or other disabilities.

For example, it seems to be accepted wisdom in the health commentariat that the stepped abolition of prescription charges will be probably be arrested where it currently lies, at £3 per prescription. Not continuing the motion and abolishing charges altogether will save roughly £25 million, hardly a huge amount. With the free eye examinations, there is a wide disparity in the claims for potential savings; the Auditor General suggested £91 million; a back of the fag packet calculation indicates that between £15-£20 million is probably a more realistic estimate.

What we should acknowledge, though, is that, unlike most of the other universal benefits, the current free eye examination is actually a classic example of “spend to save”. Those assessments of potential savings which could be accrued in the short term are misleading. For a start, the eye examination is carried out in the main by optometrists based in local communities, thereby shifting the balance of care from secondary care in hospitals. The cost to the NHS for an examination by a local optometrist varies between £21.50 and £45 depending on the clinical circumstances. This compares very favourably with the cost of the same examination carried out by a hospital ophthalmologist, which is in the region of £120.

Second, and perhaps most importantly, is that because of the much more comprehensive nature of the examination – it is a health examination, not just an eye test – it allows early detection of eye and general health disorders, thereby introducing a vital element of preventative care. In particular, by detecting the onset of sight threatening conditions like glaucoma and age related macular degeneration early, it can help eliminate avoidable blindness. Permanent visual loss is estimated to cost the country between £300,000 – £500,000 per individual over their lifetimes, a significant amount.

Finally, the free eye examination brings with it a whole host of less tangible or measurable benefits; because it is free, it encourages everyone to participate, including those who previously thought they couldn’t afford it. It avoids the potential stigma of means testing, and encourages those who would not, or could not, attend for hospital appointments to get treatment locally. And it forms the basis for further innovations, like electronic referrals, which will enhance the service throughout Scotland.

To cut back on the free eye examination, therefore, just as it is proving its worth and potential, is clearly a case of false economy. A small saving now may well lead directly to substantial expenditure in the future, an intellectual incoherence which does not stand serious scrutiny.

Will the Scottish Government see sense and preserve the eye examination status quo? It should do, but sadly much may depend on how politically “sexy” it is perceived to be compared to the other universal benefits in the firing line. Informed political commentators regard tampering with free care for the elderly as electorally suicidal. And we have already discussed how the reduction in prescription charges has probably gone as far as it can for the moment.

But will the eye examination be seen as a safer target for savings, politically, than dental checks or free bus passes for the elderly. Will it be, figuratively speaking, above the red line?

We will know the answers pretty soon. But it would be a shame to undo what has been done just as it is showing its true value to the nation.

A nurse holding a syringeDoctors’ leaders have described as “scandalous” reports that patients are sometimes admitted to hospital inappropriately to avoid breaching A&E waiting times.

According to an Audit Scotland report, published today, hospital emergency departments are under pressure to deliver on the four-hour waiting target, and staff question its sustainability, particularly in winter, when it is often missed.

“Over 55 per cent of staff feel that patients are sometimes inappropriately admitted to hospital to avoid breaching the standard and only 13 per cent of staff who responded agreed that ‘there are no trolley waits in the emergency department’,” the report says.

The report paints a picture of Scotland’s emergency departments struggling to cope under increasing demands and pressures.

It singles out staffing as a problem, warning that shortages in junior doctors must be tackled at a national level, says that services vary from department to department and that there are information gaps which are hampering efforts to understand and improve services.

The report also questions whether resources are being used effectively, revealing that over £2 million per year is wasted on patients who are brought to A&E departments by ambulance, but then leave without treatment.

On the positive side, however, the report, called Emergency Departments, finds that patients are, on the whole, satisfied with the care they receive, with four out of five saying it was excellent or very good.

Demand on emergency departments is rising, the report says: in 2008-09, there were 1.4 million attendances, a rise of nine per cent over a decade; the cost of emergency departments in this year was £148 million.

But attempts to reduce attendances have not been based on evidence of what works or how much it would cost to have patients treated in another setting, such as a minor injuries clinic, where appropriate.

Auditor General Robert Black said there was a real need for a clear national approach to emergency care to get the best out of resources available. “Patients are happy with the care they receive and the length of time they wait to be treated has reduced with the introduction of a four-hour target,” he said.

“However, information about the quality and effectiveness of care provided is limited, for example there is little information about the medical condition of patients attending emergency departments. The services available for vulnerable groups, including people with a mental health problem, vary across Scotland.”

Brian Keighley, the BMA Scotland chairman, said the report highlighted a number of issues that must be addressed, including the reasons why demand for services is increasing “at a time when the general health of the population is improving”.

He disputed suggestions that the new consultant contract and European Working Time Directive (which puts a limit on doctors’ hours) were to blame for staffing difficulties, pointing the finger instead at failure to take tough decisions on rationalising services.

“The NHS had more than 10 years to prepare for the implementation of the working time regulations and it is a failure to effectively plan for changing working patterns that is the problem. There is also a reluctance to make difficult decisions on health service reconfiguration and it may be that in some cases consideration will have to be given to service redesign for emergency departments in parts of Scotland, to ensure that services are fully staffed and safe for patients,” he said.

This last point may have particular resonance for the SNP government, which, in one of its first acts since coming to power, reversed decisions to close A&E departments at Ayr and Monklands Hospitals.

Dr Keighley added: “Reports that more than half of doctors and nurses surveyed by Audit Scotland believed that patients are sometimes inappropriately admitted to hospital to avoid breaching the four hour waiting times target is scandalous and I would urge the Government to investigate this matter. They must also consider the issue of trolley waits, which can strip patients of their dignity.”

The RCN also called for action on the target and said the public should be equipped to understand when going to A&E was appropriate. RCN Scotland director Theresa Fyffe said: “The RCN is calling for a more realistic target of 95 per cent of patients being seen within four hours rather than the current 98 per cent. This would give A&E staff the flexibility and time to deliver the personalised, quality care patients deserve.”

She added that “a lot” of work needed to be done and that health boards must listen to the concerns of nurses and other staff who work in emergency departments. “While this report highlights some huge areas of progress, it is extremely important that as the NHS begins to tighten its belt, the skills of staff are better utilised and waste resulting from inappropriate self-referrals is minimised.”

Nicola Sturgeon, the health secretary, said that work was already underway to address issues raised in the report. “We have a well-developed strategy for emergency care in Scotland,” she said. “A range of initiatives are currently being implemented jointly by NHS Boards, NHS 24 and the Scottish Ambulance Service that will allow patients to know which service to use and be treated quickly and appropriately.”

She said that NHS 24 had increased its responsiveness in directing callers to the most appropriate care a range of safe alternatives to hospital attendance had been developed.

On staffing, she said that health boards were being supported to maintain rotas, and that there had been an increase in numbers of doctors and nurses in emergency departments since 2007. “We have also invested significantly in new ways of working and the development of new and extended clinical and non clinical roles which have helped to free up medical staff time and provide safe and stable cover within clinical areas,” she added.

- audit-scotland.gov.uk

<em>Picyure: Waldo Jaquith</em>

Picyure: Waldo Jaquith

A model currently used for temporary nurses could soon be applied to the use of locum doctors in Scotland’s hospitals, the health secretary has revealed.

“Doctor banks” could be formed to help the NHS fill medical staffing gaps without spending as much money as it does at present, Nicola Sturgeon said, and could also improve quality.

Ms Sturgeon revealed that the proposal was being considered by health board chief executives as Audit Scotland was due to publish a critical report into the use of medical locums in NHS hospitals.

The report, published today reveals that spending on medical locums has doubled in real terms since 1997, and that NHS boards could save £6 million – almost 15 per cent of the money it spends on locums annually – through better planning and procurement.

Health boards spend some £47 million per year on temporary doctors, who are taken on for a variety of reasons, including covering for sickness and unfilled vacancies. Most of this (£27 million) is spent on agency locums, with the remainder on existing NHS staff providing internal locums.

In many cases, the report says, hospitals cannot say why locum doctors are being hired and for how long, and better information is needed.

The spending watchdog also warns that health boards need to be consistent in the way they screen and induct locum doctors and in the way they manage their performance.

Feedback on locums’ performance is mainly verbal, says auditor general Robert Black, and there are no formal systems for sharing information about individual locum doctors between boards.

Nicola Sturgeon, the health secretary, acknowledged that spending on medical locums had increased since 1997, but said it had remained steady over the last three years. “That is a step in the right direction, however we have more to do.”

She said the government was currently consulting health board chief executives on a package of measures designed to reduce demand for temporary medical staff and, where their use was unavoidable, ensure they were high quality and affordable.
Proposals include using existing NHS staff in “doctor banks” – similar to nurse banks – and steps have already been taken to improve procurement of agency medical staff with a new national contract, she said.

“These proposals, developed by a group which includes key stakeholders including NHS representatives and the British Medical Association, draw on the benefits of using nurse banks, where existing NHS staff undertake temporary work for their board,” the minister said. “Use of bank staff helps to maintain quality standards and has resulted in substantial savings in spending on agency staff. Guidance for boards on the implementation of the proposals for temporary medical staff is expected to be published later this year.”

The proposed move to a bank system was backed by Theresa Fyffe, director of RCN Scotland. “The report reveals a patchy approach to the use of hospital locum doctors, with health boards not sharing information about the performance of locum doctors, some health boards not knowing if they are using agency or in-house locum doctors and some not providing inductions for locum doctors,” she said. “In the interests of patient safety and reducing costs, the use of locum doctors clearly needs to be addressed as a matter of urgency.”

She said that nurse banks were not only helping to drive down health board costs, but also meant that health boards can be confident in the skills and ability of the nurses available to them.“The Scottish government and health boards must drive forward with the implementation of ‘doctor banks’ to ensure that the problems uncovered in today’s report are addressed and the money saved is reinvested in improving patient care.”

The BMA, which is part of the short life working group on temporary medical staffing, welcomed the report. Dr Charles Saunders, deputy chairman of Scottish Council, said: “We welcome this constructive report and believe the recommendations form a solid foundation for more cost effective use of locums.”

Disabled parking permitAudit Scotland has uncovered a miracle: the dead may no longer be with us, but they still need to park their cars.

At least that’s the charitable explanation for a report out today which shows that 4,340 “blue badge” disabled parking permits have had to be cancelled, or flagged to be checked at any future attempt at renewal, because the holders are, in fact, deceased.

The figures were uncovered by the National Fraud Initiative (NFI), which also led to 179 occupational pensions being stopped, after it was found the pensioner was no longer alive.

In addition, 4,322 council tax “single person” discounts were withdrawn because it turned out the people weren’t living alone after all and 1,042 housing or other benefit payments to public sector pensioners, and 405 benefit payments to public service workers, were withdrawn or reduced.

“Most people are honest and behave with integrity,” said Scotland’s Auditor General Robert Black. “Some do make genuine mistakes, but there is a small number who set out the cheat the public sector. Our successful National Fraud Initiative should be a deterrent.”

The initiative – the third such to take place in Scotland – saved £21 million in 2008-09, he said, with cumulative savings of £58 million. There have also been at least 80 successful prosecutions since the last report was published (in May 2008).

The process involves 74 bodies, including councils, police forces, fire and rescue services, health boards, the Scottish Public Pension Agency and the Student Award Agency for Scotland.

Using a “matching” process, investigators looked at data on deceased persons, public sector employees and pensioners, benefit applicants, council tax records, failed asylum-seekers, disability parking permits, expired visas and students.

The process flagged up potential inconsistencies which could suggest fraud or error – these were followed up in order to stop overpayments and, where possible, recover the sums involved.

Auditors are warning, however, that the risks of fraud are likely to increase because of the current financial climate, saying that the “matches” in the current report were based mostly on information gathered in late 2008, before the recession took hold.

“It is widely recognised that an economic downturn is linked with a heightened risk of internal and external fraud and error,” the report says. “Bodies need to bear this in mind as they plan for the next NFI exercise and must remain vigilant in their efforts to keep losses to a minimum.”

The next NFI investigation is due to begin in October of this year, and is expected to involve a greater number of public bodies, when new powers for data matching are likely to have been enacted in Scotland.

Audit Scotland

<em>Picture: Michael Coghlan</em>

Picture: Michael Coghlan

By Allan Laing

A total of 77 murder cases remain unsolved by police in Scotland, ranging from the three female victims of the serial killer Bible John in Glasgow in the 1960s to the mysterious shooting of Nairn banker Alistair Wilson on his doorstep in 2004.

But the list includes murders which go back a lot further than the Sixties. The oldest case still on a Scottish force’s books is that of Janet Henderson, a young woman hacked to death with an axe in the kitchen of her brother’s farm at Forgandenny in Perthshire 1866.

The number of unsolved killings came to light after researchers from BBC Scotland asked the country’s eight police forces how many murder investigations they still had open on their files. Most of the 77 cases were post-1975, the last time Scotland’s police service was restructured.

However, Tayside Police had two unsolved murders still on their books which dated back before the First World War. Janet Henderson’s was one of them; the other was that of Jean Milne, a wealthy 65-year-old spinster found battered and stabbed to death at her home in Broughty Ferry in 1912. Detectives initially arrested her former lover, a Canadian, but later released him when his alibi checked out.

Strathclyde Police, Scotland’s biggest force, said it had 53 cases still open but only those murders carried out since 1975 were kept on its central database. However, it did offer the BBC details of killings carried out before then as a result of a cold case review into unsolved murders of women ordered by the Association of Chief Police Officers in Scotland.

The review, carried out for ACPOS by Lothian and Borders’ then deputy chief constable, Tom Wood, covered, among other cases, the Bible John murders in Glasgow and the World’s End murders in Edinburgh.

In 1979 two 17-year-old girls, Helen Scott and Christine Eadie, were raped and murdered after a night out in the capital. They had last been seen alive in the World’s End pub in the city’s Royal Mile. Some 30 years later, a 62-year-old man, Angus Sinclair, was tried for their murder, but the case collapsed.

Lothian and Borders Police has six unsolved murders, according to the research, including the World’s End victims. Only two forces, Central, and Dumfries and Galloway, said they had no unsolved murder cases.

While the killers’ identity in many of the open murder cases remain a mystery – even to the officers investigating them – in others detectives are sure they know exactly who carried out the crime. They just don’t have enough evidence to bring them to justice.

In addition, Scottish forces are also still looking closely at two convicted serial killers – Peter Tobin and Robert Black– both of whom are suspected of carrying out other murders north of the Border.

In November, 2006, after Tobin was found guilty of the murder of Polish student Angelika Kluk, Strathclyde Police launched Operation Anagram in a bid to analyse a timeline for the killer’s movements and share information with other UK forces which would enable them to see if he had links to other unsolved murders.

Tobin has also been convicted of the murders of 15-year-old Bathgate schoolgirl Vicky Hamilton and 18-year-old sixth former Dinah McNicol from Essex.

Lorry driver Robert Black, from Grangemouth, was found guilty in 1994 of the kidnap and murders of three young girls, five-year-old Caroline Hogg, 10-year-old Sarah Harper, and 11-year-old Susan Maxwell. In the 1980s. Like Tobin, police suspect that he carried out more killings.

NHS Scotland logoHealth boards across Scotland are applying differing rules on whether patients are removed from or sent to the bottom of waiting lists, watchdogs have warned.

This means that while patients in one area might be given more chances to accept an appointment which suits them, others might be penalised after refusing a “reasonable offer” – defined as up to two dates with a minimum of seven days’ notice – or for cancelling or not attending.

The situation is becoming more acute as waiting times fall, Audit Scotland says, because patients now receive less notice than previously, which can cause some people difficulty in making arrangements to attend.

In a report published today, the watchdog says that although a new system of managing NHS waiting lists is generally working better for patients, more improvements are needed.

In particular, health boards need to do more to make patients understand the consequences of turning down appointments or failing to attend, the Audit Scotland report says.

Hospitals also have to get better at communicating with patients with additional needs – such as people who require information in other languages, or who have learning disabilities – to make sure they understand they are being asked to attend an appointment, the report says.

The “New Ways” system of managing waiting lists was introduced in 2008, and was meant to put an end to the “hidden waiting lists” – where patients could lose their guarantee of being treated within a certain time.

New Ways operates a “stop-the-clock” process which is supposed to ensure that patients don’t languish on waiting lists for years and aren’t excessively penalised if they cannot attend for appointments.

Auditor General Robert Black said the new arrangements had improved the way the NHS manages waiting lists, but added: “The NHS now needs to build on this to make sure that the new arrangements work well for everyone.

“Patients have responsibilities to attend for appointments. Under the new guidance, patients who fail to attend may be taken off the waiting list and referred back to their GP, and it is crucial that the NHS tells patients this.”

The report raises concerns about whether people get information in a format they understand. Although around two-thirds of boards provide some communication tailored to individual needs (such as access to translation, letters in larger print and materials for people with learning disabilities) these aren’t always available when hospitals contact patients to arrange an appointment.

“Recording information about people’s additional needs would help patients have a better experience and help hospitals to be more efficient in the way they communicate with patients about their appointments,” the report says, adding that boards are not doing this consistently.

Good communication with patients is even more essential as waiting times fall, the report says, because people are getting less notice of appointments.

Since April 2009, NHS boards only need to give patients a minimum of one week’s notice – and if patients do not accept two appointments, or do not attend, they can be referred back to their GP or put to the bottom of the list.

The report highlights particular problems with computer coding of what is happening to patients, particularly where they are being transferred between health boards. Some patients were being incorrectly coded as “treatment no longer required”, for example, when they had been referred to the Golden Jubilee Hospital (the national waiting times centre), which distorts the data.

Patients may also be removed and coded as “treatment no longer required” if they could not attend an appointment – even if they still needed treatment. “The national statistics show that high numbers of patients are being removed from lists in this way,” the report says. “NHS boards should investigate any apparent anomalies and ensure that they are managing these patients appropriately.”

Although it does not single out health boards which are stricter about non-acceptance of an appointment, Audit Scotland calls for more consistency. It recommends that the Scottish government should consider issuing additional guidance to NHS boards “about the treatment of patients who do not or cannot attend appointments to make sure that patients are managed fairly across Scotland, while still allowing for clinical judgement”.

Health secretary Nicola Sturgeon said that plans were already underway to implement the report’s recommendations. “Before New Ways, tens of thousands of patients were held on ‘hidden waiting lists’ with no treatment guarantees; now these people are treated within the Scottish government’s waiting time targets.

“New Ways has also introduced more flexibility so that appointments and treatments can be made to suit patients’ individual needs and schedules. This means that appointments are less likely to be cancelled and patients who would previously have had to wait indefinitely can get the care and treatment they need.”

The report also shows the new system has had no impact on the number of patients who fail to attend an appointment. Around one in ten patients do not attend Scottish hospitals for their first outpatient appointment, costing the NHS almost £60 million per year, approximately the same proportion who failed to attend before the new system was introduced.