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Published: 27/03/2003, Volume II3, No. 5848 Page 12 13

Waiting-list manipulation can no longer be dismissed as the tabloids' plaything. Is there a case to answer? Tash Shifrin reports

Manipulating waiting lists might be the fastest way to get yourself on the front page of the Daily Mail. If you like that kind of thing.

But it is not only the screaming tabloids that have raised the subject recently. The National Audit Office, MPs on the powerful Commons public accounts committee and the Audit Commission have been at it, too.

And the three cases of fiddling highlighted by the Audit Commission last month - at South Manchester University Hospitals, North and East Hertfordshire and Scarborough and East Yorkshire Healthcare trusts - are only the latest of a string that have come to light over the past few years.

The Department of Health lists 11 other cases in the past three years, all highlighted by the National Audit Office.

The scandal of waiting-list fiddling can seem more widespread than it actually is because waitinglist management itself is controversial. Members of the public - and, more vociferously, doctors - may consider that someone who is not in need of urgent treatment, but is nevertheless prioritised, has got there because of 'fiddling'.

Then there is 'gaming'. One senior figure with experience of the problem draws an analogy with 'tax evasion, which is illegal, and tax avoidance, which feels wrong but is legitimate'.

Both list management and 'gaming' are different from out-andout deliberate misreporting. But the phrase 'grey area' crops up a lot - as do people who would rather not be named.

And there is the DoH itself, which recently told chief executives exactly which week they could expect accident and emergency waits to be measured. One NHS source says: 'This is a nudgenudge message: cancel your electives that week. What will staff think? That we are being asked to fiddle? People were not taking the hints, so the chief execs' bulletin spells it out.'

The current round of scandals hit the headlines when NHS chief executive Sir Nigel Crisp was interrogated by the public accounts committee in January last year over the NAO's findings.

MP Gerry Steinberg asked if it was pressure to meet national targets that had led to fiddling. 'Was it pressure or just plain cheating?'

Sir Nigel answered: 'There is no evidence that it was pressure because if it was then everybody would be doing it, would they not?'

'That is my point, 'Mr Steinberg returned.

So is everybody doing it? And if not, does that mean there is no pressure? And if fiddling is not solely down to an individual wrong 'un, what is the cause?

As a follow-up to the recent revelations, the DoH requested an Audit Commission spot-check of waiting lists at 41 trusts. Just three escaped with 'no significant weaknesses'. Deliberate fiddling was found at three. Reporting errors were discovered at 19 and system weaknesses that 'increase risk of reporting errors' at 15.

The commission's damning report prompted what one HSJ source called a 'vicious spat' between the DoH and the commission. In fact, a bleak picture might have been expected as the 41 trusts were selected because they were thought to be high risk for waiting-list problems.

Audit Commission head of health Peter Wilkinson confirms that 'people do find ways to play the system legitimately, but this may not be in the patient's best interest'.

'Managers sometimes use the argument that if it is not affecting individuals, then why does it matter? I think the issue is about honesty and integrity across the whole system.'

He is unable to say whether the specific problems found by the Audit Commission's report have affected resource allocation, but managers with their eyes on the£1m prize for three-star status could take a guess.

The Audit Commission wants an 'open debate' on list manipulation, deliberate or otherwise. 'The DoH needs to look into why it has occurred. Understanding why people are prepared to manipulate the figures is a very important lesson, ' says Mr Wilkinson.

Asked if fiddling might be intrinsic to the waiting-list targets that have been set, King's Fund chief economist John Appleby is blunt: 'Yes, ' he says.

'They are almost personal pledges by health secretary Alan Milburn - more than targets - and managers know that. When they are set in terms of 'no-one must wait more than 12 months' by a certain date, then the hospital can achieve that 99.9 per cent, but if one person is over. . . Failure by a little bit is total failure.

'The fiddling and the real pressure on managers comes when you have got patients about to breach the waiting time.'

NHS Confederation policy director Nigel Edwards says: 'The performance management system almost entirely points us to the small number of people who drop off the end [of the list] rather than speeding up treatment for the majority. This focuses on the negative exceptions rather than rewarding people for doing better.'

Not surprisingly, managers tend to speak anonymously about 'bullying' from further up the performance management tree. 'I am not the only person who has been rung up and told the figures are not good enough, do something about them, ' says one.

Unison national official Roger Kline is clear about the pressures to which managers are subjected: 'The bullying culture towards staff, and especially managers, is on the increase.There is no doubt that the obsession with hitting targets - and fear of the consequences if they are not hit - inevitably leads to some fiddling and undermines good management culture.'

Former north west regional director Professor Robert Tinston's review on corporate governance at Royal United Hospitals Bath trust followed findings of deliberate manipulation of waiting-list data there. His report says it is essential 'that the pressure to succeed in delivering an ambitious and widely lauded NHS plan does not hamper openness and an expectation that honest failure will be dealt with maturely'.

Perhaps the NHS could learn something from the various inquiries in which deliberate fiddling has been found, although the investigations themselves have come under fire.

Sir Nigel was forced to admit to the public accounts committee that that the inquiries themselves had not necessarily found favour: 'I do accept that some of the investigations, in hindsight were not satisfactory. . . what we are doing is we are putting in place a standard format.'

Guidance to standardise inquiries has now been in place since September. But recent inquiries have still thrown up some worrying inconsistencies.

The inquiry at Good Hope Hospital conducted by Birmingham and Black Country strategic health authority, for example, produced a damning report. But the team failed to interview Jeff Chandra, then the trust's chief executive, who was suspended at the time.

The trust says it is not accusing Mr Chandra of manipulating waiting lists, although he is now taking the trust to an employment tribunal, claiming constructive dismissal. A disciplinary panel found him guilty of gross misconduct - because he 'did not take firm enough action' to deal with waiting-list problems.

The SHA said its team had not spoken to Mr Chandra during its inquiry because 'they were checking the process rather than the people', and referred to the review's stated remit.

At South Manchester University Hospitals trust, an inquiry by Greater Manchester SHA sparked the resignation of previous chief executive Jane Herbert from her post as Hertfordshire and Bedfordshire SHA chief executive.

But Ms Herbert, although admitting to an 'error of judgement' in not reporting correctly to the board, has challenged the inquiry's findings on 18-month waits. She is understood to have taken out a grievance against Greater Manchester SHA over the investigation process, which she branded 'flawed' in a statement at the time.

The DoH guidance says inquiries should have 'clearly defined and agreed terms of reference', but does not suggest what these should be, so remits can vary widely. Review teams must have access to relevant trust staff, but there is no duty to speak to key players.

Styles can vary, too. The South Manchester report makes very specific statements about individuals, identified by their job.

The Bath report talks about 'the former executive team' more broadly.

The Manchester report was published in full, while only a summary of the report on waiting lists at Bath that prompted Professor Tinston's review has been published. The guidance also says that reports should cover disciplinary action. Yet the Tinston report excluded this issue, even though it was in the original remit, as the trust had taken action itself.

Professor Tinston says: 'I am happy that they took that on themselves. Our pitch had to be that we were making points to make things better.'

If the reviewers - rather than the trust as employer - had been looking at disciplinary issues, he says, 'we wouldn't have had people being so open with us'.

First Division Association head of health Paul Whiteman, whose caseload of chief executives and directors with grievances is growing rapidly, says disciplinary recommendations should remain outside the remit of investigations: 'The inquiries should be independent and just find facts.

We do not think the inquiries stand up to scrutiny in terms of the standards you would need for disciplinaries. They are very superficial and designed to come to a pre-determined end.'

And he adds that once a report is published, it can mean the end of careers, even though it 'could be inaccurate because it has not been challenged through the disciplinary process'. Nothing should be published until after the disciplinary process, he says.

The NHS Confederation's Nigel Edwards says: 'Terms of reference are essential, but if there is a standard approach there should be some idea how wide the terms of reference are.'

And with inquiries often commissioned by SHAs, he asks: 'What if the suspicions of serious malpractice implicate the HA in some way? You might want to change the client.'

Mr Edwards adds: 'The DoH ought to get people involved in recent inquiries together and see what can be learned from their experience.'

Many would say that there are two tasks for the DoH: an open debate on what makes people fiddle the lists, and a review of the guidance to ensure that inquiries are consistent and fair.Whether Richmond House and ministers will be brave enough to do so in the gaze of the Daily Mail is another matter.

More than a wrong 'un

March 2003: South Manchester University Hospitals trust Strategic health authority investigation finds that long waiters (more than 18 month) are 'simply excluded from returns', and other patients are 'inappropriately redesignated' from the active waiting list to the planned admissions list.

Autumn 2002: Good Hope Hospital trust, Birmingham SHA investigation finds that 30 inpatients have waited over 15 months for treatment and six outpatients haved waited longer than 26 weeks for treatment, and that this has not been recorded correctly.

May 2002: Royal United Bath Hospitals trust A review finds that more than 2,000 outpatients waiting more than 13 weeks for a consultant appointment have 'disappeared' from official lists.At the time, the trust reported just 122.