NHS Scotland waiting times guidance - November 2023: equality impact assessment

Executive summary

The Equality Act 2010 at section 149(1) requires public authorities to have due regard to eliminating discrimination, advancing equality of opportunity, and fostering good relations under the Public Sector Equality Duty (PSED). The Equality Act 2010 (Specific Duties) (Scotland) Regulations 2012 require public authorities to assess and review policies and practices against these three needs. To meet this obligation, the Scottish Government promotes a mainstreaming approach to equality, ensuring that the impact of its policies, programmes, and legislation, on people with protected characteristics is assessed across all areas and levels.

The Scottish Government has undertaken a national Equality Impact Assessment (EQIA) of the revised NHS Scotland Waiting Times Guidance: November 2023. This report summarises the findings, considering impacts on age, disability, gender reassignment, sex, pregnancy and maternity, marriage and civil partnership, race, religion or belief, and sexual orientation. The guidance applies universally to all NHS Scotland Health Boards and all patients on inpatient/day case, diagnostic and new outpatient waiting lists for planned care, upholding the founding principle of the NHS of fair and equal access at the point of need.

The NHS Scotland Waiting Times Guidance was updated in November 2023 to provide guidance for Health Boards to assist them in the delivery of the national waiting times standards. This followed a review in collaboration with key groups, including Health Boards and Public Health Scotland (PHS), and included patient input via a Gathering Views exercise carried out by Healthcare Improvement Scotland (HIS). The updated guidance replaces the previous 2012 publication and continues to ensure that patients who are waiting for an outpatient appointment, diagnostic test or treatment are managed fairly and consistently across NHS Scotland and takes account of service improvements.

The changes made align with our commitment to deliver sustained improvements and reductions to waiting times through service redesign, as well as enhanced regional and national working across NHS Scotland.

The EQIA evaluates how the updated guidance may affect different population groups, both positively and negatively, and therefore subsequently recognises the proactive duty to promote equality as well as mitigate risks. A full EQIA was required because the policy affects a large number of people, involves multiple protected characteristics, and has potential for both positive and negative impacts.

Key areas assessed, due to changes from the 2012 guidance, include:

• Implied acceptance will affect new outpatients’ waiting times clock, with an increased 10-day deadline (based on patient engagement) and should be considered a reasonable offer.
• New rules about how to adjust overall waiting time calculations for patients who do not attend their appointment or are unavailable for appointments for personal or clinical reasons are incorporated into the guidance.
• GPs and other referring clinicians to be copied into patient communications at agreed points along the patient journey so all parties are aware of the patient’s next steps, and GPs can provide advice and support accordingly.
• Communications can be in any form that the patient has consented to, including via telephone, electronically or by post. Health Boards are also encouraged to maximise use of digital services for appointments.
• Waiting list validation is incorporated into the guidance and should be embedded throughout the patient pathway. Details on the National Elective Coordination Unit (NECU) has also been included in the guidance.
• Patient Focussed Booking timescales have been extended (based on patient engagement) to allow patients a longer period of time to arrange appointments. The process now allows 14 calendar days (previously 7 calendar days) to respond to the initial communication before a reminder is issued and a further 7 calendar days is given to respond. Treatment Time Guarantee (TTG) patients must then be offered an appointment and the reasonable offers guidance followed. For new outpatients, a clinical review must take place to determine next steps if the patient does not make an appointment within the 21-calendar day timescale.
• Guidance on Active Clinical Referral Triage (ACRT) has been included and should be incorporated into business-as-usual processes for NHS Boards as they manage referrals.
• Greater clarity is set out in the guidance on what constitutes a reasonable offer: An offer of appointment from a Health Board to a patient is reasonable:
  • if at least 10 calendar days’ notice is given (previously 7 calendar days);
  • if the appointment is at any location across Scotland deemed clinically appropriate for the patient’s needs;
  • if the patient consents to the mode of contact used to communicate the offer (e.g. video, phone call);
  • if a date is provided, not just location;
  • if the consequences of refusing a reasonable offer are clearly explained;
  • at short notice if accepted by patient.

Some of these changes may impact patients based on age, disability, gender and race, with possible further detriment linked to sex in relation to waiting list validation and booking processes. While not a protected characteristic in and of itself, individuals with limited English proficiency may also experience challenges if communications are not fully understood.

There was extensive input from stakeholders throughout the development of the updated waiting times guidance, which included territorial Health Boards, PHS, and patient input. Following publication, the review team sought further engagement with third party organisations that represent groups with protected characteristics; however, responses were limited, with only one external response received. The EQIA therefore draws on existing literature, internal policy discussions, the aforementioned input from territorial Health Boards, and patient feedback gathered through HIS during policy development.

The review found that the policy will benefit all patients by allowing more time to respond to offers of appointments and treatment and enabling alternative communication methods tailored to patient preferences, thus improving equality of opportunity. While potential negative impacts were identified for four protected characteristics, mitigations are embedded in the guidance, including requirements for accessible communication and clinical review before removal from pathways. Significant work was undertaken during policy design to identify and address risks, and the policy is not considered directly or indirectly discriminatory.

The review team also welcomes the continued work of the Waiting Times Query Group, which includes PHS and Health Boards. This group meets monthly to address implementation queries, ensuring patient needs and equality considerations remain central as new issues arise.