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

Key Findings

Data gaps

Lack of stakeholder information

Following the publication of the updated guidance, the review team sought feedback from third party organisations that represent groups with protected characteristics. Specifically, stakeholders were asked to indicate any positive or negative impacts that may impact the demographic they represent, and were asked to consider the following questions when formulating a response:

1. Has there been any positive impacts on this demographic since the implementation of the NHSScotland Waiting Times Guidance (2012), and what recommendations do you suggest Health Boards should consider when implementing the revised NHS Waiting Times Guidance (2023)?
2. Has there been any negative impacts on this demographic since the implementation of the NHS Waiting Times Guidance (2012), and what can the revised NHS Waiting Times Guidance (2023) implement to mitigate these negative impacts?
3. Would this demographic be affected positively or negatively by the way they are contacted by the Board?
4. Would there be barriers to this demographic attending appointments a) locally and b) outside of their local areas?
5. Are there any barriers which may prevent this demographic accepting appointments?
6. Could you provide any additional data or source material to support the answers provided.

However, despite efforts to gather feedback from stakeholders, responses were limited. As a result, the information contained in this EQIA relies primarily on internal Scottish Government sources, feedback gathered through the initial development of the guidance, and published research. We acknowledge this lack of additional input is unfortunate; though, it should be noted that the development of the revised guidance involved broad engagement with NHS Scotland Health Boards, PHS and patients, including a Gathering Views exercise led by HIS. Throughout these engagements, and the development of the 2023 Guidance, equality impacts were discussed extensively.

Impact of specific changes

To inform the assessment, the review draws on broad research which explores patient experiences of accessing NHS services. It was not possible to identify literature specifically reflecting the policy changes introduced in the updated waiting times guidance; therefore, proxy measures such as patient experience of admission and ‘did not attend’ (DNA) rates were considered in the analysis.

Intersectional impacts

The review team acknowledge that public health policies sometimes have unexpected effects which have the potential to affect people differently. This review has concentrated its analysis on the impact of the NHS Scotland Waiting Times Guidance: November 2023 update on people with protected characteristics; however, the review team recognise that a thorough analysis of protected characteristics must include elements of intersectionality if it is to go beyond a singular understanding of the experiences of protected groups.

While there is a wealth of existing research on the particular forms of advantage and disadvantage that individuals who embody multiple forms of protected characteristics experience, the extent to which the existing intersectional literature reviewed had direct applicability to the guidance policy was limited.

It is nonetheless recognised that while the NHS Scotland Waiting Times Guidance: November 2023 provides formal equality to all patients on an inpatient/day case, diagnostic or new outpatient waiting list, intersecting systems of power do not operate independently from one another but come together to shape lived experiences of inclusion and access. This can potentially lead to the exclusion of certain individuals, including in access to public services.

Future EQIA reviews of the NHS Scotland Waiting Times Guidance: November 2023 should be intentional in seeking out intersectional perspectives, which should be informed by the lived experiences of all those on inpatient/day case, diagnostic or new outpatient waiting lists across NHS Scotland. Therefore, a more pluralistic perspective should be considered in subsequent reviews to ensure a greater understanding of the disparities in the experience of patients across Scotland as a direct result of the intersectional axes.

Overall findings

The review found that increasing the reasonable offer period from 7 to 10 calendar days advances equality of opportunity as it gives patients more time to respond to appointment offers. A reasonable offers package is the offer of two or more different dates of appointment for each stage of the patient’s pathway.

Communications can now be delivered through any method consented to by the patient, including digital formats and paper copies, which helps safeguard against digital exclusion.

The updated ‘Additional Support Needs’ section of the guidance sets a clear standard for accessible communication for patients requiring extra support. In addition, patients are protected from administrative removal from pathways because a clinical review is required before any such action is taken. This provides a safety net for non-responses. The implementation of ACRT further supports clinical prioritisation and enables earlier decision-making.

Age

The review found no evidence that the policy would affect individuals positively or negatively on age grounds in terms of eliminating unlawful discrimination or fostering good relations between different age groups.

In relation to advancing equality of opportunity, both positive and negative impacts were identified. Patients with memory or cognitive impairments, which are typically associated with older aged individuals, may struggle to contact a Patient focussed Booking (PfB) office and arrange an appointment. PfB is a system that requires additional actions from patients, where failure to respond results in no appointment being offered, could be considered discriminatory on the grounds of age.

To mitigate this, the reasonable offer period has been extended from 7 to 10 calendar days, ensuring postal communications are received and patients have time to respond. This helps to address patient concerns regarding post arriving too late to allow patients to attend their appointments. Patients can now receive appointment offers through any communication method they have consented to, including digital formats and paper copies. This change aims to prevent digital exclusion by ensuring consent for alternative communication methods. The guidance also includes specific mitigations, stating that all communication with patients, including PfB, must be provided in a format appropriate to their needs, as outlined in the ‘Additional Support Needs’ section.

Whilst there was no direct policy change in the updated guidance in relation to the adjustments to patients’ clocks for non-attendance at NHS appointment, the potential impact of Did Not Attend (DNA) and Could Not Attend (CNA) guidance was considered by the review team. This was considered in deference to the related updates in the Guidance regarding adjustments to waiting times clocks for periods of medical or personal unavailability. This decision was made based on the supposition that there are reasonable grounds to assume a relationship between DNA and CNA and medical or personal unavailability in some cases.

In terms of advancing opportunity, the review team found the DNA guidance could have a negative impact as non-attendance varies significantly by age, with younger adults generally demonstrating higher DNA rates than older populations. This may be due to younger patients experiencing competing demands such as employment, education, and caring responsibilities, which can affect their ability to attend scheduled appointments.

To ensure any referrals back to Primary Care are appropriate, the guidance states a clinical review must take place by the receiving service within the Health Board, prior to any patient being removed from a waiting list. This will ensure that patients will only be referred back to Primary Care if it is considered clinically appropriate to do so.

Disability

The review found no evidence that the policy would affect individuals positively or negatively on disability grounds in terms of eliminating unlawful discrimination or fostering good relations between disabled and non-disabled people.

In relation to advancing equality of opportunity, both positive and negative impacts were identified. Patients with impairments of brain function, such as cognitive difficulties or learning disabilities, may lack the capacity to contact a Patient focussed Booking (PfB) office to arrange an appointment. A system which requires additional actions from patients, and where failure to respond results in no appointment being offered, could be considered discriminatory on the grounds of disability.

To address this, the guidance specifies that all communication with patients, including PfB, must be provided in a format appropriate to their needs, as outlined in the ‘Additional Support Needs’ section. This requirement ensures that reasonable adjustments are made so that disabled patients can access services equitably. Furthermore, the reasonable offer period has been extended from 7 to 10 calendar days, ensuring postal communications are received and patients have time to respond. Patients can now receive appointment offers through any communication method they have consented to, including digital formats and paper copies. This change aims to prevent digital exclusion by ensuring consent for alternative communication methods.

Evidence also shows that disabled people, including individuals with mental health conditions, are at increased risk of DNAs. Disabled people and those with long-term conditions may face significant structural barriers to attending appointments, including transport difficulties, physical accessibility issues, fatigue, pain, cognitive impairment, or reliance on carers. Therefore, adjustments to patients’ clocks for non-attendance at NHS outpatient appointments could have a disproportionately negative impact on disabled people in terms of equality of opportunity.

To remediate this issue, the guidance states a clinical review must take place by the receiving service within the Health Board, prior to any patient being removed from a waiting list. This will ensure that patients will only be referred back to Primary Care if it is considered clinically appropriate to do so.

Gender reassignment

The review found no evidence that the policy would affect individuals positively or negatively on the grounds of gender reassignment in terms of eliminating unlawful discrimination or advancing equality of opportunity. However, a positive impact was identified in relation to fostering good relations.

Following the publication of the guidance, a Director’s Letter was sent to NHS Board Chief Executives from Scottish Government in April 2024 specifying that the application of the 2023 Guidance extends to Gender Identity Clinics, and all four NHS Scotland clinics have been made aware of its application.

To strengthen transparency and monitoring, the Scottish Government has commissioned PHS to improve data reporting for gender identity services, establishing robust national systems for waiting times data collection, monitoring, and reporting.

Additionally, literature frequently cites a lack of communication during waiting periods as a source of uncertainty and distress for individuals awaiting Gender Identity Clinic appointments. The updated guidance addresses this by emphasising the importance of clear, accurate, and transparent communication at the start of the care journey, alongside expectations for waiting list validation and standard management principles.

Sex

The review found no evidence that the policy would affect individuals positively or negatively on the grounds of sex in terms of eliminating unlawful discrimination or fostering good relations between men and women. However, in relation to advancing equality of opportunity, both positive and negative impacts were identified.

All referrals undergo Active Clinical Referral Triage (ACRT) based on the information available at the time of referral, with a Senior Clinical Decision-maker determining whether it is reasonable and clinically appropriate for the patient to be seen in clinic. Research indicates that clinicians may sometimes dismiss women’s symptoms, particularly in relation to reproductive health conditions, such as endometriosis. Mandating that all referrals to secondary care are triaged by a Senior Clinical Decision-maker could result in indirect discrimination if clinicians hold ingrained beliefs that women exaggerate symptoms, normalise reproductive pain, or lack understanding of reproductive conditions. This could lead to inappropriate referral back to primary care.

Through its design, ACRT is intended to improve services by responding more effectively when patients are referred to secondary care. A Senior Clinical Decision-maker reviews all the electronic patient records (including imaging and laboratory results), and triages the patient to the optimal, evidence-based, and locally agreed pathway. This process of enhanced vetting adds value to the initial management of the referral by providing patients with written clinical information, the opportunity to “opt-in” after considering the information provided (with no time limit), remote consultation with the most appropriate clinician, direct referral for investigations, and onward referral to the most appropriate service or speciality, if required.

Therefore, ACRT has the potential to improve patient care and reduce waiting times by eliminating unnecessary face-to-face attendances. For example, rather than patients waiting an unacceptable length of time for clinical information, this can be readily provided by other means such as a letter or virtual appointment.

By working more efficiently, time is automatically freed-up and can be reinvested into providing a higher quality of service for those patients who need to be seen face-to-face. Patients reviewed under ACRT may also be moved up a waiting list if the assessment determines they should be prioritised for urgent care or treatment.

In this way, ACRT should benefit all patients, including women and girls, as it enhances clinical prioritisation, ensures patients are seen at the right time and the right place, and delivers a patient-focused approach for the management of referrals from primary care to secondary care.

The review also found that adjustments to patients’ clocks for non-attendance at NHS appointments could have a negative impact based on sex in relation to advancing equality of opportunity. There was little consistency in the literature reviewed in terms of the gender balance of CNA and DNA, with some studies finding higher rates among females and other studies finding higher rates among males. In deference to this, and for the purposes of the EQIA, the potential impact of the guidance has been considered for both sexes.

Evidence identifies caring responsibilities as a key driver of DNAs and CNAs, particularly for women. According to the 2023-24 Carers Census, around three-quarters of unpaid carers in Scotland are female. Women continue to undertake a disproportionate share of unpaid caring responsibilities, including childcare, elder care, and caring for disabled family members. These responsibilities can significantly affect attendance at healthcare appointments, particularly where appointments are offered at short notice or lack flexibility.

Separately, the literature reviewed indicated that male gender is associated with increased likelihood of DNAs in some healthcare settings, particularly where this overlaps with socio-economic deprivation and minority ethnic groups. This is consistent with evidence that suggests men and some minority ethnic groups are less likely to engage proactively with healthcare services, including lower levels of help-seeking behaviour. This is often linked to work-related barriers, stigma, or perceptions of illness severity.

Without sensitivity to differential health-seeking behaviours, DNA policies may inadvertently penalise groups already less likely to engage with health services, thus reinforcing existing inequalities.

To mitigate this, the reasonable offer period has been extended to from 7 to 10 calendar days, giving individuals more time to respond. Patients can now receive appointment offers through any communication method they have consented to, including digital formats and paper copies. This change aims to prevent digital exclusion by ensuring consent for alternative communication methods. The guidance also includes specific mitigations, stating that all communication with patients, including PfB, must be provided in a format appropriate to their needs, as outlined in the ‘Additional Support Needs’ section.

The guidance states a clinical review must take place by the receiving service within the Health Board, prior to any patient being removed from a waiting list. This will ensure that patients will only be referred back to Primary Care if it is considered clinically appropriate to do so.

Pregnancy and maternity

This policy does not apply to obstetric services as they are exempt from the Treatment Time Guarantee. Therefore, no changes have been made, and no consideration was required regarding direct or indirect discrimination, advancing equality of opportunity, or fostering good relations.

Race

The review found no evidence that the policy would affect individuals positively or negatively based on race and there was no indication of direct or indirect discrimination, nor any impact on promoting good relations.

Evidence does, however, suggest that men and some minority ethnic groups are less likely to engage proactively with healthcare services, including lower levels of help-seeking behaviour. This can manifest as delayed presentation, irregular attendance, or DNAs, particularly where services are perceived as inaccessible, culturally inappropriate, or difficult to navigate. Therefore, there may be negative impacts for minority ethnic patients, particularly where this intersects with socio-economic class and the male gender, in terms of advancing equality of opportunity.

To implement corrective actions, the guidance states a clinical review must take place by the receiving service within the Health Board, prior to any patient being removed from a waiting list. This will ensure that patients will only be referred back to Primary Care if it is considered clinically appropriate to do so.

Religion or belief

The review found no evidence that the policy would affect individuals positively or negatively based on religion or belief. No impacts were identified in relation to unlawful discrimination, equality of opportunity, or fostering good relations.

Marriage and civil partnership

The review found no evidence that the policy would affect individuals positively or negatively based on marriage or civil partnership. There is no indication of direct or indirect discrimination, nor any impact on equality of opportunity or good relations.

Sexual orientation

The review found no evidence that the policy would affect individuals positively or negatively based on sexual orientation. No impacts were identified in relation to unlawful discrimination, equality of opportunity, or fostering good relations.