Ministers set to target access to NHS services which can vary throughout the country The waiting game

Their pledge followed the discovery that people's chances of being referred for diagnosis and treatment in heart disease can vary by as much as 88% between one part of the country and another.

The disparity emerged in the latest volume of Clinical Outcome Indicators, the sixth since the series began in 1992, but the differences that have emerged are less dramatic than those thrown up in previous reports.

Chief Medical Officer for Scotland Sir David Carter said he found the report reassuring, but acknowledged that inequality of access would be a matter of concern for the acute services review.

The tables for heart disease diagnosis and treatment are intended as an indicator of equity of access, and will be used as a guide as to whether current rates of treatment are adequate, and the right people are getting it.

This could mean an expansion of the service, either within the existing units or by adding more. Deaths from heart disease have been falling over the past 20 years according to target, but that still leaves a huge burden of disease. The Government has no doubt that there will be plenty of work for cardiologists and heart surgeons for years to come.

What the tables show are the numbers referred for angiography - an invasive diagnostic procedure - and two alternative forms of treatment, angioplasty and coronary artery bypass graft (CABG).

During angiography a catheter is inserted through a blood vessel in the leg and guided to the coronary arteries, where a radioactive dye is squirted through to highlight the areas narrowed by atheroma.

With angioplasty, a catheter is once again guided into place, but with a balloon at the tip which can be inflated to open up the obstructed area.

A CABG is used to replace one, two or three coronary arteries with blood vessels taken from the chest wall or the leg.

This is the definitive treatment for obstructed coronary arteries and 2600 were performed last year. It is a more serious and more expensive procedure than angioplasty, but is likely to last longer as after angioplasty, the artery may eventually revert to its previous state.

The tables show that where you live may have a bearing on how likely you are to be referred for one or other of these procedures, which have to be done in specialised centres.

By expressing the numbers as a ratio, with the Scottish average set at 100, it can be seen that, for angiography, Orkney's ratio is only 38, compared with Greater Glasgow's 126. Shetland is also low, at 61.

Is this because these areas are remote from the mainland?

That may not be the whole story. The Western Isles, for example, does well at 113.

For angioplasty, Orkney and Shetland are also low, Western Isles is above the mean. A similar picture emerges for CABG, and when the two alternative treatments are combined.

So what are the other factors?

One could be that heart disease rates in the Northern Isles are lower than urban areas like Glasgow and Lanarkshire; another, that people suffering from heart disease are not being identified. This would be a matter for GPs, since Orkney, for example, has no consultant physician based locally.

The latest report does not compare one NHS trust's performance against another, but deals with both cancer survival rates and access to cardiac services according to health board area.

The cancer tables cover one and five-year survival rates for stomach cancer, and survival and mortality for cervical cancer.

The cervical cancer figures reflect the uptake and efficiency of the local screening service, because of the part it plays in preventing cancer from developing.

As a result, the incidence has fallen steadily, and it has slipped from the fifth or sixth most commonly registered cancer among women, to tenth. However, survival prospects for those who do get the disease have improved only marginally in the past 20 years.

This is reflected in the survival figures, averaging 84.7% after one year and 61.8% after five. Differences for mortality are also slight, apart from Highland, with 10.4 per 100,000 population compared with a Scottish average of six per 100,000 for 1993-95.

Officials did not discount the possibility that this had been influenced by a computer fault, discovered only last month, that had led to 4500 women being omitted from recall.

Highland is currently reviewing what has been happening as a result of the blunder and its report is due out at the end of this month.

The Scottish Office said it remained ''an open question'' whether this had contributed to Highland's position in the table.

The data in the table emerged too late to alert the board to the situation - officials found out by other means - but the ongoing use of this sort of information will help to flag up future incidents where something has gone wrong.

Stomach cancer is the fourth most frequent cause of cancer death in both sexes. Discounting non-melanoma skin cancer, it is the fifth most commonly-registered cancer in both sexes in Scotland.

The incidence has been declining in Western countries - thanks to the decline in the stomach bug Helicobacter Pylori, changes in diet, and a reduction in other risk factors, but the decrease has not been as dramatic in Scotland as, for example, the US, and survival prospects have improved only marginally over the past 20 years.

Only 28.6% of victims, on average, can expect to be alive a year from diagnosis, and after five years that will have fallen to 9.7%. The comparison tables show no dramatic variance between health board areas.

Scottish Health Minister Sam Galbraith, said: ''I welcome this report which builds on past work. This Government is committed to quality assurance.

''Today's NHS must place a greater emphasis on the quality and effectiveness of services. These themes feature in both our White Paper, Designed to Care, and in the work of the acute services review.

''It is encouraging to note that the indicators published to date have been a stimulus to further investigation and to changes in practice. It is hoped that the new measures will also be used positively as a spur to examine and, where necessary, change current practice.''

A spokeswoman for the British Medical Association said: ''We believe in openness of information. But people who look at this report should treat it as a guide and not the gospel.

''The figures should be looked at to see where improvements could be made, for example, perhaps it's new equipment that's needed, or more staff.''

Standardised procedure ratios for angiography

Numbers of procedures, crude rates (per 100,000 population), standardised procedure ratios (SPRs) by health board of residence, 1993-995

Both SexesCrude

Proceduresrate(1)SPR(2)

Argyll & Clyde2242172.6101

Ayrshire & Arran1458128.974

Borders706222.6120

Dumfries & Galloway566127.668

Fife1261119.571

Forth Valley1362166.198

Grampian2777174.3109

Greater Glasgow5693207.4126

Highland790126.973

Lanarkshire2539150.891

Lothian4276187.8116

Orkney4067.338

Shetland6493.061

Tayside1916161.691

Western Isles176200.5113

Scotland25866168.1100

(1) Crude rates expressed per 100,000 population

(2) Figures standardised with respect to age and sex

Standardised procedure ratios for angioplasty

Numbers of procedures, crude rates (per 100,000 population), standardised procedure ratios (SPRs) by health board of residence, 1993-1995

Both sexesCrude

Proceduresrate(1)SPR(2)

Argyll & Clyde18314.181

Ayrshire & Arran13311.866

Borders7423.3125

Dumfries & Galloway5512.465

Fife18017.1101

Forth Valley14717.9104

Grampian19412.275

Greater Glasgow43715.996

Highland11218.0102

Lanarkshire27716.598

Lothian62627.5168

Orkney58.447

Shetland68.756

Tayside16914.380

Western Isles1820.5114

Scotland261617.0100

(1) Crude rates expressed per 100,000 population

(2) Figures standardised with respect to age and sex

Standardised procedure ratios for coronary

artery bypass graft

Numbers of procedures, crude rates (per 100,000 population), standardised procedure ratios (SPRs) by health board of residence, 1993-1995

Both SexesCrude

Proceduresrate(1)SPR(2)

Argyll & Clyde70254.1109

Ayrshire & Arran47542.083

Borders13141.376

Dumfries & Galloway24855.9101

Fife38936.976

Forth Valley43152.5107

Grampian74546.8102

Greater Glasgow163059.4124

Highland26041.883

Lanarkshire78746.799

Lothian102945.297

Orkney1016.833

Shetland2232.074

Tayside57448.494

Western Isles4955.8108

Scotland748248.6100

(1) Crude rates expressed per 100,000 population

(2) Figures standardised with respect to age and sex

Cervical cancer

Survival Rate

Health1 yr5 yr

Board%%

Argyll & Clyde85.465.6

Ayrshire & Arran77.950.6

Borders90.362.3

Dumfries & G'way76.551.8

Fife81.361.2

Forth Valley85.258.7

Grampian87.071.2

Greater Glasgow85.063.0

Highland90.470.2

Lanarkshire84.955.4

Lothian85.164.2

Tayside85.159.6

Scotland84.761.8

Stomach cancer

Survival Rate

Health1 yr5 yr

Board%%

Argyll & Clyde25.29.2

Ayrshire & Arran27.87.4

borders29.47.3

Dumfries & G'way29.414.4

Fife36.314.6

Forth Valley31.611.8

Grampian28.58.5

Greater Glasgow27.78.3

Highland27.57.7

Lanarkshire25.911.0

Lothian31.610.5

Tayside22.37.5

Scotland28.69.7

Indications of little response to reports

SIX years on and six clinical outcome reports later, what have they achieved? The Clinical Outcomes Working Group set out to find this out before they published yesterday's report.

They sent out a questionnaire to the medical directors of the 47 trusts and the directors of public health at the 15 health boards in Scotland to find out what use had been made of them.

The report lists the replies in respect of one particular indicator, ''Discharge home after admission for stroke'', and this is how they replied from the choice of six answers:

A: the indicator was not seen by the relevant clinicians - 4.8%;

B: the indicator was not useful at all - 4.8%;

C: the indicator was of interest but did not raise any issue of concern to my hospital/speciality/trust/board - 46.8%;

D: the indicator raised an issue of concern which led to discussion but no further action - 6.5%;

E: the indicator raised an issue of concern which led to further investigation . . . but no change in practice - 9.7%;

F: the indicator raised an issue of concern which brought about, or helped to bring about, a change to the service, such as a change in working patterns or clinical practice, allocation of additional resources, or new facilities - 14.5%.

However, eight trusts and three boards also provided additional information about action which had been taken after publication, including purchase of CT scanners and the setting up of specialist stroke units.

League results not always true to form

WHEN they were launched in 1992, Clinical Outcome Indicators quickly became known as death league tables, a term which still makes the St Andrew's House mandarins shudder.

But it has not deterred them from washing the NHS's linen - clean and dirty - in public in a way still unsurpassed elsewhere in the UK.

Attempts to create comparison tables for hospitals in England and Wales have produced long lists of peripheral information like waiting times, and Michelin Guide-style star ratings.

The Scottish tables have gone for the jugular. You can learn which hospital you are most likely to die in after admission with a heart attack; which one you will have to go back to a year after a hernia or prostate operation; which health board is buying most heart operations for its people.

Always, of course, they carry their own Government health warning - they have to be read and interpreted with care. The statisticians build in factors and adjustments to take account of population sizes, demography like age and sex and, where relevant, deprivation indexes, all intended to ensure that like is being compared with like.

The comparisons are also accompanied by confidence intervals to ensure that their deviation from the national average is statistically significant.

A small health board will have a long confidence interval because it would not take much to knock it out of kilter, and can vary widely from the average without much significance attaching to it.

Even when the statistical pitfalls have been taken account of, the outcomes cannot always be taken at face value. A hospital with a high reputation may attract the most difficult referrals, so that its performance may appear worse than it really is.