Waiting list prioritisation scoring systems: discussion paper no.6
December 1998
This document is a discussion paper produced by the BMA's Health Policy and Economic Research Unit. It is designed to provoke debate and does not necessarily represent BMA policy. Anyone wishing to respond to this paper should write to the Head of the Health Policy and Economic Research Unit at BMA House, Tavistock Square, London WC1H 9JP. (info.hperu@bma.org.uk)
Background
1. The increasing focus of central government on numbers of patients on waiting lists for surgery and length of time spent waiting has raised concerns amongst the profession that the clinical priority of patients for their surgery is in danger of being forgotten in the search for shorter waiting lists [1], [2], [3]. It also places additional burdens on the professionals who are faced with trying to explain to patients why they must wait such a long time and makes it very difficult to give patients an indication of how long they will need to wait. There is also a burden on the GP who may have to send further letters to the hospital to bring pressure to bear when a patient's condition deteriorates. This can lead to unnecessary tensions between the doctors in the different sectors and interferes with the doctor/patient relationship.
2. There are problems associated with this focus of the government which could potentially have a significant effect on patient care:
(a) Recent announcements [4] of additional funds to decrease the numbers on the waiting list is likely to mean that the easier, shorter cases will be brought in for surgery. This will certainly achieve the political wish for fewer people on the list (in the short term) but those remaining are likely to represent those with more complex conditions and quite likely those who have waited longer. It should also be noted that if the numbers being put on the list and those being operated on is not in balance then increasing waiting lists are inevitable (see chart below).
| Numbers put on waiting list (cumulative) |
Numbers operated on (cumulative) |
Waiting list | |
| Month 1 | 500 | 400 | 100 |
| Month 2 | 1,000 | 800 | 200 |
| Month 3 | 1,500 | 1,200 | 300 |
| Month 4 | 2,000 | 1,600 | 400 |
| Month 5 | 2,500 | 2,000 | 500 |
| Month 6 | 3,000 | 2,400 | 600 |
Reducing the numbers in the final column with waiting list initiatives will provide only temporary relief if no other initiative is started.
(b) The patients' charter states that no patient should wait longer than 18 months for surgery. The effect of this is that as a patient, who might have a very minor condition, awaiting surgery becomes an "18 month waiter" he/she will jump to the top of the list. They may overtake those with a greater clinical need in order to ensure that the trust satisfies one of the indicators by which it is assessed. (This might have potential medico-legal implications if a patient who was "overtaken" on the list subsequently dies and it can be proved that the delay, caused by the "18 month waiter" jumping the queue, significantly increased the likelihood of the death.)
3. BMA policy and views on waiting lists can be summarised from the following statements and announcements:
i. At the ARM in July 1998 the following resolution was passed: "That this meeting welcomes the Government's commitment to treatment being based on clinical need, and proposes that for appropriate clinical conditions hospital waiting lists should be subject to a clinical prioritisation scoring system rather than crude lengths of wait. That this meeting regrets the current high priority given to reducing waiting lists, which can have the effect of distorting clinical priorities. Council is requested to bring its concerns to the attention of Government."
ii. In response to the March 1998 budget announcement of extra funds for the NHS to tackle waiting lists the BMA stated: ". . . think it is time we took a more intelligent approach to the waiting list issue. Absolute time limits should not be the main focus of our efforts. We should be looking at real clinical priorities . . . It should be possible to create a grading system which gives greater priority to more pressing cases."
iii. In May of this year, in response to the Government's announcement of the waiting lists figures the BMA stated: "We hope that over the coming months we can begin to move away from the obsession with the number of people on waiting lists and look more constructively at the time that patients are waiting for different types of treatment and surgery."
iv. The JCC issued a paper in September 1998 [5] which stated: "The maximum acceptable waiting time for admission to hospital for a diagnostic or therapeutic intervention should be categorised and recorded against each patient's name on the waiting list."
It then lists five categories: emergency, urgent, soon, in turn, and planned repeat re- admissions for follow up. In the case of " in turn" it suggests they should be admitted within twelve months with a long term aim of within six months. (See paragraphs 16 to 27 on the New Zealand experience which has attempted to take this type of approach.)
4. This paper examines the feasibility of the introduction of some form of scoring system to help prioritise cases on the waiting list for surgery in the UK. It examines systems that are already in use in other countries and also some local schemes in this country.
References
1. DH press release "Waiting lists fall by 45,000 - supertanker turns". 26th August 1998.
2. BMA press release "BMA response on waiting lists". 21st May 1998.
3. BMA press release "BMA says waiting times are the true measure of NHS success or failure". 26th August 1998.
4. DH press release "New £320m to keep NHS waiting lists falling". 30th September 1998.
5. JCC news release "Waiting lists". 23rd September 1998.