Queues for cure?

Let's add appropriateness to the equation

If waiting were a disease it would be one of the commonest and least studied diseases in England. There were 628800 people on an inpatient waiting list and 442300 people on a day case waiting list in England on 30 September 1994.1 Of these, 7% and 4% respectively had waited more than one year. The first assumption made by politicians—irrespective of political colour2—and therefore inherited by managers is that being on a waiting list is a measure of need. One study even defined need in such terms.3 The second assumption concerns a dose-response relation: the longer the wait the greater the need. Consequently, initiatives to reduce waiting lists tend to act as if it is the long wait itself that warrants treatment.

The patient's charter enshrines the right to admission for treatment within two years of being put on a waiting list. It does not distinguish between the different procedures for which people wait, although since 1986 separate targets have existed for hip and knee replacement and cataract operations. The NHS Executive acknowledged that patients for whom “delay in investigation or treatment would pose an unacceptable risk to life or risk of major morbidity” should be treated promptly.4 But no central guidance exists on how to resolve potential conflicts between clinical priority and considerations of cost effectiveness or benefits to populations as opposed to individual people. Still less are the opportunity costs of such policies discussed.

Money to facilitate reductions in waiting lists has, until now, been allocated by the Department of Health to help implement the patient's charter. The department has imposed penalties on regional health authorities that do not try to reduce waiting lists. The regions pass such fines on to district health authorities, which in turn pass them on to providers. Currently this may amount to up to pounds sterling4000 per patient.5 Our own region, formerly North East Thames, had the highest number of patients who had waited a long time in 1993 and was fined pounds sterling147000. In some cases performance related pay for managers may be linked to preferential clearance of such patients.

The recent Abrams report states that the “public health function underpins all NHS purchaser and provider activity” and that this requires “an assessment of the health needs of any given population to inform decision-making on aims and priorities so as to achieve appropriate and effective services leading to improved health and value for money.”6 The most recent guidance from the former NHS Management Executive exhorts health authorities to purchase procedures specifically in relation to their effectiveness in conditions for which clearcut clinical guidelines are merited.7 Of course, patients on waiting lists have had their needs assessed by individual clinicians. Yet most health authorities—and to an even greater extent general practice fundholders—do not consider the needs of people on waiting lists as requiring further assessment. They are happy to accept the waiting list as reflecting an aggregate of unquestioned clinical decisions, which may be influenced by factors such as the visibility of waiting lists and the perverse incentives built into the NHS market rather than by evidence of effectiveness. The driving force behind this acceptance is the patient's charter.

The assumption that waiting lists reflect need (that is, ability to benefit) may be tested by considering the indications for various procedures. Increasingly, systematic reviews and techniques for identifying consensus have been used to set criteria of appropriateness for clinical procedures. There seems, however, to have been little interest in using this work to tackle waiting lists. The appropriateness of some procedures may be questioned regardless of the clinical indications (for example, dilatation and curettage in women under 408), but for most procedures for which there is a waiting list, the situation is far more complex. The intended procedure, the precise indication for that procedure (the condition and its severity), and any comorbidity must be assessed. These factors could be used to generate an appropriateness rating.9

For example, in coronary artery bypass grafting the procedure has been judged inappropriate in patients with single vessel disease, moderate or severe myocardial ischaemia, and mild left ventricular dysfunction.10 Yet such patients continue to be operated on. Furthermore, a recent study of a waiting list for tonsillectomy showed that nearly one third of patients had waited more than one year.11 The natural course of recurrent throat infection, the main indication for tonsillectomy, may be one of improvement12; a prospective study to determine the morbidity caused by a delay in tonsil surgery found that a fifth of patients grew out of their condition and were spared surgery.13 This raises the possibility that, in certain circumstances, need may fall with longer waits.

Maximum waiting periods for procedures of accepted effectiveness have some appeal, although surgery may be inappropriate when judged against local guidelines or when resources are constrained.14 Existing criteria for appropriateness may require refinement,15 but they offer a reasonable tool, possibly with local modification, for examining waiting lists. The next stage is for commissioners to agree with general practitioners and providers the criteria for appropriateness for entry to and clearance from a waiting list. Such an approach should be widely debated in local community settings. Furthermore, the criteria for appropriateness should be linked with a commitment to audit. This would allow the standards given in the patient's charter to be achieved on the basis of need rather than political whim. For all those concerned with appropriateness, the time spent on waiting lists allows an opportunity to assess the costs and benefits of intended treatment.