In the Literature
In countries with universal health insurance, waiting times for elective surgery are used as a mechanism to restrict access and control costs. But they also have the potential to lead to poorer health status and reduced ability to benefit from surgery once it is provided.
In "Measuring and Reducing Waiting Times: A Cross-National Comparison of Strategies," (Health Affairs, July/Aug. 2007), a team of former Commonwealth Fund Harkness Fellows in Health Care Policy examine waiting time strategies used in five countries: Australia, Canada, England, New Zealand, and Wales. Among the five, the researchers found that England achieved the most sustained improvement in reducing waiting times, due to "major funding boosts, ambitious wait-time targets, and a rigorous performance management system."
Strategies Across Five Countries
Looking across the countries over the past five years, the researchers report that Canada, England, and New Zealand have demonstrated a stronger commitment to addressing the issue of waiting times—through measures like national plans and dedicated spending—than have Australia and Wales.
All five countries have used popular supply-side strategies, like targeting funding toward increased hospital capacity and staff. In addition, some have implemented more complex initiatives that address health sector productivity or demand-side techniques, like using explicit criteria to prioritize access to surgery. Initiatives in each country include:
Australia. Without a national policy on reducing waiting times, Australia's states have the responsibility for managing public hospital waiting times. The Victoria government, for instance, has had success using sizable financial incentives, both bonuses and penalties. Other approaches have included targeting long-waiting patients in particular specialties, like cataract surgery, and allowing them to be treated at hospitals with excess capacity; providing Web-based information on waiting times; and establishing a dedicated elective surgery center to reduce cancellations associated with emergency patients.
New Zealand. In 1996, New Zealand introduced the Clinical Priority Assessment Criteria (CPAC) to give priority to patients with the greatest need and ability to benefit. While not without controversy, CPAC scores have been developed for coronary artery bypass graft, cataract operations, hip and knee replacement, and general surgery.
Canada. Like New Zealand, Canada has invested in priority-setting tools. In addition, provinces have employed various strategies to reduce waiting times. Ontario, for instance, has used targeted funding to achieve specified target volumes and waiting times, established benchmarks, and published waiting times for hospitals on a Web site.
England. Between 1997 and 2000, England used extra investments and promoted the sharing of best practices to reduce the total number of patients waiting for surgery and ensure no one waited longer than 18 months. Since then, the focus moved to setting targets and introducing independent inspection and a public rating system. The 2005–2008 focus will be on ensuring that that maximum wait—from referral to treatment—is 18 weeks.
Wales. In April 2004, the government in Wales began allowing patients who were likely to wait more than 18 months for inpatient or day surgery a guaranteed offer of alternative treatment in a different hospital in Wales, or in
England or the private sector. In March 2005, this was expanded to patients waiting more than 12 months. Other strategies have included the redesign of care processes, such as improved scheduling of outpatient visits and preoperative assessment by nurses.
Progress Toward Reducing Waiting Times
In terms of setting waiting-time targets, England and Wales represent opposite ends of the spectrum, say the authors, with England setting much tougher targets and aggressively managing providers against them. "The target for the total waiting time from GP referral to treatment in England has been set at 18 weeks by December 2008, while the combined inpatient and outpatient waiting time target in Wales is 16 months by March 2007," they say.
England has also had success, relative to the other four countries, in reducing the number of long-waiting patients. Wales and New Zealand have also had achievements in this area, but not on the scale of England's reductions.
Key Policy ImplicationsDrawing from their analysis, the authors offer the following recommendations for policymakers to consider:
- Extend the measurement of waiting times to include the point of referral to treatment, in order to reflect patients' actual experience.
- Systems for prioritizing patients can help manage demand, though these may be controversial and require considerable investment and commitment.
- Emphasize system and process redesign to address inefficiency and poor performance.
- Tightly focused use of private-sector purchasing may help reduce waiting times for some services.
- Imbalances and shortages in the workforce supply have the potential to affect waiting times; planning mechanisms could prove useful in addressing work-force requirements.
Waiting Time Management Outcomes in Five Countries
Country Outcomes in managing wait times Australia Median national waiting time for all patients admitted for surgery from waiting lists was 29 days in 2004–05, up from 27 days in 2000–01 Canada Median self-reported waiting times were about:
Four weeks for a specialist visit for a new illness or condition in 2003 and 2005
Three weeks for a selected nonemergency diagnostic tests (angiography, MRI, and CT scans) in 2003 and 2005
Four weeks for nonemergency surgery in 2001, 2003, and 2005
England Numbers of long-waiting patients have declined:
Inpatient treatment: number waiting more than 6 months for treatment fell from about 265,000 in March 2000 to about 12,000 in November 2005
Outpatient treatment: Number waiting more than 13 weeks fell from about 390,000 in March 2000 to about 40,000 in September 2005
New Zealand Numbers of long-waiting patients have declined:
First specialist assessment: number waiting over 6 months fell from about 45,000 in 2000 to about 24,000 in 2005
Treatment: number waiting over 6 months fell from about 30,000 in 2000 to about 6,000 in 2005
Wales Number of long-waiting patients was:
Outpatients: number waiting over 6 months fell from 83,878 patients in October 2002to 68,845 patients in March 2004
Outpatients: number waiting over 18 months fell from 16,641 in October 2002 to 6,204 in March 2004
Inpatients: number waiting over 18 months fell from 5,964 in September 2003 to 1,401 in March 2004
Note: MRI = magnetic resonance imaging, CT = computed tomography.
Source: S. Willcox, M. Seddon, S. Dunn et al., "Measuring and Reducing Waiting Times: A Cross-National Comparison of Strategies," Health Affairs, July/Aug. 2007 26(4):1078–85.