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Part 1 (Waiting in the NHS: a diagnosis) highlighted the deficiencies of waiting-time targets as the principal means of managing lists and concluded that a more comprehensive approach is required1. Waiting-time targets introduce perverse incentives and are isolated from issues of health sector efficiency and opportunity cost. Furthermore, priority on waiting lists is determined not explicitly but implicitly, by clinical judgments. These vary between doctors and between regions and do not relate strongly to patient-experienced health status1. Consequently, we have a poor understanding of the health status of patients on waiting lists, and variation in general practitioner (GP) referral practices leads to differences in apparent need. Simple target-setting is therefore also divorced from NHS equity goals. In this paper we suggest a way forward. We describe moves towards explicit prioritization of patients in other countries, particularly New Zealand. These experiences suggest new directions for the NHS—and pitfalls to avoid.
Box 1 summarizes the benefits and drawbacks of explicit prioritization in principle. The NHS is not pursuing improved waiting-list management in isolation2,3: explicit criteria for prioritizing access to surgery have been or are being implemented to varying degrees in several countries, including the UK4,5,6,7,8,9. However, to date, there has been little opportunity to evaluate the successes and failures of these systems in practice10. Experience in New Zealand provides an opportunity to explore the outcomes of explicit prioritization.
New Zealand introduced a nation-wide system for explicitly prioritizing and booking patients for elective surgery. Most of the clinical priority assessment criteria (CPAC) include a range of dimensions (clinical health status, patient-experienced health status and social), scored according to severity and added to provide a total score ranging from 0 (lowest priority) to 100. Financial threshold scores indicate the points required by patients to receive treatment funded from existing budgets. The system as it was conceived16, and as it has changed17,18, is described elsewhere. Box 2 presents an example of patients' journeys through the New Zealand ‘booking system’ as it was implemented in 1996.
Box 1: Explicit prioritization: pros and cons
Some of the difficulties encountered by the New Zealand system were contextual; it was introduced at a time when health funding was declining19. The existing internal market contributed to the establishment of different financial thresholds, different financial arrangements and the use of different CPAC tools for the same surgical condition17. In appraising the system it is helpful to look separately at the prioritization component and the booking component.
Many of the difficulties were attributable to the CPAC. These were inadequately evaluated before introduction, being assessed only for agreement with clinical judgment16. When CPAC were evaluated they were found to have poor reliability and validity20,21,22, and not to relate strongly to patient-experienced health status23,24 or serious health outcomes, including mortality25,26. Some patients reported that the process of CPAC ‘scoring’ detrimentally affected their relationship with clinicians; the method complicated the path to reassessment and was unresponsive to their preferences regarding treatment23. This drawback was even more obvious when health professionals other than surgeons completed the CPAC. Scoring also seemed to interfere with discussions that ought to occur between surgeons and patients about anticipated risks and benefits of surgery—again particularly when the scoring was undertaken by someone other than the surgeon.
Some clinicians reacted negatively22, and suspected that the motivation for explicitness was not to improve patient prioritization but simply to manage the allocation of scarce resources through financial thresholds27,28. Explicit prioritization highlighted tensions between processes determining access for groups, and traditional doctor—patient relationships emphasizing standards of care for individuals29, leading to concerns that patients and doctors would ‘game’ the system. In practice, a regional study found that few patients received surgery beneath the financial thresholds for surgery—i.e. there was little gaming by patients23. One clinician openly expressed willingness to exaggerate the severity of patients' conditions if he judged that this would ensure surgery for those who needed it; but many clinicians rejected this approach as unfair to other patients.
Box 2: New Zealand's ‘points system’
In New Zealand, patients' journeys through the booking system began on referral to specialist clinics at a public hospital. Letters of referral were evaluated by hospital staff using explicit access criteria for first assessment (ACA), and patients were prioritized for outpatient appointments according to their ACA. At outpatient clinics, if specialists determined that patients were likely to benefit from surgery, patients were prioritized for surgery according to clinical assessment criteria (CPAC).
Financial thresholds (CPAC scores at or above which surgery was to be provided) were calculated for each CPAC tool from historical rates of referral, case complexity and funding provided. People with CPAC scores at or above the financial threshold were to be booked for surgery within six months of their outpatient assessment. Those scoring below the financial threshold were to be referred back to their original healthcare provider for ongoing care and treatment. If their conditions worsened they were to be re-referred, reassessed and rescored by CPAC.
New Zealand's system also generated important positive outcomes, many of them associated with the booking of patients for surgery. Patients who scored above the financial threshold, and were guaranteed surgery, seemed much more satisfied than patients on waiting lists under the implicit system23. This tended to be so even when patients were not provided with set dates for surgery far in advance: the certainty of treatment within the next six months (or longer) was the crucial factor.
Many patients expressed support for mechanisms allowing faster access to surgery for those with severe conditions, sometimes even when they personally had been denied access. However, this may change if inadequate funding denies access to many patients with clear needs—or if patients become less altruistic23.
The CPAC, despite their flaws, also provided positive outcomes. More is known about regional inequities and differences in the financing of elective surgery than was known under the previous implicit system30. The system revealed that some patients were not gaining access to surgery simply because financial thresholds were higher in some parts of the country than in others. This observation prompted a debate on equity issues in funding for elective surgery.
Importantly, each of the CPAC included some measures of patient-experienced health status. This contrasts with implicit prioritization, where clinicians vary in the consideration they give to such matters. Further, use of explicit tools permitted evaluation of the health status and outcomes of patients in relation to the criteria. Although research has revealed questionable relationships between CPAC tools and patient health status or outcomes23,24, the strengths and weaknesses of the new system are more clearly identifiable than those of implicit prioritization, in which the three priorities (A, B or C) are assigned without explanation1.
Do the difficulties experienced in New Zealand and elsewhere mean the NHS should steer clear of explicit approaches to waiting-list management? Many of those described above are largely avoidable. By contrast, there is no obvious solution to the problems of waiting-time targets if the NHS continues to rely on implicit prioritization1. The benefits apparent in New Zealand argue for a change of approach to waiting in the NHS, though the way forward must be plotted with great care. The NHS should not simply adopt prioritization criteria from other countries, particularly when these have shown scant relation to patient-experienced health status—the core issue for much elective surgery23,24.
The first step should be agreement on the purpose of waiting-list policy. Is it to reduce the numbers of people waiting for surgery? To reduce the average time spent waiting for surgery? To improve the health status of patients waiting for treatment? Or is it to ensure that those with equal need gain equal access to treatment irrespective of where they live—and that those in greatest need gain quickest access?
Waiting times and numbers targets do not address the latter aim and, as we pointed out in part 1, distort clinical priorities. Explicit ordering of people on waiting lists is necessary both to ensure equal treatment for equal need and to ensure that the NHS budgets yield the greatest possible improvements in health.
Priority criteria could initially be used in conjunction with waiting-time targets, to overcome perverse effects on priorities. Longer-term appropriate thresholds could be determined. Thresholds, together with other current strategies31,32,33,34, could facilitate sophisticated ‘whole systems’ management of waiting lists and resource allocation.
Great caution is needed in development of explicit criteria. No good tools exist to enable prioritization across a wide range of conditions or types of surgery24; and even if such instruments were available, they might not be acceptable to health workers or the public12,13. However, there are patient-experienced health status measures that relate to likely benefit from specific treatments, and these can help inform the ordering of patients. Where such instruments do not exist, clinicians and researchers should work with patients to develop and refine such tools. Explicit health status criteria ought not entirely to usurp clinical judgment: no patient should be prioritized for surgery when the clinician doubts the likely benefit. Clinicians must be actively engaged in the use, development and continuing improvement of explicit criteria35.
Concerns about gaming must be considered when more explicit approaches are contemplated12. However, gaming is not confined to explicit prioritization. Indeed, one of the reasons for implementing explicit systems is to address gaming within implicit systems. Probably a minority of patients and doctors will always exaggerate to obtain benefits at the expense of other patients. Explicit approaches provide opportunities to address this behaviour through clinical governance and through between-hospital and between-region comparisons. Prioritization criteria also offer information to planners and policy-makers about the actual situation for patients on waiting lists, and facilitate debate about the allocation of resources to groups of patients in greatest need—in accordance with the NHS aims of maximizing health gain and minimizing health inequalities.
Rather than building on the gains emerging from the explicit system, New Zealand has in some clinical areas returned to implicit prioritization based solely on clinical judgment18,36. This move is said to have been supported by clinicians. The motivation for the retreat from explicitness has not been clearly stated, but seemingly the reversion was not driven by a perception that the political costs exceeded the benefits3. The British NHS can learn from New Zealand's successes and mistakes and develop better approaches. There have long been calls for improved incorporation of patient-experienced health status: the time is now ripe for such a change—with prospective evaluation of the process and of the outcomes for patients and clinicians.
We thank Paul Zollinger-Read (Director of Demand Management, Modernisation Agency), Ruth Kipping (Primary Care Development Manager, Demand Management Team, Modernisation Agency) and Charlotte Paul (Department of Preventive and Social Medicine at the University of Otago) for helpful comments.