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Is it time to review waiting lists?

10 Jul 2014

Miss Clare Marx 

President of the Royal College of Surgeons

How does the question: “Would I be happy to be treated in this way if it were me or a member of my family?” help surgeons to address waiting times?

When we are treating patients referred for surgery, their individual clinical need is paramount. No-one should wait longer than necessary to have an operation. On occasions time is needed for detailed planning, tests, skilled interventions, specialised equipment to be ordered and high dependency post-operative beds reserved and some patients have complex medical conditions. All of this results in a necessary delay. At other times delays could be eliminated by better pathways of care and the standardisation of processes.

Waiting time targets are a visible part of the NHS’s constant struggle with rising demand and financial constraints on supply. As surgeons, we have experienced the effects of initiatives by successive governments’ to tackle the queue for care. Three years ago, David Cameron set out his commitment to the NHS and noted the importance of waiting times. Information on waiting times was thought to help patients choose which hospital they would attend.   It is not known how much patients do study and compare waiting times between hospitals as this is only one of the factors in their choice.

Waiting lists are just one part of the NHS’ duty to provide excellent healthcare but an area of particular concern to surgeons.  At a time when the future of the NHS, its funding, its purpose and its structure is once again dominating debates at Westminster, we need to establish what patients particularly value from the NHS and what can realistically be delivered given current financial constraints.  As there is an 18 week line in the sand why not ask the patients the question “would you accept us prioritising patients so that if your condition warrants it, you will be treated faster, but if it is less serious, you will wait a little longer? “ I believe that the target of an 18-week maximum wait from referral to treatment for elective (non-urgent) care is too blunt an instrument. Past and the current government have supported this logical target but we should not accept it as the only criteria for when patients are treated. Clinicians should have flexibility to prioritise those cases we know to be more urgent. There is the two-weeks to outpatients target for cancer referrals, but what about other urgent conditions? Take for example patients who need a gall bladder operation, one may be able to wait while others may need rapid treatment to avoid dangerous inflammation of the pancreas.

The target of 18-week maximum wait applies to 90% of patients, so there is 10% tolerance.  The 10% who exceed the target should be those who have either chosen to wait longer or for whom the wait is clinically appropriate. Most surgeons are not comfortable that clinical priority really has been applied to identify those who could wait and that reviews are in place to check that the delay is still clinically appropriate for those initially identified as less urgent.

Managing the gap between demand and supply in healthcare has thwarted and perplexed successive governments. In 1948 the NHS took on a waiting list of over 476,000 patients.  Three years later, that list had grown to 504,000, apparently due to limited investment in facilities such as beds. Waiting lists may be an inevitable part of the NHS but we should strive to ensure they are better managed by clinicians and administrators.

No one wants to see waiting times rise again. Now there is a real opportunity to hold informed conversations between the public, those who commission health care, politicians and the medical professions on the best options for managing current waiting lists. Subjects to be covered include the best use of current funding, or even additional funding, but also the provision of consistent quality in seven-day care, particularly for emergency work. For discussion too should be the stream-lining of practices, diagnostics and theatre availability and fully utilising the skills of the many surgeons already work on Saturdays and Sundays.  My own experience of Trauma lists at weekends including treating broken hips more efficiently is that this approach helps lower complications, lengths of stay and mortality rates and also improves the chances of a full recovery for many patients.  In the end this reduces costs and the impact on the stretched elective services. These types of initiatives and changes could be applied with advantage elsewhere in the NHS.

Surgeons have essential knowledge and experience and will be fully engaged in the debate on how to offer patients the best possible service, at the right time when they join the queue for care in a system which has capacity constraints.

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