Priorities for Health: Waiting Times
November 2006
Introduction
For individual patients waiting for NHS treatment can be a difficult time and it is important that those with the greatest clinical need receive appropriate care within a reasonable timescale. The BMA has welcomed recent waiting times figures that demonstrate the commitment and hard work of NHS staff to achieve targets. Targets to reduce waiting times to 18 weeks will present a real challenge to NHS managers and it is important that they work with clinicians to design services in a way that delivers on this target.
Waiting times for elective surgery has become the benchmark of success for the NHS in Scotland. Elective surgery accounts for a small amount of total expenditure on health but, because it can be measured, it has an inordinately high political priority.
In August 2006, BMA Scotland conducted a survey of members to identify their priorities for health. Around 600 doctors from all branches of the profession responded to the survey and their priorities for waiting times and service redesign are reflected in this policy briefing.
Waiting times targets in NHS Scotland
In general terms the number of patients waiting for treatment and the length of time they wait is falling in Scotland. Many targets to reduce the longest waits for patients by 2005 have been achieved. For example:
- 18 weeks from GP referral to outpatient appointment
13,148 patients were waiting more than 18 weeks for treatment in March 2006. This is a reduction of more than a third on figures for March 2005. - 18 weeks for inpatient care
6117 patients were waiting more than 18 weeks for inpatient care in March 2006. This is a reduction of almost 50% for figures in the previous year.
Prioritising care
Doctors believe that waiting list initiatives have distorted clinical priorities in the past resulting in patients with less serious complaints being treated before those with more complex medical problems. 98% of doctors who took part in the BMA survey said that patient waiting times should be based on the individual patient’s clinical needs and not political targets.
Doctors believe that NHS managers should encourage local innovations led by clinicians which would have a positive impact on waiting times. 84% would back a system where waiting times for services with outcomes that are not easily measured (e.g. mental health) are given equal, if not greater, priority than current targets for certain types of elective surgery.
The BMA does recognise that targets are necessary to help governments demonstrate and measure progress. However, the BMA would call on the political parties to work in partnership with clinicians to develop targets that are meaningful, relevant and that deliver benefits to patients who are most in need of care.
Accident and Emergency waits
In 2005, the four hour target for A&E waits was introduced in Scotland [Reference 1]. By the end of 2007, patients are due to wait only four hours from arrival to admission, discharge or transfer.
According to a BMA Survey of A&E departments in England (where a 4 hour target has been in place since 2002), 11% of patients waited more than four hours [Reference 2]. The main reasons for delays were waiting for admission and waiting for treatment.
The BMA has expressed concerns of the threat to patient safety from the pressure to meet the four-hour target. In England, doctors complain that care has been compromised, patients have been discharged too quickly and that some patients were being moved to inappropriate areas or wards.
In order for waiting times targets to be sustainable, they need be developed in discussion with the clinicians delivering the services and receive support from management for hospital-wide changes.
Waiting times for diagnostic services
In 2005, a target of 9 weeks maximum wait for diagnostic testing was introduced, to be achieved by 2007 [Reference 1].
Figures on the number of patients waiting for access to diagnostic services are not available centrally. However, recent media reports claim that patients are waiting for as long as 36 weeks for “brain scans, heart checks, endoscopy and other procedures”, while in Lanarkshire patients wait up to 18 weeks for a CT scan. In Fife, patients can wait for as long as 20 weeks for an ultrasound and in Grampian 22 week waits for an endoscopy [Reference 3].
Investment in NHS mobile diagnostic units (and the staff and other resources required to run them) would provide a practical way in which long waits for diagnostic interventions can be provided to patients without having to travel to the hospital. Waiting for diagnostic tests delays access to specialist treatment and must be addressed as a matter of priority.
Availability status codes (ASC) will be abolished by end 2007
In June 2006 more than 35,000 patients waiting for inpatient or day case treatment had been given an availability status code: almost one third of the total waiting list [Reference 4]. For these patients, waiting times guarantees do not apply. This is an increase of almost 5% on figures from 2004, but similar to figures in 2005.
ASCs were initially introduced to reflect that, for a small number of cases, it is not always possible to treat patients within the waiting times guarantees for either clinical or personal reasons. These ASC codes were never intended as an administrative loophole to hide patients who could not be treated within waiting times guarantees. For that reason, BMA Scotland has welcomed plans to abolish these codes in 2007. However, it should be recognised that for some cases it will not be possible to meet waiting times guarantees and mechanisms must be created for dealing with such cases to ensure that these patients do not fall through a gap in the system and lose out on appropriate and timely treatment.
Access: local service configuration
Doctors believe that local service configuration of health services should be based on clinical need and patient safety and where decisions are taken on service redesign, that they involve doctors and the public in consultation.
Those with responsibility for service configuration must consider how they can best provide services that are safe for patients. Implicit in this will be the question of distance that patients are required to travel to receive care. It would be naive to assume that the same service or choice of service can be immediately available to a patient in a remote sparsely populated area and a patient in a densely populated urban area. In some cases, in order to access the best quality care, patients will have to travel. However, this does not preclude the provision of less complex care closer to home. Of doctors who took part in the BMA Survey on priorities for care, 86% said that where patients are required to travel for specialist treatments, it was important for transport networks to be improved to facilitate access.
The current strategy to shift service delivery outside of hospitals and into local communities is one that has been welcomed by the medical profession. However, 92% of doctors in the BMA survey agreed that this should not be seen as an opportunity to reduce funding from hospital services.
While certain types of procedure can be undertaken in smaller, local units, there is still a requirement for specialist doctors who undertake complex procedures to do so regularly if they are to maintain their skills and provide safe patient care. Consultants also have a commitment to train the next generation of junior doctors who need experience to develop the necessary skills. In some cases, small units will not generate enough activity to maintain the skills of the current workforce or contribute to the skills of the next generation. More thought should be given to how services and training can be delivered in the variety of NHS settings.
The provision of more concentrated services does enable clinicians to provide a better quality and wider ranging service. As part of a larger ‘team’ of consultants within a specialty, there is additional scope to organise core responsibilities such as management, teaching and research, audit and professional representation. However, the flexibility of working within a larger team creates an opportunity to devolve work to provide services in smaller, more local satellite units in order to ensure continuity of care for patients.
Recommendations
- Establish waiting times that are based on the individual patients’ clinical needs.
- Encourage local innovations led by clinicians which will have a positive impact on waiting times.
- Give waiting times for services where outcomes are not easily measured (e.g. mental health) equal, if not greater priority than current targets for certain types of elective surgery.
- Make sure that decisions on local service configuration are based on clinical need and patient safety.
- Ensure that the shift away from secondary care into primary care is not seen as an excuse to reduce funding for hospital facilities.
- Improve transport networks to facilitate access where patients are required to travel for specialist NHS treatments.
References
1. Waiting Times Targets National Services Scotland [http://www.isdscotland.org] June 2005
2. BMA Health Economic Policy Research Unit Survey of Accident and Emergency Waiting Times, BMA; London; 2003
3. R Gray NHS scan delays ‘put lives at risk’ Scotland on Sunday 13 August 2006 . They report that, in Greater Glasgow and Clyde, patients are waiting 27 weeks for MRI
4. ISD Scotland Inpatient, day case waiting list census NHS National Services Scotland, August 2006
For more information contact:
BMA Scotland Public Affairs Office
Tel: 0131 247 3050/3052
Email: press.scotland@bma.org.uk