Facts and Opinions: Hospital Wait List Lessons From the UK
The barriers to change were substantial; the UK system had not been through the years of reengineering and restructuring that many provinces in Canada have experienced. The result initially was shock, followed by the realization that hospitals did not know how to start to deal with the problems. This led to many false starts and embarrassing media reports.
The government initially chose to take a strident shame-orblame approach, using a method that resulted in public exposure on a regular basis. Chief executives in hospitals that didn't conform were removed. Fear was the main motivation for change. The levels of resentment increased, and finally the government took a less aggressive approach. Fear only worked for a short time.
Getting compliance internally was easier in the UK than it may be in Canada; many more physicians in the UK are on salary (or some other sessional payment scheme), and so conformance with a hospital-based wait list process was easier to implement in the UK than it may be in Canada. In addition, unlike in Canada, where physicians' secretaries are often the only people who know the extent of the wait, procedure, scheduling and the documentation of wait lists, in the UK, this information was already administered by the hospitals.
Another issue facing hospitals in the UK was the extensive (some would say excessive!) governmental reporting requirements. The government initiated a "star" ranking system, which required hospitals to report annually on 140 key performance indicators. Based on the performance of the hospitals on these 140 indicators, the hospitals achieved zero- through three-star ratings. The results were made public. In addition, they were either rewarded with more money or penalized by having the equivalent of an operational review. Hospitals already had to report case costs, and each year, case-costing was expanded to other areas of activity such as ambulatory care, community care and more. Currently, some funding in the UK is based on case costs, and all hospital funding will be in the near future. Hospitals suddenly had extensive reporting requirements that weren't just paperwork; serious funding was at stake and careers were on the line. So in a matter of a few years, hospitals became inundated with reporting requirements that required increased staff to accomplish, with no new resources. Staff that had been hired in the past to collect data and submit it to government suddenly had to become information experts.
Put simply, reducing procedure wait lists requires increased patient throughput. Beds could be freed up by reducing lengthof- stay, but other resources, such as operating room time, pharmaceuticals and physicians could not be easily made available to increase throughput without additional fiscal resources. In addition, unlike in Canada, UK hospitals were in a system where patients who lived in their area went to that region's hospital. Competition and patient choice didn't really exist (that is changing in the UK now). That meant that, if a hospital was in an area with long wait lists, it was still the only provider; therefore, the hospital was perceived to be the source of the problem. If, due to a problem in a region, a particular hospital didn't achieve targets, then it lost stars, which meant it lost new money and possibly jobs.
As mentioned, there were false starts. One notorious false start was the issue of urgency. Hospitals were given a strict government directive to reduce waiting; target months were announced. Hospitals did what they were told: they brought in tattoo-removal cases that had been waiting for 18 months and cancelled relatively urgent procedures that had only been waiting six months. Hospitals met the targets, but the media quickly exposed the impact of the directive when physicians and patients wrote in about the situation. The politicians looked ridiculous for a while, but they learned from their mistakes and changed guidelines to factor in urgency.
Issues continued; a few hospitals played within the rules - for example, offering surgery when it was known that the patient couldn't make the appointed date, so that the reason for cancellation was patient-based and, thus, the wait list clock could be reset to zero. A few hospitals were less subtle and simply used creative bookkeeping; a few chief executives were fired as a result!
More recently, the government came to the realization that reducing wait lists means more throughput, which means either you give the hospitals time to achieve efficiency targets, or, if they are efficient, you give them more resources. Although many argue that Blair never gave hospitals time to become efficient, the government has finally put considerable resources into the system to try to fix the problem and although this system still has issues, the situation is beginning to resolve, with wait lists much reduced.
Canada has started down the same path of wait-list management. Giving resources to inefficient hospitals would be a waste, and withholding resources from efficient hospitals will cause unnecessary patient wait times. Some provinces have already spent many years achieving efficiency levels; others have yet to begin. Canada does not currently have comparable national standards for efficiency. Canada needs a set of measurable and achievable standards of efficiency, then after deciding on appropriate wait times, provide resources accordingly.
About the Author(s)
Michael McCartney, President,
Clinsaver Software Inc. and McCartney Consultants Inc.
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