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Letters

Strategy to reformulate waiting lists

BMJ 1999; 318 doi: https://doi.org/10.1136/bmj.318.7199.1698a (Published 19 June 1999) Cite this as: BMJ 1999;318:1698

New Zealand has some suggestions for NHS priority system for elective surgery

  1. Janine Cochrane, Project leader for booking systems (JanineC{at}HealthOtago.co.nz)
  1. HealthCare Otago, Private Bag 1921, Dunedin, New Zealand
  2. Health Authority ULSS 2, 32032 Feltre, Italy
  3. Booking Service, Health Authority APSS, 38100 Trento, Italy
  4. Paediatric Hospital “Bambin Gesy,” 00153 Rome, Italy
  5. 47037 Rimini, Italy

    EDITOR—I have some suggestions that the BMA might like to consider when it designs the NHS priority system for elective surgery.1 My four suggestions are: use a scoring system instead of “banding” patients; don't use the words “severity score”—instead use “priority score”; include consumers in the groups for developing the priorities; and set up a booking system when you introduce priority assessment.

    I recommend that patients are scored instead of banded because clinicians will be compelled to use the assessment tool to get a score (the alternative is to determine a category for the patient, based on the current clinical decision making). If you have to ration (determine to which level you can provide publicly funded operations) it is much easier to work with a scoring system as opposed to, for example, 25% of D category.

    We have found that the assessment tool (and score) should reflect ability to benefit from surgery as well as “need” factors. If you use only severity as an indicator then all patients for day surgery will wait for a long time or miss out on their surgery. This, in fact, is a group who benefit greatly for each health dollar/pound spent on them, both directly and indirectly (days off work, quality of life, etc). To determine your priority assessment tool, please include consumers. Consumers are good at prioritising benefit and need and are essential to getting the community to “buy in” to the scheme and for transparency to priority setting.

    Giving people an idea of when they will receive their treatment means changing the way that waiting lists are managed. The main impact in our system has been projecting out our surgical booking lists to six months. I don't think that you can introduce a priority assessment tool without looking at capacity and booking issues. If you start prioritising patients and give people certainty you need to be able to say, “Yes, we can carry out surgery on all of these people and the new patients expected each month within this time frame.” If you are not able to do this then you have to determine the level to which you will be providing elective surgery.

    References

    1. 1.

    Italy's public health system is changing from waiting times to priority

    1. Giuliano Mariotti, Medical director (mariotti{at}tqs.it),
    2. Rosanna Sommadossi, Trained nurse,
    3. Tommaso Langiano, Medical director,
    4. Roberto Raggi, Public health consultant
    1. HealthCare Otago, Private Bag 1921, Dunedin, New Zealand
    2. Health Authority ULSS 2, 32032 Feltre, Italy
    3. Booking Service, Health Authority APSS, 38100 Trento, Italy
    4. Paediatric Hospital “Bambin Gesy,” 00153 Rome, Italy
    5. 47037 Rimini, Italy

      EDITOR—Fricker reports that the BMA proposes a strategy to reformulate waiting lists in the United Kingdom.1 In the public health system, issues such as priority setting and appropriateness ratings in the referral of patients by general practitioners to specialists are usually faced in a hard (top down) way. Negative or positive lists exist or protocols are set up, commonly by insurance or government bodies, that have to be used by all professionals concerned.

      In some areas of the Italian public health sector we are now experimenting with dealing with this matter in a soft (bottom up) way. General practitioners and specialists are called together to set up criteria for a simple priority model by specialty; each higher priority level contains more causes (and other clinical signs or facts) for referral, related to the consequences that delay of non-emergency care (diagnostic procedures in particular) would have.

      Each priority level has its own space on the specialist timetable, and bookings are given by a booking centre, where staff have received full instruction on the procedures after common planned criteria in identifying the right level (and, consequently, the right time for the consultation) have been met. Specialists are asked to report if patients they checked were not appropriately booked, and monitoring of these reports gives the chance for remodelling and strengthening the model.

      First results are positive, and the appropriateness of the referral system is improving quickly. A composite evaluation by specialists of 570 cases from the quoted surgeries was performed; in 67 of these cases the waiting time was considered to be delayed, in 53 cases it was early, and in 446 cases it was appropriate. (In the remaining four cases prescription was considered to be inappropriate.) We are now working with general practitioners to identify more clinical data able to define clinical categories with different levels of priority and to simplify the booking procedure; the general practitioner will define his or her prescription as priority A (or B or C or D).

      We will be able to identify major results as soon as the model starts in other areas of the Italian public health sector. We think that both an improvement in accessibility to healthcare services and a more effective allocation of the resources will be important consequences of this model.

      References

      1. 1.
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