MANAGING WAITING TIMES: A GOOD PRACTICE GUIDE
MANAGING WAITING TIMES
1.1 WHY WAITING TIMES ARE IMPORTANT
Waiting times are important to patients because:
The patient's condition may deteriorate while waiting and in some cases the effectiveness of the proposed treatment may be reduced.
The very experience of waiting can be extremely distressing in itself.
The patient's family life may be adversely affected by waiting.
The patient's employment circumstances may be adversely affected by waiting.
Excessive waiting times may be symptoms of inefficiencies in the healthcare system and should be addressed as part of good management.
A comparatively short period of waiting which is managed in the patient's best interests may support the appropriate scheduling of routine and emergency care and ensure the most urgent patients are seen first. Excessive waiting times, however, must be reduced. The Health White Paper, "Partnership for Care", holds NHS Boards accountable for a three-tier approach to improving waiting times by:
1. Ensuring that national targets will be met.
2. Ensuring that condition specific targets set by NHS Quality Improvement Scotland are delivered.
3. Requiring NHS Boards to set challenging local targets which reach and then exceed national targets.
The national waiting time standards which all NHS Boards must achieve as a minimum are outlined in Appendix A of this guide.
1.2 THE REASONS FOR UNACCEPTABLE WAITING TIMES
There are a number of reasons why waiting times may become unacceptable:
1. There may be insufficient provision of services to meet demand.
2. There may be poor management of additions to the waiting list. This may result in patients being added to the waiting list before they are ready for treatment or added for treatments that later prove to be inappropriate.
3. There may be poor management of admissions from the waiting list. This may result in patients waiting longer than necessary as patients are admitted in any order, without adequate consideration of each individual patient's waiting time or clinical urgency.
4. There may be poor administration of the waiting list and poor communication with patients. This may result in waiting list information being out of date and patients not being properly informed of admission dates.
The patient also has important responsibilities in supporting the efficient use of healthcare resources and shortening waiting times by:
providing accurate information to healthcare professionals;
updating general practice and hospital services of any changes in circumstances, and in particular changes in contact details;
attending appointments as arranged and avoiding cancelling appointments at short notice.
1.3 IMPROVING WAITING TIMES
To be effective, plans to improve waiting times should take account of the entire waiting time journey, commencing with the initial outpatient referral and working through assessment and diagnostic tests to treatment and discharge from hospital.
To effectively develop plans to improve waiting times, each health system should:
Manage Demand - ensuring each referral represents the most appropriate decision for the care of the individual patient.
Manage the Queue - ensuring waiting lists are well managed and patients are called for treatment in appropriate order.
Manage Capacity - providing efficient and effective services that meet the level of demand from appropriate referrals.
Provide Leadership - ensuring that all parts of the local NHS work together to achieve waiting time improvements in the best interests of patients.
Management of Demand
A patient's waiting time normally commences within primary care. There should be a close partnership between primary and secondary care in managing and delivering improved waiting times. This should include shared information on waiting times and agreement on local waiting time standards to be set.
Referral protocols should be utilised as appropriate to identify the most effective referral options for patients and the most effective use of both primary and secondary care resources.
The number of referrals received from primary care is the initial indication of demand for services within secondary care. The referral process should be actively managed and the number of referrals received should form a basis for calculating the level of services to be provided.
Management of the Queue
A waiting list is simply a queue of patients waiting for treatment. Every patient waiting in this queue has a valid expectation of treatment within a reasonable period of time. Waiting lists should be regularly reviewed to ensure they are accurate and it should be possible at any time to access up-to-date information on any individual patient on the list.
Patients should be called from a waiting list in order of clinical priority and within agreed waiting time standards. Patients with similar clinical priority should be admitted predominately in the order of the longest waiting patients first.
Management of Capacity
Waiting time standards should be delivered on the basis of a clear capacity plan. Referrals indicate the level of demand and the waiting list shows clearly how many patients are waiting and how long they are waiting. It should therefore be possible at any time to assess the level of capacity required to maintain a waiting time standard. Clinical activity plans should be set to take account of the assessed capacity required to maintain acceptable waiting times.
Potential pressures on waiting time standards should be identified at an early stage, for instance an increase in the number of outpatient referrals, additions to the waiting list, emergency admissions or reduced capacity. Regular and effective performance review will identify requirements for management action which should be taken to ensure waiting time standards are maintained.
The number of patients treated is related to the efficiency of services. The effective utilisation of resources, for instance beds or theatre time, should be ensured through regular management against agreed efficiency targets.
There should be clear leadership and accountability within NHS Boards for the delivery of improved waiting times. It is recommended that a Board director leads a multi-disciplinary team drawn broadly from the local health care system, to provide leadership and direction in the reduction of waiting times.
Each NHS Board should have a detailed and comprehensive plan setting out the manner by which waiting time standards will be achieved and maintained. This plan should address the requirements of all patient groups who wait for treatment and address services from primary care through assessment and investigation to discharge from the treatment process.
Waiting Time improvement should not be seen as the responsibility of a narrow group of "experts" within a health care system. All of those involved in the care of patients who wait for treatment have a responsibility to ensure that patients are well informed, supported and wait as short a time as possible.
It is important to build a positive culture around the improvement of waiting times. Local standards should be set following discussion with clinicians, patient representatives and the general public. The benefits of improving waiting times should be understood by all, including the benefits to patients and to the efficiency of the NHS. No interested groups should be excluded from the process of improving waiting times.
1.4 WAITING LIST INITIATIVES
Increasing clinical activity to improve waiting times
Additional activity to improve waiting times may be provided for two purposes:
1. The short-term requirement to treat a "backlog" of patients on a waiting list and achieve an improved waiting time.
2. The long-term requirement to close any on-going gap between the number of patients joining a waiting list and the number of patients leaving a waiting list.
Treating a backlog of patients from the waiting list
A "backlog" of patients to be seen from an outpatient or inpatient waiting list may take two forms:
1. The number of patients waiting longer than the waiting time standard which is to come into force.
2. The extent to which the current waiting list is too large to allow the maintenance of the waiting time standard. Whilst a waiting list size is not an objective in itself, a specific maximum waiting time will only be maintained if the waiting list is not over a manageable size.
It may be possible to admit a backlog of patients through improved efficiency and improved queue management. If this is not possible, then a one-off waiting list initiative may be required to see additional patients.
Waiting list initiatives may be used effectively to reduce the number of patients waiting and ensure a waiting time standard is achieved at a point in time. A waiting list initiative, however, will not necessarily ensure a waiting time standard is maintained.
The inappropriate use of waiting list initiatives will undermine the maintenance of waiting time standards. Waiting list initiatives should not be employed in isolation as a short-term means of attempting to solve long-standing problems resulting from poor demand management, poor waiting list management or insufficient capacity to treat patients.
Closing the gap between demand and capacity
Closing a recurrent gap between demand and capacity requires a different approach from treating a non-recurrent backlog of patients from the waiting list. It is necessary to project the expected recurrent difference between the number of patients joining the waiting list and the number of patients leaving the waiting list. Efficiency measures and additional resources should be agreed as appropriate to bring into balance the number of additions to, and removals from, the waiting list.
It should always be understood that the non-recurrent requirement to treat a backlog of patients on the waiting list is not the same as the recurrent requirement to close any gap between demand and capacity. The first approach may ensure that a waiting time standard is achieved, the second approach is designed to ensure that the standard is maintained.
1.5 THE 10 'GOLDEN RULES' FOR WAITING TIME MANAGEMENT
1. The patients' interests are paramount.
2. Referrals for health care services should be clinically appropriate and directed towards the most suitable service.
3. Adequate services should be available to meet appropriate referrals for assessment and treatment.
4. Patients should be offered care according to clinical priority and within agreed waiting time standards.
5. Patients should be advised of any waiting time standard that applies to their treatment and kept up-to-date on their expected waiting time.
6. Health care services should maintain accurate and complete information on patients waiting for treatment and provide patients with clear guidance to be followed when notifying any changes in contact details or availability for treatment.
7. Patients should be clearly advised of the action that will be taken if they fail to attend for an appointment and failures to attend should be minimised.
8. Improvements in waiting times should be delivered through an effective partnership between Primary and Secondary Care, with appropriate protocols and documentation in place for referral and discharge.
9. The factors which influence waiting times, such as changes in referral patterns, should be regularly monitored and management action taken in sufficient time to ensure waiting time standards are maintained.
10. Leadership and accountability for the improvement of waiting times should be explicit within each NHS Board area and staff should be adequately trained to ensure waiting times are managed and administered effectively.
1.6 DEVELOPING LOCAL PLANS TO DELIVER WAITING TIME STANDARDS
The Health White Paper, "Partnership for Care", requires NHS Boards to have in place local plans to deliver a three-tier approach to improving waiting times by:
1. Ensuring national targets will be met.
2. Ensuring that condition specific targets set by NHS Quality Improvement Scotland are delivered.
3. Setting and delivering challenging local targets which reach and then exceed national targets.
The requirement for each NHS Board to develop and implement local programmes for waiting time reductions has been set out in the 2002/03 and 2003/04 guidance for the completion of Local Health Plans.
NHS Boards are required to:
Set challenging local targets for their inpatient, day case, and outpatient services. They will demonstrate the progress which each Board is expected to make in reaching and then exceeding our national guarantees.
NHS Boards should ensure that the whole patient journey is addressed, including waiting times for outpatients, inpatients/day cases and diagnostic tests.
In setting local waiting times standards and laying the foundation to achieve the National Waiting Time standards, NHS Boards should consider the relevant risks/opportunities within their own local system (e.g. winter pressures, junior doctors, hours of work, service redesign projects and organisational development).
Waiting time improvement plans should set out clearly any manpower or other resource implications necessary for the successful attainment of national and local standards.
NHS Boards should consider how they consult with appropriate bodies to ensure that patients' views are reflected in the selection of local standards.
NHS Boards and Trusts are encouraged to consider how best to link across existing organisational boundaries both internally and within NHS and externally with other organisations.
NHS Boards Local Health Plans will be supported by implementation plans for waiting times which are both specific and detailed.