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Austerity and waiting times (2)

22/06/2010
by Rob Findlay

In the first part of this posting we looked at austerity and waiting times from the hospital’s point of view. Here, we will look at it from the commissioner’s perspective (which is similar to that of senior hospital managers who are deciding how to allocate resources).

Waiting times – the commissioner’s perspective

As commissioners, we are often asked for money; we have to know when to say “yes” and when to say “no”. But this can be very difficult, especially when we cannot get hold of all the information we need to make a proper informed judgement.

Bids for extra resources to prevent waiting time breaches are a case in point. It is easy for a provider to show us that they are breaching the target. What is harder to establish is whether they could solve the problem themselves without extra resources.

For instance, imagine that our local hospital has a service that is struggling with the waiting time target, and they send in a request to increase contracted activity. The number of patients waiting longer than the target has been rising. So has the total number of patients waiting. They say they have done everything they can to pool activity, reduce demand, reduce inappropriate referrals, and so on, and actually we believe them. They say the only option left is to do extra activity to reduce the size of the waiting list. What they don’t tell us, though, is the detail about how they are scheduling patients.

We know that good scheduling can often solve a waiting time problem without any extra resources being needed. How can we tell whether this request for extra activity is justified, or whether better scheduling would do the trick?

There are two ways of doing this: examine the data, or examine the processes.

Let’s look at the data approach first. We want to work out whether this service would have a waiting time problem if it were well-managed. This turns out to be quite a complicated calculation, and in practice this would be performed by a good planning tool*. The result of the calculation will be the achievable waiting time target, and if this is less than the target in force then better scheduling should solve the problem.

As an alternative, we could use a good simulator to investigate whether good booking practices would bring the service back within target.

Or we could use a process-based approach. We want to assure ourselves that capacity is being correctly partitioned between urgent and non-urgent bookings, and that best practice is being followed when issuing patient appointments.

If the service is using a good automated booking assistant then they can demonstrate good practice using the system’s compliance log. Otherwise we will need to examine their processes in detail and check that casemix urgency has been properly evaluated, that the booking template is correctly designed, and that the rules used to allocate appointments are correct and are being followed accurately.

It all sounds quite involved, so is it worth it? When a “waiting list initiative” for inpatients can easily run to six figures, the answer must surely be “yes”. If that kind of money is spent in the wrong place, then it isn’t available to spend where it is really needed. That could make the difference between success and failure when austerity clashes with waiting time targets.

*e.g. the rule of thumb for a list with fully-booked, well-managed scheduling, and a target that 90% of activity must be admitted within target, is:
Achievable waiting time target in weeks =  1.25 * ( number waiting / average additions per week – ½ * maximum weeks waited by any urgent * proportion of urgents in casemix ) / (1 – proportion of urgents in casemix)+ 16 * (proportion of removals) – 3.5
Different formulae apply for partial booking, snapshot based targets, and very high proportions required to meet the target; a ready-reckoner is included in Gooroo SimActive’s Booking Rules calculator. Training packages, scheduling assistance, booking simulation, planning software, and research papers can all be found on the main Gooroo website.
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