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Minimum waiting times, and hopelessness

08/08/2011
by Rob Findlay

As British schools broke up and everyone headed off for their summer holidays, the Co-operation and Competition Panel (CCP) published their final report on Any Willing Provider. One passage that caught journalists’ and commentators’  eyes was this (para. 91):

The imposition of minimum uniform waiting times at providers [by PCTs] also appears reasonably widespread.

The CCP reported that PCTs claimed two benefits of minimum waiting times.

  • more equitable treatment for patients across different providers;
  • reduced expenditure for taxpayers.

The CCP criticised the first as “an unfortunate levelling-down”, and the second as a “one-off benefit that cannot be repeated”. In response to the argument that longer waits can save money as patients remove themselves from the list, they said (in a much-reported footnote to page 29):

We understand that patients will “remove themselves from the waiting list” either by dying or by paying for their own treatment at private sector providers, and that there is a relationship between the self-pay market in private healthcare and the length of waiting lists in the NHS. However, research suggests that the effect of increasing waiting times at all hospitals is unlikely to be significant. A 10% reduction in waiting times is associated with an increase in demand of between 1.35% and 2.35%. Assuming increases and decreases in waiting times have a similar effect, it is likely that an increase in waiting times will have a small impact on overall demand for services.

Actually a 2 per cent fall in elective demand sounds like a very useful saving to pocket, in return for a small increase in waiting times from (say) 15 weeks to 16.5 weeks. Unfortunately the CCP do not provide a reference for their statement that “research suggests” this. There is other evidence that waiting times over 10 weeks may deter patients: RAND Europe, City University  and the King’s Fund surveyed patients’ attitudes to waiting times in 2006, and found (in para. 5.3.2):

For waiting times of 8 weeks or less, a change in waiting time is valued as zero. That is to say, on average there is no benefit from reducing the waiting time from referral to treatment below 8 weeks. Once the waiting time reaches 10 weeks, there is, however, a step change where the increases in waiting time are valued negatively (and significantly different from zero). It can be seen that the rate of change is relatively constant, implying that for waits of 10 weeks and above the valuation of waiting time increases approximately linearly.

In other words, patients are unfazed by waiting times under 10 weeks. But when waits are over 10 weeks, every extra week adds the same amount of extra disincentive. Whether this disincentive actually translates into reduced demand, unfortunately, is not something that RAND et al come to any clear conclusion about.

So what about the argument, advanced by the CCP and others, that it is pointless trying to save money by lengthening waiting times, because you only get the savings once? I think most commissioners would respond (as some did to the CCP) that once is better than never, and that if the requirement is 18 weeks then why divert scarce resources towards even-shorter waits for the least-sick patients in the system?

But I think minimum waiting times are objectionable for another reason: they create hopelessness.

Waiting times and waiting lists are not simply the balance of activity and the demand for healthcare. A fair amount of NHS activity is devoted to patients who are stuck in follow-up loops, who attend clinics when the result of their diagnostic test is not in the notes, who are referred to the wrong specialist, or who keep coming back as emergencies because their long term condition is not being managed.

If clinicians and managers can achieve system improvements that drive out this “failure demand” then waiting lists and times would largely disappear in those services. But no clinician or manager is going to bother, if all the benefits of system improvement are going to be instantly confiscated by a minimum waiting time requirement, bluntly imposed by the commissioner.

payment should not be withheld for short-wait activity, nor should individual patients be deliberately delayed

For this reason alone, minimum waiting times should not be an operational requirement; payment should not be withheld for short-wait activity, nor should individual patients be deliberately delayed.

Having said that, it is surely unrealistic to expect commissioners and trusts to plan activity based on (say) 10 week waits across the board, when their figures say that only 16 weeks is affordable? Or to continue to fund 8 week waits in General Surgery when Orthopaedics is struggling at 22 weeks?

To be sure, planning activity and capacity on the basis of 18 weeks, when the service concerned is currently achieving 10 weeks, is a step backwards. More than that, it is a shame, because those short waits were hard-won, and there is always the worry that letting patients wait is the easy way out for the NHS.

But times are tight. There is a difference between, on the one hand, commissioners using 18 weeks as their planning assumption, and on the other hand imposing 15-week minimum waiting times operationally on a patient by patient basis.

Good planning protects urgent patients

It is worth remembering that good planning, based on realistic assumptions about what is possible with waiting time management, also protects hard-pressed services by releasing resources for them. When long-wait targets are being aggressively pursued, this extra resource may be essential to stop urgent patients being delayed.

This post first appeared at HSJ blogs
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