Waiting lists and elective surgery: ordering the queue

In Australia and other countries with publicly funded health systems, such as New Zealand, the United Kingdom and Canada, waiting lists provide a buffer between the demand for elective surgery services and the capacity of the public system to provide them. Waiting lists are consistently newsworthy because they are perceived to reflect the inadequacy of health care funding. They are portrayed as one of the major problems of publicly funded health systems and are a perpetual source of community and political discontent.

Over the past decade, an increased demand for elective surgery has been observed in Australia1-3 and overseas.4,5 The capacity of health systems to respond to this is limited by funding and workforce availability. Under these circumstances, it is essential that those who have the greatest need for surgery and will benefit most from it receive it in a timely manner and before those with lesser need. Three recent high-level reports have underscored these concepts and emphasised the need for reforms to ensure equitable, efficient delivery of elective services.6-8

In this article, we review how patients access elective surgery in Australia, focusing on the assessment of need and timeliness (prioritisation). We examine the current status of prioritisation here and overseas and explore the potential for improvement in prioritisation practices in Australia.

Most commonly, a patient’s name is placed on an elective surgery waiting list after a lengthy process of referral, specialist assessment and investigation. Patients placed on a waiting list have been assessed to have a clinical need for surgery and are expected to benefit from that surgery. Despite this, the concepts of clinical “need” and “benefit” are ill defined. Currently, patients are classified into one of three nationally agreed-upon clinical urgency categories that take into account the likelihood of deterioration and are aligned with recommended waiting times for surgery (Box 1).9,10 Some states have additional subcategories and categories for patients not ready for care. Guidelines developed in New South Wales recommend particular urgency categories for specific procedures.11 The guidelines issued by the Victorian Government Department of Human Services (DHS) simply indicate that patients should be assigned to urgency categories based on clinical need.12

In public hospitals, it is common practice for waiting list offices to select patients for elective surgery admission and to manage their admission process. This occurs in consultation with the surgeon who will perform the procedure.

Patients with the most urgent need for surgery (Category 1) take precedence over those in lower urgency categories (Category 2 and 3). Victorian DHS elective surgery guidelines advise that selection should be based on clinical priority, although other factors should be taken into account, such as length of time already waited, previous postponements to surgery, and resource availability.12

In NZ and Canada, there have been concerted efforts to make prioritisation for elective surgery more systematic and publicly accountable. In both countries, this has involved a shift from implicit prioritisation to practical, explicit tools that help prioritise patients on waiting lists.

Victorian research has focused on the development of tools suitable for prioritising patients for joint replacement and prostatectomy. For the period July–September 2008, waiting times for Category 2 hip replacements and prostatectomy ranged from 15 to 315 days and 15 to 336 days, respectively,31 indicating substantial waiting lists at some Victorian hospitals.

The Victorian Waiting List Prioritisation Study used WCWL questionnaires as a starting point to develop Australian tools suitable for prioritising local patients for total hip or knee replacement and prostatectomy.32 Ranking and rating exercises performed by medical professionals and laypeople using real patient vignettes showed that clinical symptoms and psychosocial criteria were considered equally important when assessing a patient’s urgency for surgery.33 This information provided the foundation for prioritisation tool frameworks.

The Victorian DHS subsequently established the Orthopaedic Waiting List Project, which developed a Multi-Attribute Prioritisation Tool (MAPT) through a process involving concept mapping, review and validation with orthopaedic surgeons and patients.34 The final MAPT contained 11 clinical and psychosocial domains, and included questions about pain, psychological and economic impact, limitations to activities, and deterioration. It has been built into the Victorian Osteoarthritis Hip and Knee Service, an improved service model for management of patients requiring joint replacement that has been piloted at several Victorian hospitals.35

An important preliminary step in designing a system that provides better outcomes for patients is to decide on its main purpose. UK researchers described five possible goals for waiting list policies, including reducing numbers of people on waiting lists, reducing the average waiting time, improving the health status of those on waiting lists, ensuring equal access for those with equal need, and ensuring quickest access for those with greatest need.36 The latter two goals are fundamental objectives that can facilitate improvement in waiting times and health status, and should form the foundation of an improved system. Equity, transparency and certainty should be key elements of this system, and Box 2 shows how they could be represented. NZ and Canadian experiences serve to highlight the importance of ensuring the scientific validity of all prioritisation tools (Box 2).

This requires debate about the key clinical, social, and other patient- or health service-related criteria that should be considered, development of methods for scoring these criteria and a contextual framework. Progress is also needed in many other related areas, some of which are shown in Box 3.

Australia is predicted to see an increasing mismatch between patient demand for services and the capacity of public health systems to deliver the highest standards of medical care. Although prioritisation methodology will be important to ensure fair access to high-demand surgical procedures, it will also be applicable to new, expensive medical technologies and specialised levels of care where many issues of access already exist. Allocation policies are widely debated, but progress will be limited without a foundation of scientifically valid prioritisation methods. Strategies that support the prioritisation process for access to elective surgery therefore represent an important advance in the broader health care resource allocation debate.

2 Key elements of a prioritisation system for elective surgery