Public hospital waiting lists – can a necessary evil be better managed?

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‘Blow-out in hospital waiting lists’ – the familiar heading to a recent story in The Sun-Herald (April 3, 2005). Apart from noting that the number on the list was 24% greater than at the last State election, the newspaper also reported on the political embarrassment involved – ‘The latest figures are so politically damaging they were released at 4.59pm on Friday in the hope of avoiding media detection.’ In Victoria, as recently as this July, while the State Government announced a further $30 million to ‘cut hospital waiting lists’, the Opposition health spokesman made much of the assertion that ‘waiting lists were longer than in 1999’. Similar stories are told across Australia and have been since waiting lists have been reported. A Current Affair, on the 18th October 2000, for example, opened a segment on waiting lists with ‘(i)n all but one state around Australia, public hospital waiting lists have hit an all-time high, and patients are feeling the pinch.’ Public hospital waiting lists draw much attention and resource while appearing intractable to solution. They need more examination and debate.

We owe the reporting of hospital waiting lists to the trend of ‘new public sector management’ that swept through Australia in the 1990s. It sought to enhance public sector management by measuring performace and thus make accountability more transparent. As often happens, the more easily measured gets measured and becomes the focus of accountability – often at the expense of other more important things. Once available, the data can be readily used as ammunition by others with different agendas to those who initially devised it to help learning and solving problems. It may well be that State governments would now wish waiting lists figures away – there has certainly been less reporting of late and Victorian data has been atomised to the level of the individual hospital, in a form that makes it very difficult to track trends. Unfortunately, this genie is well and truly out of the bottle!

Waiting lists are an integral part of health systems that use public funding and public production – they are used to ration supply to a level deemed to be efficient by the central purchaser. These arrangements substitute for price signals in the normal market, where consumers make this determination through their own purchasing decisions. Central purchasing in health is rationalised on the grounds of information asymetry and lower transaction costs, but this sacrifices individual choice, influence and responsibility. In Australia, with a mixed public/private funding and private/public production, the community, while continuing to value the public components of the system has increasingly supported in Federal elections more choice through initiatives to encourage private payment and production. Concern about public hospital waiting lists is arguably one of the main drivers of this.

Given the size of the public hospital system in Australia waiting lists are here to stay, but they should be more logical and useful for matching patient need to hospital supply. This will become more important as developments in medical technology beyond elective surgery, such as vascular stents and cardiac defibrilators, will also require rationing in the public system on the grounds of cost.

The typical approach to waiting lists has been to categorise surgical patients into three strata according to perceived clinical urgency. This has been undertaken by the surgeon at the time that the patient is booked for surgery. However, there has been growing evidence of the inadequacy of this approach. There are very large differences in the proportions of patients allocated to the three categories at different hospitals indicating a certain level of gaming. This occurs because State government health departments typically penalise hospitals for not attending to the more urgent strata of patients. Surgeons, consciously or subconsciously, can react to this ‘incentive’ and gain additional hospital resources (e.g. operating theatre time) for their patients and units by swaying their judgement of urgency to a higher level. There has also been a drift from the low to the intermediate category, so that a high percentage of cases are now in this stratum and it is likely that it now contains a large group with widely differing levels of urgency.

In other countries with public funding and public provision similar issues have arisen in the scheduling of patients for elective surgery and for some high cost diagnostic procedures. Efforts have been made in NZ and Canada to develop better methods for assigning priority that can provide a more precise level of categorisation. Both are based on point scores that create finer divisions of clinical severity and they are also looking at the feasibility of including social and psychological characteristics. There is also concern about the adequacy of medical management of patients on waiting lists.

We have been reviewing these methods for prioritisation of patients for hip and knee replacement therapy and found that all categories of reviewer (doctor, patient and general public) placed equal emphasis on psychosocial factors as they did on clinical factors. For example a high level of distress or a need to support others were seen as major contributors to urgency by every category of reviewer.

Before employing criteria based on a systematic assessment of psychosocial criteria more work would be needed to see if this finding can be operationalised in a useful way. Can social imperatives be scored in an impartial and consistent fashion? Can psychological distress be measured consistently? Who would have time to seek the information needed to make these assessments? Would the stoical be penalised in favour of the demanding? These and other questions will need to be addressed before introduction of a new prioritisation process that has the confidence of the public. This would seem to be a worthwhile endeavour if we are to shift the attention from the political ramifications of waiting lists to optimising care.

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