Rapid review of the evidence on potential health impact of waiting times initiatives in Wales
Author: Geri Arthur, Specialty Registrar
Date: 061109 / Version: 1
Status: Final
Intended Audience: Welsh Assembly Government
Relevant Previous Documents: Not applicable
Purpose and Summary of Document
This report reviews evidence in an attempt to estimate the impact of An orthopaedic plan for Wales of 2004 and the waiting times strategy of 2005 on the health of the population of Wales.
The evidence on the impact of waiting on patient’s health is unclear but where it exists is condition specific. There is evidence of adverse psychological impact. There is little evidence about physical outcomes at a population level in terms of waiting for surgery. Because current information systems do not capture appropriate data it is not possible to determine the absolute impact of waiting time initiatives in Wales in terms of health or mortality. It can be surmised from the scientific literature that some adverse outcomes have been prevented but due to variation in research methodology quantifying the resulting health gain would be problematic.
Publication/Distribution:
· WAG
· NPHS document database
· NPHS stakeholder e-news
Table of contents
Executive summary 3
1 Introduction 5
2 Aims 6
3 Methods 6
4 The political and policy context 6
5 Results of the literature search 10
5.1 Waiting times 10
5.2 Orthopaedics 15
5.3 General surgery 18
6 Conclusions 19
7 References 21
Appendix 1 Literature review search strategy 27
Appendix 2 Evidence levels and quality grading 36
Appendix 3 Evidence table 37
© 2009 National Public Health Service for Wales
Material contained in this document may be reproduced without prior permission provided it is done so accurately and is not used in a misleading context.
Acknowledgement to the National Public Health Service for Wales to be stated.
Author: Geri Arthur, Specialty Registrar / Date: 061109 / Status: FinalVersion: 1 / Page: 37 of 78 / Intended Audience: WAG
National Public Health Service for Wales / Rapid review of the evidence on potential health impact of waiting times initiatives in Wales
Executive summary
Introduction
The National Public Health Service for Wales was asked by the Welsh Assembly Government to review the evidence examining whether or not the implementation of the Orthopaedic plan for Wales and the waiting times strategy of 2005 have or are projected to have an impact on the health of the population of Wales.
Waiting times for health interventions, perceived by the public as excessive have been an emotive issue for decades. They have also been the subject of much policy intervention. Considerable resources have been utilised in order to reduce waiting times.
Methodology
A rapid review of the scientific literature was performed together with a review of relevant policy documents. The evidence was evaluated and summarised.
Results of review of scientific literature
Waiting times
The causes of long waiting times can be split into demand and supply issues with strategies usually addressing one of these. There is no international consensus as to what is considered an excessive wait. Successful strategies to reduce waiting times tend to take a ‘whole systems’ approach rather than considering the waiting list to be a temporary backlog.
The evidence in terms of physical implications for patients caused by waiting is conflicting and psychological affects may be more important than physical ones. Waiting times currently collected give no qualitative information about the appropriateness of the wait. The time waited appears to be unrelated to the age profile or morbidity of the population under examination.
In terms of what matters to patients, they are tolerant of short to moderate waits with 12 weeks seen as acceptable but over six months seen as too long. The patient’s own perception of their condition may be more important in terms of the acceptability of waiting than an independent assessment by a clinician. The acceptance of waiting can be increased by giving clear information about the length of waiting and allowing patients to exercise preference.
The evidence in relation to the costs of waiting is unclear but it appears there is a societal cost, including an excess financial cost within that measure.
Orthopaedics
Orthopaedics is the largest and most expensive specialty within the UK however there is a lack of evidence in terms of either cost effectiveness or cost utility in relation to orthopaedic interventions.
There is evidence that hip and knee arthroplasty are quality of life enhancing and that age is no barrier to positive surgical outcomes. On the whole patient prefer active management of their condition rather than ‘watchful waiting’, even though evidence for many interventions indicates little difference in the long term between active and conservative management. The evidence is conflicting in terms of the effects on quality of life of waiting for orthopaedic surgery with studies often not being comparable for methodological reasons.
The length of time patients wait is not determined by quality of life. This may be a debate that should take place as there is a small amount of evidence that increased capacity to benefit may improve cost effectiveness of interventions.
General surgery
There is evidence that both healthcare professionals and the public support prioritisation of waiting based on clinical need however neither group support prioritisation on the basis of cost effectiveness.
Patients may suffer adverse psychological outcomes as a result of waiting. Those who perceive themselves to have more severe symptoms desire surgery more quickly, even though their assessment may not agree with that of a clinician.
Conclusion
Evidence suggests that any future investment in waiting time initiatives should use a ‘whole system’ approach. We can learn from effective strategies that have worked elsewhere focusing on long term rather than short term initiatives targeting the causes of waits. Monitoring and evaluatory mechanisms should be built into initiatives from the start in order to determine which are effective. This could provide a real opportunity to add to the paucity of scientific research on the effects of waiting.
The evidence on the impact of waiting on patient’s health is unclear but where it exists is condition specific. There is evidence of adverse psychological impact. There is little evidence about physical outcomes at a population level in terms of waiting for surgery.
Because current information systems do not capture appropriate data it is not possible to determine the absolute impact of waiting time initiatives in Wales in terms of health or mortality. It can be surmised from the scientific literature that some adverse outcomes have been prevented but due to variation in research methodology quantifying the resulting health gain would be problematic.
1 Introduction
The National Public Health Service for Wales was asked by the Welsh Assembly Government to review the evidence examining whether or not the implementation of the Orthopaedic plan for Wales and the waiting times strategy of 2005 have or are projected to have an impact on the health of the population of Wales. The time patients have to wait in order to access NHS services has been an important emotive and political issue for decades. The Organisation for Economic Co-operation and Development (OECD) in a report on tackling waiting times using data from 12 countries3, states that waiting times at worst can lead to deterioration in health, loss of utility and extra costs. Surveys of the public indicate that waiting for elective surgery is unpopular. In the UK, the British social attitudes survey4 has shown that waiting for specialist assessment and waiting for elective surgery are considered to be the first and second most important NHS failings. The reduction of waiting times has been an important element of health policy of the Welsh Assembly5. The National Audit Office Wales has argued that long waiting times can have a real human cost; they create greater anxiety for patients, reduce their quality of life, risk their condition deteriorating and add to the cost of their care. They cite a European poll in 20046 which stated that British respondents felt the time between diagnosis and treatment was more important than being treated at a time and place to suit the patient; being treated using the latest medicines or technologies; having enough information to make an informed choice about treatment or being treated by the doctor of your choice. Most of these features of healthcare are the subject of policy initiatives in the UK.
Waiting times have increased over the years as demand for healthcare has increased. Advances in surgical procedures have contributed to this rise and despite added investment in healthcare by both governments and insurers across Europe3; supply has struggled to keep up with demand. Increased demand is not the only issue.
Inefficiencies in health services have been blamed including: poor management of waiting lists; poor utilisation of healthcare resources such as theatres; and elective surgery beds unavailable due to emergency admissions, delayed discharges or transfers.
Considerable resources have been invested and utilised in trying to reduce waiting times. Thus it is only natural that attempts should have been made to estimate the positive or negative affects of waiting. This review considers the evidence with regard to waiting. It is not possible to quantify or describe the benefit to Welsh residents specifically, this would require primary research. The review summarises the evidence in relation to waiting times, what represents an excessive wait and what makes waiting more acceptable. The review covers orthopaedics and specialties covered by the Welsh Assembly waiting time’s initiative, predominantly the Second Offer scheme7 and the Access 2009 project8, examining the evidence about the potential outcomes of waiting.
2 Aims
The aim of this review is to summarise the evidence about waiting times in general and orthopaedic surgery and general surgery more specifically in order to inform estimates of the likely outcomes of waiting for treatment.
3 Methods
Policy in relation to waiting times was reviewed, including policies from the UK government, the Welsh Assembly and internationally where appropriate.
Existing studies were identified through a literature search. The literature review search strategy is outlined in Appendix 1. Papers were critically appraised, methodological quality was assessed using the Critical Appraisal Skills Programme tool9 and the quality of the evidence graded using a modified version of the NICE guideline tool (Appendix 2).
An evidence table was compiled from the research data relevant to the review questions (Appendix 3).
The results of the literature review are presented in the following sections:
· Waiting times
· Orthopaedics
· General surgery
4 The political and policy context
4.1 Waiting lists to waiting times
In March 2000, when the NHS plan10 was published, 264,370 individuals had waited more than 6 months for treatment in the UK11. Public dissatisfaction led to this being a key policy area. The initial focus of the new Labour government in 1997 had been a reduction in absolute numbers waiting12 but the focus now moved to guarantees about maximum waiting times with staged targets. Waiting lists had been growing exponentially over time, between 1979 and 1996, the list grew by 35% to 1,040,152 across the UK.
In 2000, the Welsh Assembly Government’s Health and Social Services Committee considered the detailed report from the Waiting Times Strategy Development Group13; eighteen recommendations were made by the group. In November 2002, the committee reviewed the work of the group. The Assembly had targeted priority areas, especially heart surgery and orthopaedic surgery and Improving health in Wales14 had set out a specific target in 2001 of reducing waiting times year on year until patients in Wales received services as speedily as elsewhere. In July 2001 the Waiting times strategy15 had shifted the emphasis away from waiting lists to waiting time. The Minister argued that
“Waiting lists are heavily influenced by the decisions of those responsible for referring and treating and at any time can include both people who do not need care and omit others who do. If performance is measured solely on the basis of changes in waiting list numbers, there is a danger that little attention will be paid to improvements in the quantity or quality of services, or to how long people wait and to the clinical needs of patients.”
4.2 Orthopaedic services
The committee concluded that there had been successes in the priority areas of orthopaedic surgery and cardiac surgery; however they highlighted the significant rise in demand within NHS Wales both in outpatient referrals and patients admitted to hospital as an emergency which would be a challenge to meet.
A review of orthopaedic service in Gwent16 published in 2003, indicated there were still problems in meeting the demand for orthopaedic services, with waits in some cases as long as three years. Professor Edwards made recommendations which were accepted by the Assembly. He stated that there was not enough capacity to handle future demand and that orthopaedics was particularly affected by surges in emergency medical admissions and the existing bed capacity being taken up by delayed transfers or discharges. He also recommended more flexible use of theatres, better use of the multidisciplinary team and tighter management of waiting lists.
4.3 Second offer scheme
In 2004, the 2nd offer scheme was established7, it guaranteed any patient who was at risk of waiting longer than the maximum waiting time, the opportunity of a 2nd offer referral. The commissioning team was centrally funded and based within Rhondda Cynon Taff Local Health Board. Central funding was start-up funding only and when finished, payment responsibility would fall to either the commissioner or the trust. However at the end of 2004, concerns were raised about one of the 2nd Offer providers in England17 and a review of knee surgery carried out by the provider was published at the beginning of 2007, which confirmed there had been adverse outcomes for some patients18,19. This attracted a great deal of media attention.
4.4 Orthopaedic plan for Wales
The Orthopaedic plan for Wales1 picked up many of these issues, the source document20 highlighted capital investment and the continued redesign of services supported by the Innovations in Care programme. However the document also detailed previous non-recurrent funding that had been allocated to reduce waiting lists and which the Wales Audit Office argued had done little to deliver sustained change5. The plan also pointed out that whilst the inpatient and day-case surgery list had reduced between April 1999 and April 2004, the numbers waiting for their first appointment had risen.