Health Policy

Report on Criteria for the management of waiting lists and waiting times in health care


European health care systems are faced with common problems due to a difficult economic environment. At the same time the demand for new technologies and sophisticated health care is increasing. This has led to waiting lists and waiting times for health care.

This phenomenon can have a negative impact on patients on a waiting list and is a challenge for both health care systems and their managers. Waiting lists and waiting times can put pressure on the principle of equity in access to available health care services. They can also have an influence on the health of patients. Health services that are compelled to put patients on waiting lists vary, as well as the multiple factors influencing this phenomenon.

In 1997, the European Health Committee (CDSP) set up a Committee of Experts on criteria for the management of waiting lists and waiting times for health care. The committee was asked to

examine in general the current situation in the member States with regard to waiting lists and waiting times for health care

explore the negative effects of waiting times on the health of the individual and describe the types of health care most subjected to waiting lists

explore the main causes of waiting lists and waiting times taking into account both medical criteria for eligibility to get on the waiting list and the organisational and managerial aspects of the health services in question;

consider current means of management of waiting lists and waiting times applied in various members States, the influence of funding systems and of medical criteria drawn up by the health professionals and the results obtained.

The Committee was also asked to draw up a report on:

- the current situation in and experience of member States with regard to means of management of waiting lists and waiting times for health care;

- the establishment of criteria for the management of waiting lists and measures which in the short or long term may lead to a reduction of waiting lists and must be in full respect of the principles of non-discrimination (e.g. gender, age, ability to pay, etc.) and of equity in access to health care;

- the role of the Council of Europe with regard to this phenomenon.

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1. Scope

The Committee considered aspects of waiting in elective health care and did not look at issues around access for emergency care. Three aspects of waiting were discussed at the Committee's first meeting:

- Waiting for a consultation with a doctor in primary health care
- Waiting for hospital treatment both out-patient and in-patient
- Waiting for nursing care at home or a place in a nursing home

In principle, all of these areas are of interest when waiting times in health care are discussed. The Committee decided to focus the discussion on waiting times for accessing hospital treatment, as this is the topic that has the greatest interest in most European countries.

The Committee also decided to discuss the waiting times to the start of treatment (or examination) in hospitals, and not the waiting times during an admission to hospital, for example when an admitted patient is waiting in the x-ray department for the actual x-ray pictures to be taken. The Committee did not discuss waiting times within emergency rooms for the treatment of acute illness. Neither did the Committee discuss waiting times for organ transplantation as this was outside of its brief.

2. Background

The health care systems of European countries are experiencing both rising costs and demands on their services. There is a gap between what most countries health services are able to do and what they can afford to do. And this gap is growing. Important reasons for this growth are:

- Dispersed technology: The development of medical technology makes it possible to treat illness which could not be treated before;

- More chronic care: People who survive acute illness because of new treatment techniques become chronic patients;

- Demographic changes: People are getting older, and the elderly consume a relatively high proportion of health care;

- Changes in the pattern of diseases: for example there is a greater prevalence of both cancer and infectious diseases;

- The «medicalization» of our societies: problems are defined as health conditions that previously would not have resulted in demands for heath care.

One of the results of these developments is that some people are experiencing longer waits before getting treatment as demand for medical care exceeds available supply. At the same time people generally expect better services in European countries, and this consumerism also applies to health services. There is an increasing focus on waiting times and waiting lists as an issue in many European countries. Patients and politicians, and often also the health care professionals, are very concerned about patients’ waiting times.

The Committee is aware that in some member states patients can usually access specialist hospital services as an outpatient only if they are seen first by a GP (General Practitioner) and then referred to the hospital or clinic. In others patients can access specialist care directly by making an appointment in a specialist's office or clinic. The Committee did not take a view on the issue of direct access to specialists but observed that waiting can exist both with and without direct access and that their conclusions would have different applications dependent on the mode by which patients access specialist care in member states.

3. Efficiency and effectiveness

The rising costs of health care is an issue in all European countries, and there is a strong focus on cost containment for health care services. Probably all European countries have made health care reforms concerning all parts of the health care systems during the last decade. Most countries have focused strongly on making their health care systems more efficient and effective.

    Efficient in that they produce the maximum volume of health services for the actual resources used
    Effective in that the right kind of health services are delivered

4. Quality of health services

There has been an increased focus on quality matters in health services, both as a result of rising standards of customer service in society, and as a result of cost containment in the health care industry itself. The difficulties in providing capacity in health services to meet in full the demand for maximum production of health services has strengthened the focus on quality issues. Total quality management methods have been adopted from the business community into the health services.

Waiting times are increasingly considered to be an important aspect of the quality of health services. This development has created a need for definitions concerning waiting times and waiting lists, in order to improve the delivery of services and to make it possible to compare waiting lists and waiting times within countries, between organisations and inside organisations over time. One approach in some member states has been to set out national standards for waiting times for some or all procedures. There have been some reservations expressed about whether such policies lead to distortions in clinical priorities with less urgent patients receiving treatment ahead of more seriously ill patients in order to avoid the breaching of waiting time limits.

5. Evidence Based Medicine

The growing emphasis on delivering the right kind of health services combined with the demand for greater quality in health services, has led to a stronger focus on evidence based medicine, in the sense that the continued use of diagnostic and treatment methods should be dependent upon an evaluation as to whether they have the desired effects. One of the results of this focus has been the Cochrane collaboration, which started in the United Kingdom and has spread internationally. «Meta-studies», where all research projects that have been performed in the different diagnostic or treatment methods are thoroughly evaluated, is one way this is being done. Medical technology assessment, which employs other tools to evaluate new (and sometimes old) diagnostic and treatment methods is another method used.

6. Whole systems approach

It is necessary to have a whole systems approach to health care spending, in at least two ways:

- A strong focus on waiting times in health care will easily lead to higher priority for acute illnesses. The result may be that surgical treatment and treatment of high focused illnesses such as heart infarction will get a high priority, while chronic and psychiatric care will lose in the prioritising process.

- The cost of health care has to be balanced with the needs of other parts of society. This is a necessity for society as a whole, but also for health care: The need for health care is in many ways a result of decisions in other parts of the society. For example, public hygiene, infectious disease and road traffic accidents.

7. The process of delivering health care

In all European countries there is a strong focus on making the health care production as efficient and cost-effective as possible. This has included improving the efficiency of hospitals through in part thinking of the organisation of hospitals in business terms as production facilities. In turn this gives an emphasis to the process of production. In most hospitals the production processes can be made more cost-effective. Also, waiting may arise because part of the process of delivering healthy care is not functioning correctly.

8. Prioritisation models

The imbalance between available supply and demand in health services has led to a debate about prioritisation in most of the European countries. National guidelines for prioritisation have been drawn up in Denmark, Finland, the Netherlands, Norway, Portugal, Spain, and Sweden with local examples from the United Kingdom. Outside Europe developments have taken place in New Zealand, Ontario (Canada) and Oregon, (USA). A key issue in all these countries has been which, if any, criteria should form the basis for prioritising between treatments and how the criteria should be ranked in relation to one other. A common feature to such systems and proposals is the importance given to hat fr The Danish, Swedish and Finnish approaches also recommend the criterion of demand, which in part overlaps with the criteria covering the gravity of the patient’s state of health.

Common to all of the proposals to date is a regard for both the effectiveness and the cost-efficiency of the treatment. There is universal rejection of the notion that a patient’s social characteristics should be relevant priority criteria, although employment status has been regarded as a criteria in some systems. Age in itself is only to a limited degree presented as a relevant priority criteria. The principle of equality and justice are stressed by all. Importance is attached to the evaluation of medical technology to identify which types of treatment are most effective, and should be given priority over the less effective treatments.

The debate on prioritisation would appear to be moving on from seeking to develop an overarching, centralised model of prioritisation, towards a more decentralised clinical approach to practical everyday decision-making based on a common framework which can be applied by all doctors. The Committee observed that although the development and application of such frameworks were still in their early stages, it is important that decisions about how patients access specialist care should be made by objective and accountable means.

Why waiting lists and waiting times exist in health care 

Waiting times and waiting lists are important issues for health care in most European countries. Long waiting times are a problem for patients not only because of uncertainty but also because the state of the patient may deteriorate if not treated early enough. Short waiting times generally indicate that there are fewer problems in accessing care.

1. Waiting lists

Waiting lists can be seen as a hospital’s working list or order book. They are necessary for the hospitals to plan their production processes. hey are necessary for the planning of hospital production processes, and constitute a means of prioritising care.In themselves, as a managerial tool, they do not constitute a problem. It is therefore important to be aware that waiting times constitute a problem to be managed. However the public and media frequently attach grat importance to the number of people on hospital waiting lists and in the light of this public perception it is important for health tinstitutions to pay close attention to the processes of delivering elective care.

Some commentators have stated - with support from economic theory - that waiting lists will always be a part of the health care system as long as the use of health care services in principle is free. In markets where prices regulate demand and supply a long wait can be avoided by paying a higher price. Since there are no real prices to regulate demand in public health care, waiting lists become an instrument for rationing access to supply. However, others who have studied the issue see waiting lists as result of lack of resources. Another view is that waiting lists can occur as result of bad management. As a result organisations that have long waiting times do not have clear enough goals about what is to be achieved, and thus have an inaccurate strategy to reduce the waiting lists. Variations in surgery rates between hospitals have led yet some researchers to explain waiting lists by differences in doctors’ medical practice and different views of priorities and efficiency in the use of resources.

2. Multifaceted problem

There is no single reason why waiting times and waiting lists exist in health care. They are a multifaceted problem and are the result of a complicated interplay between demand and supply. If at present there are more people that demand a service than it is possible to supply with the present production capacity then waiting lists will generally occur. In addition if demand rises and supply is unchanged, waiting times and waiting lists will be longer. A rise in the supply in combination with a stable demand will give shorter waiting times and waiting lists. If supply is increased but demand also continues to rise then waiting times and waiting lists will probably not be reduced.

Waiting lists increase in seriousness if they are associated with a delay in accessing services. Large numbers waiting for a few days or weeks for treatment would present health systems with a scheduling problem that could be resolved through improved management. However, large numbers waiting for long times present a more fundamental challenge as it will require choices to be made over the priorities to be assigned between the different treatments that are being demanded.

Demand for health care has been rising as long as modern medicine has existed, and the sve to a degree been a function of expanding demand for services. Supply has also expanded, but for some services, it has not been possible to support all of the demand without having some patients on waiting lists.

3. Demographic change

One of the more obvious reasons for demand to increase is demographic change, with the numbers and proportion of elderly people in the population increasing. The expectations for a good quality of life in old age are becoming higher. There is also a so-called medical . That is, people who in previous years would have died of their illness now can live longer and they will have a need for medical services, such as hip replacements and cataract removal. Coincidentally, the waiting times for such treatments have generally been longer than the average in most countries.

It is not only the elderly that have higher expectations concerning health, quality of life, and the health care services. With new information technologies and higher living standards, people in general are more informed, demanding and impatient. These demands increase the pressures on health services.

4. Concentration in certain surgical specialities

From different studies of the nature of waiting lists we also know that they are more frequent in some specialities than in others. One such study of waiting lists in the UK in 1991 found that just under one half of all waiting occurred in general surgery and orthopaedic surgery. Three specialities; ear, nose and throat, gynaecology and ophthalmology made up a further quarter of the waiting. This pattern was repeated in many of the member states represented on the committee. Waiting lists are naturally concentrated in parts of health care that can be postponed in time, that is,, elective care.

5. Introduction of new technology

In many cases it is also clear that a major explanation for waiting lists is the introduction of new technology, like improved anaesthetic procedures, laparoscopic surgery and total knee replacement. When there is a new technology it often becomes possible to treat patients that earlier could not been taken care of, and when the technology is introduced in routine care it is common that indications for surgery widens and demand expands even more. It is not always easy for the health care system to match rising demand with resources such as equipment and skilled personnel, and as a consequence there will be more patients on waiting lists. This has led some observers to believe that waiting lists are ‘temporary’ and the remedy would be to set aside resources and raise capacity for a limited period of time, a backlog of unmet demand was cleared waiting times and waiting lists would be shorter. The Committee observed that such increase in production can lead to even more demand, as the ability to benefit from treatments is expanded.

6. Balance between routine and complex procedures

However, not all patients waiting for care are waiting for a treatment that is at the frontier of technological development. Many of them are waiting for minor and operations, such as varicose veins or enlarged tonsils. In those cases it may be that the doctors’ priorities are in favour of treating more complex and challenging cases.

7. Priority setting

Patients waiting for treatment on a waiting list for special care, are not waiting only because they want to or they demand to be there, but rather, a doctor must have approved to put them on the list in the first place. Thus it is the doctors’ perception of need and benefit from different treatments that is crucial for the decisions to put someone on a waiting list. Different doctors make different choices in practice about which patients to treat at what stage of morbidity. Some doctors may chose to put a patient on the waiting list at an early stage of the disease, while others rather will wait until the disease has progressed.

Priorities can also be set between different kinds of treatments so that one doctor finds it more efficient to concentrate on cataract surgery, when others choose to do check-ups on patients with diabetes. The crude surgery rates for different treatments vary within most countries, and a major explanation is varying practice patterns. The relationship between waiting lists and surgery rates, is however not very strong, and high treatment rates do not always mean that the waiting times are short.

8. Perverse incentives

In health care systems where a centralised budget model is used for the distribution of resources, there can be incentives for having long waiting lists, since many patients on waiting lists can be a sign of excessive unmet demand, and a motive for getting more resources. There are many examples of waiting lists that contain patients that actually do not need an operation because they have already been operated, they are not fit enough, or they have moved or died. One explanation for poor management of waiting lists in some institutions could be that a long waiting list is not seen as anything negative in the organisation.

9. Improving process of care

Waiting lists can also be caused by inefficiencies in production. If there are bottlenecks due to not enough resources in some part of the production process, it will not be of any help if other parts are well supported. If, for instance, there is a shortage of beds in which to put the operated patients, it will not be possible to do any more operations even if the surgeons have time to do more. Bed shortages can be a not least because of the so called bed-blockers, that is, patients who do not any longer need the hospitals’ resources, but do not have anywhere to go where they can be cared for, like a nursing home or home care. Another cause is with lack of trained or specially experienced staff. In small units it can be devastating if some specialised personnel are on sick leave for a long period.

10. Data

Organisations that do not record data on waiting will have great difficulties in improving waiting time problems exists. Without adequate data it is not possible to. In the absence of data they may not be aware that a problem identify at what stages problems are occurring within the delivery of health care. Even the most basic data such as the numbers of patients registered for treatment, the date when referrals were received and when patients were seen in the clinic and listed for treatment would assist in the management of waiting times.

11. Summary of reasons for waiting lists and waiting times

There are many origins of waiting lists, and if a unit has problems with long waiting times it can be related to one or more of the following conditions:

· The need for care has increased - caused by an ageing population (increased prevalence) and/or an increase in the incidence.
· Growing expectations and demand.
· New technologies leading to widening indications for treatment and an increase in demand.
· Managerial or administrative shortcomings - decreasing productivity.
· Logistic problems - ‘bottlenecks’.
· Absence of data
· Decreasing resources.
· Medical practice - priority setting.

Information and Data on Waiting Lists and Waiting Times 

Reducing waiting times and waiting lists requires addressing the issue as an element of improving the organisation and delivery of health systems. Such work is much more than an issue of collecting data however. Waiting times and waiting lists cannot be tackled in the absence of adequate information systems. A waiting list, whether held on computer or on manual records, must contain enough information to assist their subsequent selection for admission and treatment. This information should be updated regularly. Each patient's record should include a minimum amount of data in common within the health care system. Ideally, all health care systems should have a minimum data set for patients waiting to be treated developed at the appropriate national or regional level. Examples of two such minimum data sets, from Spain and the UK are at annex A.

A hospital's system should be sufficiently adaptable to accommodate changes in the data required for clinical or administrative purposes. The system should be flexible to enable records to be sorted, counted and presented as required by users who will likely be both medical and administrative staff. Staff responsible for recording and maintaining the data should be given appropriate initial training. This is especially important when staff retire or move to a new job and are replaced by someone unfamiliar with the record system.

Waiting lists fulfil two main functions. First, as a formal record or patients registered as requiring admission for treatment ensuring that patients do not get overlooked. Second, they provide a statement of known demand for treatment to assist the planning of hospital resources. Patients should only be added to a waiting list when they have accepted the advice of a specialist to have treatment. Specialists should not place a patient on a waiting list to reserve a place against the future possibility that treatment may be necessary. Wherever possible patients should be given a date for admission at the time when a decision is made to admit them. A waiting list for a hospital department or an individual specialist should have details of patients in different categories such as procedure type. This will assist in the planning of operating lists.

Evaluation and Appropriateness 

In addition to assisting in the management of the admissions process waiting lists should be reviewed in order to monitor the appropriateness of referrals and indications for which procedures patients are waiting. A number of approaches can be taken to evaluate the impact of waiting on individual patients and the appropriateness of health care. Examples of these include:

- reviewing the number of potentially avoidable elective hospitalisations. These are a useful indicator to monitor access to care (inequity and inefficiency).
- comparing waiting times of procedures to take into account rates of appropriateness as a high rate of inappropriateness may be a big factor causing unusually long waiting times.
- choosing sentinel health events and monitoring their incidence to assess whether any delay in accessing care had been encountered and the extent to which this was responsible for any avoidable health damage;
- checking the stage of the disease when patients are added to the list. This may be an indicator of the performance of the referral process and of the equity of access. The less advanced the course of the disease, the better the referral process.
- analysing waiting times according to socio-economic characteristics of the patients to evaluate the accessibility for vulnerable groups.

Consumer's Role and Patients' Rights 

1. Solidarity and quality

Waiting lists and waiting times have medical, organisational, financial, ethical and legal implications. These are linked to the political and legal principles that govern health care systems including solidarity, quality of care, freedom of choice and the public's right to know. There is also the individual dimension, that of the patient waiting for treatment. There will be competing interests and perspectives within health care systems but that of the patient should be of main importance.

Patient's needs and urgency in terms of acceptable waiting time and ranking on waiting lists should be determined on the basis of fairness and urgency according to evidence based medical criteria which include the patient's condition and risk factors, emotional and psycho-social criteria and the patient's quality of life.

Despite differing health care systems there is a basic concept of solidarity in health care across the member states. The United Nations Universal Declaration of Human Rights states, in article 25, that "everyone has the right to medical care and necessary social service ... and the right of security in the event of ... sickness and disability...". This has been developed in other Charters, for example the Council of Europe's Convention on Human Rights and Biomedicine recommends that member states provide "equitable access to health care of appropriate quality".

Equitable access should not be confined to absolute terms of ensuring that no one is denied access but it is also a matter of scale and timing. Appropriate quality also implies that services will be delivered at the right time. Timing is an aspect of appropriateness and is related to the effectiveness of an intervention as well as to the amount of suffering, discomfort and risk for patients.

2. Timing and urgency

Where waiting lists have waiting times that exceed reasonably acceptable lengths then problems of scarcity and priority arise. This should be dealt with on the basis of equity and equitable access with ranking on waiting lists determined in objective terms according to professional obligations and standards. These should include evidence-based risk factors of a patient's medical condition and the relative conditions of patients waiting for an intervention. As well as the pathology of a patient's condition certain emotional and psycho-social aspects should be taken into consideration when medical priority is monitored. This has to do not only with psycho-somatic risk factors but also with possible infringements on a patient's quality of life when a waiting time gets too long.

There can be a degree of subjectivity and arbitrariness in a physician's understanding of priority factors. These factors could probably not be fully standardised. However, some objectivity and transparency are needed, especially with regard to quality of life criteria. Health care professionals in many countries are trying to come to terms with these issues and there is a need for more research, interdisciplinary exchange and ethical discussion on them.

3. Non-discriminatory ranking

Apart from these individual and condition related aspects of priority and ranking by physicians and institutions there are basic fundamental aspects of equity that should govern access to elective care. Need and urgency should never be deter-mined on the basis of race or religion. Neither should sex or age determine priority except when account needs to be taken of the general medical condition of a patient or as a risk factor.

A possible threat to equity on waiting lists comes from different kinds of economic interests. It should not be acceptable to buy preference on a waiting list. The offer of bribes to, or their acceptance by, professionals or institutions should not be tolerated. This would undermine the fundamental principle of equity of access. Attention also needs to be given to the activities of employers and third parties as funders of health care. For example employers could have a potential interest in seeking quicker treatment for their employees ahead of people that are not employed for whatever reason or those that are not getting paid for their work. Employers' and third party interests alone should not entitle a patient to priority for admission. However, despite ethical agreement on this principle it is hard to analyse this in absolute terms since the structure of insurance systems and the legal basis for accessing care differ from country to country. These are serious issues for equity and equitable access in health care. There is a need for research of these issues, including any arrangements for regulation, within member states and across Europe.

4. Quality of life

Priority for treatment should not be based purely on the nature of a patient's disease and issues about the quality of a patient's life should also be considered. In this context the quality of life relates to an individual's ability to carry out the activities of daily living and to live an independent life. The application of strictly medical criteria needs to be accompanied by an assessment of the whole person. This requires an examination not only of medical and technological issues, but also psycho-social and psychological ones. This should be a part of considering the priority for treatment and also for long term care. All health care professionals - medical, nursing and therapy, have a role to play in helping with assessing a patient's condition. These assessments also need to be, as far as possible, based on objective and transparent criteria that are evidence based.

5. Transparent and independent information

Patients and consumers of health care are entitled to have adequate general information on waiting lists and waiting times in specific settings. This should include access to individualised information about their own ranking on waiting lists. Information at an institutional level should be transparent - but without allowing individuals to be identified to third parties - and available to the general public, consumers, patients, governments and decision makers as well as insurance companies and health care providers. As well as the management and planning uses for such information that are covered elsewhere in this report there is great potential to use waiting list/time information to enable consumers to make deliberate choices about the options available to them for treatment. To assist this, information needs to be accessible, standardised and adapted for individual users and intermediaries. It also needs to be compatible with registration systems used within individual health systems.

Providing such information will help serve organisational goals for developing health care systems by promoting patient and consumer involvement. The Committee noted the experience reported by the Scandinavian countries and the UK where data have been developed and made available publicly. These experiences have shown the complications of explaining and interpreting the data to the media, general public and individual consumers. However, citizens should be able to know about these important aspects of health care in their countries.

Organisations representing patients and consumers should be involved in the dissemination and interpretation of waiting list information and in monitoring capacity problems. Citizens and patients should be able to get guidance and assistance when interpreting waiting list/time information for their personal use. Patients and their representative organisations should also be able to examine information on waiting list policies. The role that governments and insurance companies will play in the dissemination of this information will depend on the nature of the insurance system in each country. The provision of information to the public is another area that would benefit from research and exchanges of finding between countries.

6. Conclusions

The management of waiting times and waiting lists can be considered from a medical, organisational and financial point of view. Many ethical and legal aspects are also involved. These points of view represent their own sets of values and modes of operation. By definition there is a conflict of interests. When analysing what interest or scope will prevail the patients' "frame of reference" should be an aspect of main importance. This should be linked to political and legal fundaments of our western health care systems -solidarity, good quality of care, freedom of choice and right to know. Ranking on waiting lists and priority primarily should be put in terms of patients' rights on the "individual" and on the "collective" level.

Equitable access to health care:

Patients' needs and urgency in terms of acceptable waiting time and ranking on waiting lists should be determined on the basis of fair referral and urgency according to:

- medical criteria compared to personal condition and risk factors (evidence-based);
- individual components such as emotional and certain psycho-social criteria;
- quality of life

Basic ethical guidelines regarding equity must be taken into account:
- need and urgency should never be determined on the basis of race and religion;
- age and sex should not determine priority and ranking either; they may only be taken into account as an aspect of the general medical condition of the patient and as a risk factor.

Economic interests should not entitle to preference or priority in admission. Especially not the economic interests of others than the patient himself (employers, third parties, governments, etc.)

Access to ranking information:

- Consumers are entitled to have adequate general information on waiting lists/times in specific settings. They should have access to individualised information about their own ranking.
- The general information must be transparent, standardised and accessible:

    · transparency for individual choice;
    · compatibility of uniform registration systems.

- Citizens/patients should be able to get guidance/assistance when interpreting waiting list/time information for personal use and choice.
- Organisations of patients and consumers should be involved in dissemination and interpretation of waiting lists information and in monitoring capacity problems. They are entitled to get transparent information on waiting list policies.

Legal and Institutional Setting 

Access to hospital and the maintenance of waiting list records will need to be managed within the existing framework of national legislation of member states that govern civil rights and issues such as data protection. An approach taken by some countries has been to set out the standards expected from hospitals over the waiting time for an outpatient appointment or inpatient treatment. The Committee found that in most, if not all, cases these standards were not contained within legislation and therefore were guidelines to be followed by the health system rather than legally enforceable rights. Maximum waiting time limits can form part of a strategy to reduce waiting times and if they are pursued then a view needs to be taken as to whether they should be left to local discretion by institutions or a national set of limits agreed.

Referral, Selection Criteria and Priorities 

1. Referrals from General Practitioners to hospitals

In systems where access to specialists for elective treatment requires referral from a GP then it is important that patients, GPs and specialists are working within a common under-standing of how the process works. In the period from the time of the GP referral to the hospital until the patient is actually examined or treated in the hospital there is a risk that the patient «falls between two chairs», meaning that neither the GP nor the hospital takes responsibility for the patient. It is necessary in this period for responsibility for the patient to be clearly understood. This should include the provision of information to the patient (and GP) about when he/she will be seen in the hospital and what action should be taken if the patient's situation changes. The patient may get worse and need treatment quicker than the hospital is expecting from the information in the GP referral, or the patient may get well and not need treatment at all.
In most European countries hospitals are responsible for the selection of patients to be seen in out-patient clinics by a specialist, whether patients are referred by a GP or contact the hospital directly. A development in Spain is that GPs are responsible for selection of patients to be seen in out-patient treatment in the hospitals funded by the Ministry of Health. The GPs are informed by the hospital when there are free appointment times for patients in the different out-patient clinics. The GP then books the appointment for the patient, and is in this way responsible for the selection of patients to be seen in clinics.

2. Standardised referral information from GP to hospital

To assist specialists in making choices about which patients to admit, and what priority to assign to them, it is necessary for appropriate information to be available for the group of patients seen in clinic. The amount of information in GP referrals can vary considerably. Ranging from a note with one word and a question mark (for example: Ear?) to a focused referral with all the necessary information including a clear problem for resolution or a print-out of an electronic journal of several pages with no clear problem stated. It is difficult to prioritise between patients if the relevant information is not provided to the specialist. This problem can be addressed and a standardised referral letter is one way to achieve this. Committee members reported of initiatives within their country at both local and national level.

3. Development of selection criteria for admission

Individual departments or specialists within a hospital generally have in practice criteria, perhaps informal ones, used when admitting patients to hospital. The Committee considered that it would be beneficial if these criteria were standardised and made available publicly. In developing criteria a view needs to be taken as to the level at which these would be agreed: national, regional, local, institutional or department. The Committee concluded that ideally national criteria should be developed that could be applied locally. Approaches to define selection criteria at national level would need to involve the various interests within the health system:

- Government (as funding agency, regulator and representative of the tax payer)
- Producer (individual clinicians, hospital management, medical professional groups)
- Citizens (current and potential patients as well as tax payers)

The Committee concluded that socio-economic and demographic factors should not be included as criteria for determining access to health care. However, it was considered to be important to monitor admissions to hospital to ensure that waiting lists are not being used as a means to deny access to hospital to the more vulnerable groups in society.

The key decisions about priority are made when doctors assess patients and decide whether to admit them or not. Systems have been developed in some member states to assign a rank or score for individual patients to help assist in setting priorities on waiting lists. These have generally been developed at local level although a national exercise has been carried out in Norway (Lønning 1 and 2).
In developing standard criteria for the admission of patients to hospital, and by extension on to waiting lists the following points could be considered:
· levels at which priorities will be set: national, regional, local, institutional, clinician;
· if any services are not to be provided;
· whether a description of the main prioritising mechanisms and the agencies involved in deciding priorities for treatment decisions is needed;
· the width of public discussion, information and counselling about what services are to be provided;
· proposals for future action.

4. Example from the literature

The Committee did not undertake a full literature review. However, the country reports annexed to this report provided a substantial amount of information on developments within member states. In addition, the members of the Committee provided further papers and articles that were circulated to the Committee for consideration. An example of developments in priority setting from the literature include the following from Salisbury (England).

Salisbury District Hospital
Variables used for ordering waiting lists:

    Progress of disease
    Pain or distress
    Disability or dependence on others
    Interference of disease with normal occupation
    Time spent on waiting list

The first four variables must be improvable by surgery.
Each variable is scored on a scale of 0 to 4 as patients are assessed in
out-patient clinics and an overall score is generated.
BMJ, p. 811 1995.9.23

5. Developing criteria in Norway

The second Norwegian prioritisation report in 1997 (Lønning 2) included several criteria for consideration in the management of waiting lists.

The committee proposed the following division of priority groups:
i. Basic health care
ii. Supplementary care
iii. Low-priority care
iv. Forms of care/treatment that have no place in publicly-financed health care

An example of this is the suggested criteria for what they call «Basic Health Care» and «Low Priority Care» is shown below:

Priority Group I: Basic health care
(Conditions A, B and C must be met)

A Health state (at least one of the following conditions must be met):
1. Loss of prognosis: The risk of dying from disease within five years is greater than 5–10 per cent
2. Diminished physical or mental functions (or a significant risk of such a reduction): permanent and significant reduction in the patient’s ability to perform tasks which he/she would generally perform in everyday life (occupational activity, schooling, housework etc.), or tasks which patients in the same age group would naturally perform
3. Crippling pains that cannot be reduced sufficiently with the aid of non-prescription painkillers. One indication of strong pains is the diminished ability to carry out work and perform ordinary everyday activities (dressing, hygiene, sleep, cooking etc.)
The term permanent means that the patient’s state of health is not expected to improve without treatment
B Expected benefit (at least one of the following conditions must be met)
1. Increase in the probability of five-years’ survival is greater than 10 per cent (absolute risk reduction)
2. Improved physical or mental functions: Complete or partial restoration of previous state of health
3. Reduction of pain which leads to improved level of functioning
4. Nursing and care that can secure adequate nutritional intake, natural functions, hygiene, dressing and the opportunity for external stimulus or social contacts
C Cost-efficiency
Costs should be in reasonable proportion to the benefits of the treatment/care

Priority Group III: Low-priority care

Low priority may be given to:
- Health states where the patient can assume responsibility for himself
- Health states that result in an insignificant reduction in the level of the patient’s physical or mental functions
- Care/treatment that has minimal expected benefit, i.e. less than a five per cent increase in the patient’s chances of surviving for five years (or an improvement in the chances of survival which are impossible to prove using recognised statistical methods), or treatment that does not lead to an improvement in the patient’s physical or mental functions for a certain period of time
- Treatment/care with a dubious medical effect, i.e. poorly documented
- Measures that are too costly in relation to their benefits
- Nursing and care that goes beyond securing life functions and maintaining a level of physical and social activity which is “normal” for the patient. .

Management of Waiting Lists 

Improved management of waiting lists requires an understanding of the relationship between the demand for a service and the rate of supply. This understanding requires the development of information systems which not only can record the numbers of patients waiting for admission but also enable demand and supply for particular services to be monitored. Improving waiting times is not a one-off process of clearing a backlog of waiters but an ongoing project to balance demand for elective care with supply of treatment.

Waiting lists can serve as a formal record of patients identified as needing assessment or treatment. They can also be used as a statement of known demand for surgical or other treatment when planning the deployment of hospital resources.

1. A waiting list policy

Delays in accessing health care are of considerable importance to the public and reflect poorly on health care providers. Provider organisations should ensure that access issues are addressed at Board level and responsibility taken by the Chief Executive. Organisations should have an explicit policy for the management of waiting lists and responsibility for its implementation should be given to a senior manager or clinician.

The organisation’s waiting list policy should be part of the hospital's quality assurance programme. It should include goals and objectives as well as covering details of the administration and management of waiting lists. The policy should include clear statements about all major aspects of administering and managing waiting lists. Suggested topics for inclusion in a policy are given in annex B.

The scope of waiting times policies need to be considered. They should cover both the management of access to outpatient consultations for diagnosis as well as inpatient admission for treatment. In addition, waiting times for investigations (e.g. radiology, angiography) need to be monitored. Waiting times can also exist for services not provided by doctors, such as speech therapy, or for health care appliances, such as artificial limbs and consideration should also be given as to how to manage these waiting periods.

2. Principles for waiting times to a hospital:

Referral sent by physician

Referral received in hospital

Referral evaluated by hospital

Examination of patient starts

Treatment starts

Treatment finished








Exit possible

Exit possible


Exit possible


Waiting lists can be looked at in two ways: the experience of patients still waiting for treatment (prospective waiting) and the time waited prior to admission of patients already treated (retrospective waiting). Information on both types of waiting are needed to enable good waiting list management to take place. This is so that the number waiting on waiting lists can be monitored using prospective data and actual waiting times can be monitored using retrospective data.

Data can be developed at the level of clinical specialities or in more detail using operation codes or at diagnostic level using ICD-10 classifications.

3. Access to waiting lists

Access to specialist services will vary between countries. In those systems where patients are first seen by a General Practitioner and then referred to a specialist, the development of referral guidelines can assist in ensuring that only patients who require a specialist opinion are referred. (These comments also apply to specialist to specialist referrals as well as those from private specialists based outside hospitals who are under contract to a public health system). In systems where patients can access outpatient clinics directly then consideration should be given to the development of guidelines for patients to discourage inappropriate attendances.

Guidelines can either be developed nationally for local use or can be developed after discussion in a locality following agreement between specialists and GPs. A sensible starting point is to develop guidelines for procedures which are either very common or have long waiting times. GPs should be provided with information, at least quarterly, on outpatient and inpatient waiting times of clinical departments at local hospitals. If possible the particular interests (e.g. joint replacement or hand surgery) of surgeons should be indicated. Where waiting lists are held by individual surgeons and physicians then the information should also be presented at that level of detail. Hospitals should provide information back to GPs (or the doctor who referred the patient) on rates of referral to specialist services.

4. Booked admissions

Ideally a patient’s admission date should be agreed and booked at the same time as a decision is made that hospital treatment is required. This removes a considerable amount of uncertainty for the patient, can assist in planning the use of operating theatres and beds and help reduce the incidence of patient non-attendance. Waiting time policies will need to address the waiting times of patients both with and without admission dates and waiting list totals should include both groups of patients.

5. Selecting patients for admission

Patients should only be added to a waiting list if, in the view of the doctor treating them, their condition is stable and does not warrant immediate admission to hospital. An addition to a waiting list should only be made once a patient has accepted the advice of a specialist that hospital treatment is required. Patients should not be added to a waiting list to reserve a place against the possibility that in the future treatment might be warranted. Such patients should be kept under review either as outpatients or cared for by their GP until their condition requires admission.

A waiting list policy should include criteria to be used by doctors when decisions are made about admitting patients. Setting out objective criteria is an important means of demonstrating fairness in accessing hospital services and ensuring that patients with the greatest clinical need receive treatment first. Various methods have been developed. Some approaches require the specialist to rank the patient in one of four categories: immediate, urgent, soon or routine. More objectively rankings could be determined based on criteria such as: progress of disease, pain, disability or dependence on others, loss of usual occupation and other social factors. Where there are patients of equal priority preference should be given to patients with the longest waiting times, including any time waited as an outpatient. Accordingly, consideration should be given to keeping the date of receipt of the original outpatient referral in data sets for inpatient waiting lists.

6. Communication with patients

Patient perception of the quality of health services can be influenced by the amount of communication received during the referral and admission process. When a patient is added to a waiting list it is good practice to obtain the following information: confirmation of the patient’s address, both home and work telephone numbers, whether patient is available to come in at short notice, any special circumstances (e.g. caring for elderly relatives) and any dates when the patient will not be available for admission. Printed information should be given to the patient with details of the waiting list and admissions process and a contact telephone number along with appropriate information about their condition and intended procedure. If a decision is made to admit a patient to hospital then this should be communicated to the patient’s General Practitioner, or the doctor who sent the referral. The provision of reply slips with outpatient appointment letters and admission letters can improve attendance.

7. Structure of waiting lists

Waiting list data should be available for each specialist. To aid both the clinical and administrative management each specialist’s waiting list should be sub-divided into a number of smaller lists. For example these could differentiate between individual operation groups, reflect the nature of the surgery required (e.g. major or minor) or identify children separately. The date each patient was added to the waiting list should be recorded along with the details of the criteria used to determine relative clinical priority. These data enable waiting lists to be examined either in order of when patients were added to the list or their relative clinical priority. Both factors need to be taken into account when selecting patients for operating lists. It may be of help to identify which patients have admission dates and which patients are still without a date. Waiting lists can possibly include many different categories of patients:

i. patients who have to wait because of general hospital resource constraints;
ii. patients with an advanced date of admission;
iii. patients who are having a further admission after an initial operation;
iv. patients whose admission has been deferred on medical or social grounds;
v. patients sent home at the time of admission because of lack of beds or other resources;
vi. patients who could not attend when first offered an admission date;
vii. inpatients waiting for a transfer to another speciality (except emergency cases);
viii. patients who have a booked admission date.

A separate list should be held for planned repeat admission comprising those whose inpatient or day case treatment is planned over a series of admissions. Another deferred admission waiting list could be held including those who were unable to accept an offered admission date because of a medical or social constraint. Suggestions for establishing registers for waiting lists are contained in Annex C.

8. Maintaining waiting lists

Waiting lists, whether computerised or not, must contain sufficient information about each patient in order to enable their selection for treatment. Changes in patient details should be recorded promptly. An agreed set of data should be established and held for each patient.

A senior manager in each hospital should be made responsible for the administration of waiting lists. The hospital’s waiting list policy should set out the systems to be used to administer waiting lists including the data to be obtained for all patients added to waiting lists. These procedures should be circulated to staff involved in the management of waiting lists and appropriate training provided. New staff dealing with waiting list administration should receive a structured induction programme in order that they can be familiar with the systems employed within the hospital.

9. Review and validation

Waiting lists should be reviewed at regular intervals and at least two times a year. The coverage of the review could include (for both outpatients and inpatients) patients who: have waited an excessive period of time (as defined locally), have turned down admission offers or who have been unavailable for admission for medical or social reasons. It is important to validate waiting lists in this manner to ensure that they reflect accurately the needs of patients. Validation can identify those patients who can be removed from a waiting list for a number of reasons: they have decided against having treatment, they have had the treatment elsewhere, they have moved away from the area or they have died. Validation can also be used to identify those patients requiring treatment who have not been added to waiting lists. Arrangements for review and validation should be recorded within the hospital’s waiting list policy. GPs should be involved in the review process. Information could be given to GPs at frequent intervals listing the referring GP, patient, consultant, intended procedure, date when the outpatient referral was received, date entered on to the list and intended date of admission.

10. Publication

Waiting lists are important sources of information for patients and the wider public. Patient confidentiality needs to be protected but information on likely waiting times for individual specialists should be made available to patients and their General Practitioners. Such information can assist patients in choosing a specialist and guide GPs in referral decisions. Waiting times for particular procedures could be listed under each specialist.

11. Reporting waiting lists

Information on waiting lists and times is important for improved management of hospital services. Data should be collected for use in monitoring current performance, forecasting the future position and modelling different possible scenarios. Comparative information can be shared with specialists to identify scope for improving service provision. In order to be most useful, information on waiting lists needs to be looked at in context of other hospital activity and utilisation data such as bed occupancy, average length of stay, cancellation of operations, theatre usage and emergency admissions.

12. Monitoring waiting lists

Consideration should be given by national authorities to establish arrangements for the monitoring of waiting list and waiting time information. Such arrangements should focus on the time waited by patients. The total number waiting may also be of interest. Regional and local authorities responsible for funding hospital services should participate in these arrangements in order that they can use any data required nationally to monitor performance in this area.

The balance of data to be obtained locally and nationally will need to reflect national policies for data collection from providers of health services.

13. Addressing long waits

It is important that patients with the greatest clinical need receive treatment first and that fair systems are in place to determine admission to hospital. It is also important to ensure that patients are treated within a reasonable period of time. Maximum waiting times will reflect the balance between the demand for and the supply of hospital services. Consideration should be given to setting out limits within which it is expected that hospitals should admit most patients. These could take the form of a maximum limit requiring all patients to be admitted within a certain time period. Alternatively time limits could be set for a range of priority procedures or client groups (e.g. cataract surgery or children). Another option is to set a percentage (e.g. 95%) of patients to be admitted within a given period rather than requiring this for all admissions. A view needs to be taken as to whether to pursue reductions for all diagnoses and operations or to target specific conditions.

Techniques to address long waiting times include:

    establishing waiting times policy as part of quality management and the normal planning process, with targets set annually for improvement;
    identifying procedures for which a number of specialists can agree to pool capacity so that patients with the longest waits can be admitted as admission dates become available;
    not to lose sight of the "tail" of long waiters. Identify them and ensure that admission dates are offered;
    the setting aside of an agreed proportion of operating theatre time to admit long waiting patients;
    increasing the provision of ambulatory care thereby releasing beds for long waiting cases;
    offer long waiters the chance to transfer to another provider;
    develop models of bed state availability within hospitals and plan elective admissions during times of lower emergency admissions;
    develop incentives for primary care teams and hospital departments which reward improved management of waiting lists;
    look at elective services as part of a whole systems approach, not as stand alone waiting list initiatives, e.g. by developing rehabilitation services to free up acute beds;
    evidence is available to suggest that the current levels of some operations could be reduced in number (e.g. grommet insertion, D & C for women under 40, tonsillectomy). Waiting list plans should include protocols to improve the appropriateness of these interventions;
    look to increase the scope for managing non-urgent cases in primary care, e.g. by holding non-urgent waiting lists by GPs;
    based on agreed protocols, direct access to inpatient waiting lists can be developed for some procedures (e.g. for hernias, endoscopic examinations and diagnostic investigations), thereby avoiding waiting times for an outpatient consultation. Admission in these cases should normally be preceded by attendance at a pre-operative assessment clinic;
    separating elective admission beds from emergency admissions beds can reduce the possibility that elective patients will have to have their admission cancelled;
    joint reviews of cases between physicians and surgeons can eliminate periods of specialist to specialist waiting time, for example between angiography and assessment for cardiac surgery.

Modelling of Waiting Times and Waiting Lists 

The use of modelling can help improve the understanding of the dynamics of waiting lists. Models can be developed and used to assess the impact of changes in referrals, additions to waiting lists and admissions from waiting lists. A simulation model can be described as the building of a replica of a complex system where alternative courses of action can be tried out using the model and the consequences can be assessed. “What if” questions can be assessed, for example: “What growth in admissions would be required to achieve a given target for improving waiting times in a given period.” A model could be used to investigate the effect on waiting times of increasing admissions on a one off basis, of increasing admissions on a regular basis and of an increase or reduction in demand represented either through referral rates or additions to waiting lists.

Simulation modelling can help avoid or minimise the making of expensive mistakes by avoiding experimenting in the real domain. They can also provide a useful tool for communication between the participants in the provision of health care.

Models can also be of value to hospitals as they can be used to reduce bottlenecks and improve patient throughput, for example in Outpatient or Accident & Emergency departments. Applications of waiting times simulation models include linking them to other simulation models to examine the effects of changes in emergency admissions, staffing levels or operating room and bed capacity.

Key data required are: referral levels, numbers currently on waiting lists, the distribution of waiting times, additions to and removals from waiting lists and admissions. Models can be populated with data at the national, regional, hospital, clinical speciality or individual specialist level.

Annex A: 

Examples of Minimum Data Sets 

from Spain and the UK 

SPAIN: Minimum data set


Patients registered at WL

Operations and removal from the WL

Institution number
Patient number (clinical record no.)
Date of birth
Date of registration
Waiting list diagnosis code
Literal diagnosis
Surgical procedure code
Literal procedure
Clinical priority

Date of removal
Reason of removal
Admission in case of surgical treatment

Waiting list minimum data sets



National Health Service number
Patient name
Address and postal code
Health authority of residence
Birth date
General Practitioner
Overseas visitor status
Institution code
Patient hospital number
Source of referral
Service type requested
Data referral request received

National Health Service number
Patient name
Address and postal code
Health authority of residence
Birth date
General Practitioner
Institution code
Category: planned, booked or waiting list
Admission type: day case/
Decided to admit date
Date offered for admission
Admission offer outcome
Elective admission removal date
Elective admission removal reason
Duration of elective wait
Intended procedure
Intended management
Priority type, eg urgent, soon, routine
Admitting Doctor

Annex B: 

Suggested outline for 

a hospital waiting list policy 


· Goals and Objectives
· Links to other policies (e.g. quality assurance, clinical effectiveness, communications, admission and discharge)
· Definition of waiting lists and waiting times
· Purpose of waiting list policy

· Identification of managers and clinicians responsible for implementing policy


· Services covered by the policy.


· Protocols agreed for referral and admission agreed with local GPs.
· Booking of patients for outpatient appointments, including arrangements for handling referrals from GPs.
· Criteria employed for assigning priorities to patients added to waiting lists.
· Booking of patients for admission.
· Style and purpose of Information to be provided to patients added to waiting lists.
· Criteria to be used on selecting patients from waiting lists for admission.
· Arrangements for notifying patients of admission.
· Handling patients who do not attend.
· Administrative review (validation) of waiting lists.
· Arrangements for informing GPs.
· The design of administrative systems employed.
· Information requirements for managing waiting lists, including minimum data sets.
· Information requirements for monitoring waiting lists.


· The production of guidance notes for staff.
· Training of staff: clerical, managerial and clinical.
· Monitoring compliance with procedures.


· Arrangements for the review of waiting list policies and procedures.

Annex C: 

Establishing health registers 

Registers of health are established in order to give the responsible health authorities as well as the hospitals comprehensive information on activity, waiting lists and waiting time. The information in the register can be used to make comparisons between the regions, but is not intended as a tool for making administrative decisions on individual patients.

A register can include information on e.g.:

o Municipality
o Hospital
o Department
o Treatment
o Date of referral
o Way of referral
o Referral diagnosis
o Date of examination
o Examination diagnosis
o Periods of passive waiting (waiting due to circumstances specific to the individual patient)
o Date and reason for leaving the waiting list

Before the register is established it is necessary to determine the purpose of the register. This analysis must both determine the purpose of the register today, but also try to predict for what purposes the register can be used in the future. This process is important in order to find out which variables to include in the register. To avoid lack of time-consistency it may be better to include variables with potential importance from the very beginning, instead of implementing them when the need is apparent and thereby suffer a loss of time consistency. However as every new variable raises the cost of collecting the data, variables without imminent or potential use should be avoided.

Managing the register

A health register can be a useful tool for many types of users and can serve as basis for medical-, administrative- and statistical purposes. In order to make the register available for different user groups, it is recommended that the register be placed under a central authority. The central authority is in charge of the day-to-day administration of the register. The responsibility for the data collection should however be placed under the local authorities.

Security issues:

In administrating the register, the central authority must follow a number of rules ensuring the safety of the data. As the data contains confidential information, it is important that only the central authority have full access to the register. When data is supplied to external sources identifiable information, as e.g. social service number must be encrypted, in order to observe the law of registers and to avoid misuse of the register.

Furthermore, the transmission of the data must be secured. To prevent outsiders from reading the sensitive information, either by mistake or on purpose, an encryption mechanism must be implemented in the transmission of the data, which ensures that only the approved recipient of the data is able to read them.