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National Public Health Service for Wales
Rapid review of the evidence on potential health
impact of waiting times initiatives in Wales
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
Author: Geri Arthur, Specialty Registrar
Version: 1
Date: 061109
Page: 1 of 78
Status: Final
Intended Audience: WAG
National Public Health Service for Wales
Rapid review of the evidence on potential health
impact of waiting times initiatives in Wales
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
Version: 1
Date: 061109
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Status: Final
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.
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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.
Author: Geri Arthur, Specialty Registrar
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Date: 061109
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1
Rapid review of the evidence on potential health
impact of waiting times initiatives in Wales
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.
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Rapid review of the evidence on potential health
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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
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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 2 nd 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 2 nd 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.
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4.5
Rapid review of the evidence on potential health
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Wales Audit Office report on waiting times
By 2005, the Wales Audit Office report on waiting times5 indicated that Wales spent
more per head on health than England but patients still had to wait longer. It should
be stated that by this time, direct comparison of waiting times across the UK nations
was problematic, as waiting times were not being measured in the same way. They
described the current waiting time situation in Wales as inequitable, both within
Wales and in comparison to the situation in England and Scotland. They believed the
causes to be: rising GP referrals; emergency and medical pressures; inefficiencies
such as longer average lengths of stay; long intervals between bed usage and
proportionally fewer patients being treated as day cases compared to Scotland and
England. The Wales Audit Office stated that Wanless21 had argued that the NHS did
not use its’ capacity efficiently. They recommended that the Assembly should provide
clear long-term targets and ensure that the performance management system did not
reward failure, for example, non-publicised tolerated breach levels for targets and
non-recurrent funding for initiatives to reduce waits. They found a strong positive
correlation between trust expenditure and the proportion of patients waiting over 18
months. This could indicate inefficiencies. The Wales Audit Office believed that
initiatives were treating symptoms and not the cause of long waits.
4.6
Delivery Support Unit and Designed for life
At the end of 2005, the Delivery Support Unit was established8 to provide
performance support to NHS Wales, advice on performance management, to deliver
a framework for effective delivery planning and to design and deliver the 2009
Access project.
In 2006, Designed for life was published22, it supported a radical redesign of services
with a greater emphasis on clinical quality, health promotion and early intervention.
Some commentators had argued that Wales had concentrated on ill health at the
expense of health23, Designed for life could be said to be a move away from that
approach. A report produced by NPHS24, looked at future issues in relation to
orthopaedics. It highlighted changes in demographics which might affect demand. It
also mentioned that lifestyle issues affected bone health and that prevention was
key. The report argued that consultant activity trends were influenced not just by their
own capacity to work but by management and clinical systems.
4.7
Data and day surgery
A follow up to the Wales Audit Office report25 in June 2006, found that considerable
progress had been made. It asked the Assembly to ensure that no inappropriate
activity or manipulation of data was caused by trust’s need to focus on targets. This
had been a problem identified by the National Audit Office in England where 9 NHS
trusts were found to have manipulated waiting lists to achieve targets26. The report
also stated that Wales had sufficient capacity; it just had to be better used. A further
Wales Audit Office report looked at how better use of day surgery could be made in
Wales27. It stated that where clinically appropriate, the use of day surgery reduced
average lengths of stay, lowered costs to the NHS and reduced the risk of hospital
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acquired infections. Rates of day surgery were lower in Wales than England and
much less than the level thought to be achievable. Productivity was also lower in
Wales. The range in the proportion of day surgery across Wales was 47 – 79%.
Some caution is necessary when using day surgery statistics, as variation in
adherence to definition of day surgery, that is an inpatient stay of up to 23 hours and
59 minutes. The report estimated that an additional 558 cases per month could be
undertaken if all units increased productivity to the activity in the upper quartile.
Problems were again highlighted in theatre usage, gaps in the list and cancellations,
fully equipped theatres being used for minor procedures and variable discharge
practices.
4.8
26 week patient pathways
At the end of 2006, the Assembly announced a framework document to help deliver
the 26 week patient pathway28,29. The circular states that there would be an allocation
of £80 million a year up to 2009, to achieve the target.
4.9
Delayed transfers of care
In 2007, a Welsh Audit Office report30 looked at tackling delayed transfers of care in a
number of trusts. It estimated the direct cost of bed days occupied by delayed
transfers of care across Wales at £69 million in 2006/7, not all this money would be
released but up to £27 million might be. Several problems were outlined by the
report, some were due to budgetary pressures or capacity issues, some due to
inflexibility in systems, for example delays in restarting care packages that had been
frozen when a patient was admitted. The report suggests joint commissioning
agreements between health and social care might help and highlights areas which
have taken advantage of Section 33 agreements, taking advantage of budget
flexibilities. A follow-up report31 indicated that some progress had been made but
expressed concern about robust medium to long term planning to ensure that
strategic visions became reality. It also stated that the Assembly had not yet provided
a clear overall direction to tackle whole systems problems.
4.10
Providing care in NHS facilities
The 2008/9 framework for delivery32 for the 2009 Access Project set out the
increased activity which would be required in order to achieve government targets,
outlining current progress against planned trajectories. In addition, the One Wales33
document, set out the requirement to eliminate the use of independent sector
providers by the NHS by 2011, which provides for a more challenging environment to
achieve the 2009 target
In July of 2008, the Assembly announced that there were significant performance
issues at Cardiff and Vale Trust. The Minister requested two reviews, an investigation
into waiting list management at the trust and an Assurance Review of the trust’s
processes, leadership and governance. Thus list management continued to be a
problem despite sustained policy focus. Greer has examined the changes in NHS
services post-devolution34. He argues that the 2003 NHS reorganisation in Wales
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caused problems due to local managerial capacity, fragmented local health boards
and powerful hospital trusts.
5
Results of the literature review
5.1
Waiting times
The causes of long waiting times can be broadly split into demand and supply issues
and strategies to respond to waiting times have usually considered one or other of
these. OECD3 states that there is no international consensus on what constitutes an
‘excessive’ waiting time but point out that a number of countries have set targets of
either three or six months for a maximum wait. The main consideration is whether
patients may be harmed by waiting longer and how acceptable they find waiting.
5.1.1
What causes waiting lists?
In the UK there is evidence that demand has increased, partly in response to new
treatments and technologies but there has also been an increase in GP referrals.
Alongside this, there has been an increase in emergency admissions which has had
an impact on elective surgery beds and led to inefficient practices such as admitting
the patient the day before surgery in order to ‘save’ the bed.
Demand side policies include the prioritisation of patients according to health need
and encouraging private insurance. In the UK, attempts have been made to manage
GP referrals to reduce inappropriate referrals.
Delayed discharges and transfers of care have also taken up beds that could be
used for surgery. Wales has been slower than England to exploit the benefits of day
surgery.
OECD3 states that waiting lists tend to form in countries which combine public health
insurance and constraints in surgical capacity. Public health insurance removes
barriers to accessing healthcare but capacity constraints mean that supply can’t
match demand.
Optimum waiting times may not be zero, it may be cost effective to maintain short
queues, with savings in hospital capacity.
Supply side policies increase facilities or staff or use capacity in the private sector.
They also encourage the use of day surgery and strategies to link remuneration to
activity.
One criticism of waiting statistics is that they include no information about
appropriateness of referral or wait35 and indeed are difficult to compare across
nations.
A study36 used routine health service data on waits to look at the distribution of long
waits and to look for associations with capacity markers. The analysis found no
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association with long waits and capacity, bed occupancy rate or independent sector
activity. Interestingly greater need and deprivation were inversely associated with
waiting time. This may indicate correct targeting of resources. The authors found,
counterintuitively, that trusts with more consultants and anaesthetists had longer
waits. They suggest that this may be a marker of more complex work as other studies
have shown increasing the supply of doctors can reduce demand.
The King’s Fund37 have suggested that attempts to tackle waiting times were not
successful initially because the list was seen as a backlog that needed to be cleared
and then demand would be manageable, this was not the case. Trusts that have
successfully managed waiting times have shown an understanding of the ‘whole
system’ of healthcare. King’s Fund identified five key themes: understanding whole
systems; the importance of sustained action over time; reducing demand versus
sustaining; clinical ownership and involvement and responding to unexpected
change. An audit of the NHS reforms under the Labour government indicated that
there had been large increases in demand but broadly their aims had met with
success12 although the authors state there is still much to do
An analysis of waiting times in the UK looked at the impacts of different regimes on
hospital waiting times38. The authors state that post-2001, England instituted a policy
of naming and shaming where trusts failed to hit waiting time targets, in Wales failure
was perceived to result in extra resources. There is evidence that the English
strategy resulted in falling waits but there is also evidence that there was a degree of
gaming at the beginning of the work to reduce waits, however there was no benefit to
this approach in the long term as targets became more challenging and needed to be
sustained.
An OECD economic study39 considered the possible causes of waiting lists and came
to the following conclusions for the issues considered:
 “Do countries which do not report waiting times spend more? The
evidence is equivocal, some countries with low expenditure have high waits,
and some with high expenditure have low waits but there are some countries
which don’t fit this rule. Spain has low expenditure and low waits.
 Do countries which do not report waiting times have higher capacity (e.g.
beds, doctors)? There is some evidence that countries with more acute care
beds have lower waits. Also more practising doctors and specialists are
associated with lower waits.
 Do countries which do not report waiting times treat more surgical
inpatients? It does appear that countries with lower waits demonstrate higher
surgical inpatient activity but not necessarily for all disciplines.
 Do countries which do not report waiting times have higher productivity?
The authors were unable to demonstrate a statistically significant difference
between low and high waiting time countries.
 Are countries which do not report waiting times characterised by different
remuneration systems? Countries not reporting waiting times are more likely
to reward specialist according to activity. It is also more likely that these
countries have a lower degree of restriction on the volume of activity performed.
 And does the higher surgical activity lead to lower waiting times? The
evidence is mixed at first glance. It seems to show increased activity may be
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associated with longer waits. There is likely to be a different explanation, the
authors suggest different threshold for adding certain types of patients to the
waiting list.
 Do countries which do not report waiting times have younger
populations? There was no statistically significant difference between the
means of low and high wait countries.
 Do countries that do not report waiting times have sicker populations?
The authors considered mortality, but acknowledge that this may not be the
best marker. Rates appear similar across countries.
 Are countries with no reported waiting times characterised by higher
levels of co-payment? In most countries that do not report waiting times there
are co-payments, where waits are reported, health care is usually free of
charge. However co-payments are usually small thus it is difficult to conclude
that price could be playing a role.”
A literature review40 on waiting list management supports the theory that poorly
designed systems are the cause of waiting lists and that the root causes of waiting
need to be addressed.
5.1.2
Factors affecting acceptability of waiting
Derrett et al41 describe the experiences of patients waiting for admission to a hospital
in New Zealand for elective surgery. They found that general health and quality of life
did not worsen during the study but that people who perceived themselves as having
more severe symptoms desired surgery more quickly. It is possible that more severe
cases were triaged and admitted early in which case the study may not be
representative of a general waiting list. OECD3 found that whilst patients were
intolerant of long waits, those exceeding three to six months, they accepted short and
moderate waits dependent on their symptoms. Sanmartin42 looked at the
determinants of unacceptable waits by analyzing data reported to a national survey in
Canada. Again, patients were more likely to find longer waits unacceptable,
especially if they suffered any adverse experiences during the wait. The role of socioeconomic and demographic factors was varied but low educational attainment
increased acceptability. Those aged under 65 years were more likely to find waits
unacceptable. The authors conclude that this may indicate expectations of the patient
play a role in acceptability.
Oudhoff43 et al looked at waiting for elective surgery and its impact via a crosssectional study design using a questionnaire with post-operative follow up. They
found that the waiting period involved worse general health perceptions, problems in
relation to quality of life and raised anxiety levels compared to the period after
surgery. Giving prior information about the wait reduced negative feelings. Social
activities were affected in 39-48% of patients and 18-23% experienced problems with
work. The authors conclude that waiting for general surgery involves a prolonged
period of decreased health, psychological effects and disruption of social life. They
believe that prioritisation of the most severe and more information about waiting
could promote acceptance. This finding agrees with the work of Dunn et al44, who
looked specifically at cataract surgery waits. They found waits of three months or less
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were acceptable and waits over six months were considered excessive. Lower
tolerance was found in those with the greatest self reported impairment this did not
necessarily agree with clinical findings of visual acuity. The anticipated wait time was
again the strongest predictor of acceptability.
5.1.3
Is waiting harmful?
A systematic review45 of the effect of waiting for treatment for chronic pain found that
patients experienced a significant deterioration in health related quality of life and
psychological well-being whilst waiting for treatment for chronic pain during the six
month period from referral. It was not possible to give an optimum waiting time as
results were varied, with waits as low as five weeks being significant.
Whilst waits for cardiac and cancer treatments are not covered by either of the
initiatives under scrutiny in this review, attempts have been made to quantify
optimum waits in these areas. This has proved problematic in other disciplines. There
may be some transferable lessons. Much of this work has been carried out in
Canada. A prospective cohort study46 looking at the impact of waiting time for
coronary artery bypass grafting indicated that patients waiting more than 97 days had
significant reductions in quality of life and physical function with a greater incidence
of post-operative events and a reduced likelihood of return to work. A series of
systematic reviews looked at whether prolonging waiting times had an effect on
testicular cancer surgery47, prostate cancer surgery48, renal cancer surgery49, bladder
cancer surgery50. The picture is unclear, with psychological issues possibly of
importance and need for more research apparent. The exception is bladder cancer,
with some evidence that delays in treatment may be associated with poorer tumour
grade which may mean poorer prognosis. For all reviews it was not possible to pool
data from studies due to differences in measures used.
Bandolier51 has noted that studies on the effects of waiting times are rare; they tend
to be natural experiments where the effects of existing waits are observed. Obtaining
ethical approval for a randomised study would be unlikely. A further Bandolier
appraisal52 looked at the two week rule for cancer referral. Two studies were
appraised53, 54, one a retrospective audit and the other a systematic review. Neither
study could identify any improvement in treatment using the two week rule. It did not
improve the number of cancers found or the stage at which they were found. A
prospective cohort study55 identified problems with the two-week rule; the proportion
of cancers identified in the priority group had decreased whilst the proportion of
cancers in the routine group had increased. The authors believe that this is indicative
of the poor predictive value of the two week referral criteria not of poor diagnosis by
general practitioners. Waiting times for routine referrals have increased due to
increased demand to meet the two week rule. This may have an adverse
psychological impact on patients.
5.1.4
Health economics of waiting
Feldman56 made an attempt to estimate the cost of rationing medical care by
insurance coverage and waiting. He concluded that the costs associated with over
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utilisation by insured individuals were high, larger than the costs of under utilisation
by uninsured and that both systems resulted in misallocation. The author also argues
that costs of waiting are subsidised in terms of sick pay and social opportunity cost.
Gravelle57 argues that rationing by waiting times is used in health systems with low or
zero money prices, he concludes that positive prioritisation, that is shorter waits for
interventions that deliver higher benefit for that patient are welfare improving. There
is limited scope to practice this with tight waiting times.
A retrospective cohort study58 looked at health service costs for patients associated
with waiting in order to determine whether costs are artificially increased by delay in
surgery due to lack of resources. Longer waits were not associated with higher costs
to the health service either pre or post-operatively.
A review by Rachlis59 looks at solutions to waits, particularly in Canada. He suggests
establishing more short stay clinics like the ones in the private sector that he believes
have done well. He suggests there is no need to siphon public money to
shareholders in order to address waiting times. He also suggests that lessons need
to be learned from queue management theory where bottlenecks in services are
designed out. The author cites the work of the Modernisation Agency in England who
enhanced access to services using queue management theory. Lewis60 described
this as phase two of the UK government’s ‘war on waiting times’, where waits were
managed along a care pathway. The author believed that the 18 week target would
be met in England. Recent strategy in England has been described as using targets
with performance management sanctions; procurement of additional capacity and the
introduction of a quasi-market.
A King’s Fund report61 highlights that this phase actually saw a fall in the numbers
treated and the numbers waiting, possibly due to a more evidence based approach to
treatment and the decline in procedures deemed to be of low therapeutic value such
as tonsillectomies. There was also a reduction in the numbers added to the list which
points to a degree of demand management.
5.1.5
Patient preference
Do patient’s preferences matter? It has been argued by McPherson62 that patient’s
preferences are important and that there may be a placebo effect where patients
have a strong preference. The author cites an example of a study63 where mortality
was 35% lower from coronary heart disease in participants who took their placebo
versus those who did not. He discusses a recent study64 where the treatment effect
for patients randomised to their preferred treatment were greater than in those
indifferent to treatment assignment.
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Key messages regarding waiting times
 Evidence on physical implications of waiting is conflicting
 Psychological implications of waiting may be more important than physical ones
 Waiting time statistics give no information about appropriateness of wait
 Waiting times appear unrelated to the age profile or morbidity of the population
served
 Evidence of costs related to waiting is unclear
 No international consensus on what constitutes an ‘excessive wait’
 Patients are tolerant of short to moderate waits varying between 12 and 24
weeks.
 Providing information about length of wait can increase acceptability
 Patient’s perception of their condition rather than the professional’s assessment
may be more indicative of acceptance of wait
 Patients exercising preference may positively influence outcomes
5.2
Orthopaedics
5.2.1
Background
An NPHS horizon scanning exercise24 on orthopaedics found the following:
 Orthopaedic problems impose a vast social and economic burden on society
 It is estimated that 50% of the UK population will require surgery at some time
during their lifetime
 Injury remains a ‘neglected epidemic’
 The validity of routine data in orthopaedics is questionable
 Consultant activity trends are influenced not only by individual work rates, but
also by management and clinical systems in place
The author states that the orthopaedic plan for Wales has provided a robust
foundation for change; future demographic projections may mean that delivering
orthopaedic services is more challenging.
5.2.2
Factors affecting acceptability of waiting for orthopaedic
procedures
A retrospective study from Sweden65 indicated that length of waiting time was a
predictor of acceptability, they noted that patients reported a longer waiting time than
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the hospitals did. Socio-economic patient variables and hospital type were not
predictors of negative views on waiting. People in work tended to wait less for back
surgery, possibly indicating a degree of triage. The authors found no correlation
between health related quality of life scores and waiting time and this finding is
supported in the literature. This finding is counter-intuitive as it might be assumed
that those with poorer quality of life might benefit more from surgery.
A systematic review66 of the literature on health related quality of life and total hip and
total knee arthroplasty found that this type of intervention was quite effective in terms
of improving health related quality of life dimensions. Age was not found to be an
obstacle to effective surgery and men seemed to benefit more than women. Hip
arthroplasty returned more function than knee arthroplasty and where effects were
modest, then co-morbidities were found to have played a part.
An important factor for waiting was the type of hospital, with those admitted to a
university or regional hospital waiting longer. The Swedish study65 concluded that
hospital factors were more important than patient factors in determining the length of
wait. Patients valued shorter waits and being able to influence the date of their
surgery.
5.2.3
Is waiting for orthopaedic surgery harmful?
Attempts have been made to assess the optimum waiting time for orthopaedic
procedures. A Canadian report looked at fractures67 and the effects of waiting as part
of a systems review. They found the evidence on delay in operating on hip fractures
was conflicting, there was some evidence that delays in ankle and tibia surgery lead
to complications and prolonged hospital stays. A Finnish study68 examining health
related quality of life in patients waiting for major joint replacement found that whilst
patients had a consistently worse health related quality of life as compared to
population controls it did not deteriorate whilst waiting. The authors also found that
length of wait was unrelated to quality of life measures at admission and they also
noted that there appeared to be a slight improvement in some dimensions such as,
moving, sleeping and discomfort, whilst waiting. They speculate that this may be due
to the expectation of receiving surgery.
There is some evidence that for certain types of surgery, where patients may be
managed conservatively for a time, that the benefits of early surgery may be short
lived in comparison to conservative management. A randomised controlled trial of
surgery for lumbar disc herniation versus conservative management69 indicated that
early surgery achieved more rapid relief but the outcomes for both groups were
similar at one year and had not changed by the second year. This finding is
supported by other studies for example an American prospective cohort study70,
showed improvements in both groups.
Patients who opt for surgery often express more satisfaction with outcomes, this may
be due to feeling they are acting upon their needs. A systematic review71 of surgical
interventions for disc prolapse indicated that discectomy produced better outcomes
than placebo but only four trials had compared discectomy with conservative
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management. The authors conclude that discectomy for carefully selected patients
provides faster relief than conservative treatment
Another prospective cohort study on hip arthroplasty72 from New Zealand, found that
patients who waited longer had poorer physical functioning pre-operatively and those
with poor initial health status showed greater improvement 6 months post-surgery.
Thus the evidence on whether patients deteriorate during surgery waits appears to
depend on the condition and interventions. Different measures of quality of life were
used in these studies and mean waits varied between countries.
5.2.4
The health economics of waiting for orthopaedic surgery
Orthopaedics is the largest and most expensive surgical specialty in the UK, however
cost utility analyses, considered to be the gold standard in economic evaluation are
complex. Brauer73 found that studies were limited across the range of procedures
available, with most studies relating to total joint arthroplasty and the prevention of
osteoporosis. Fielden72 found that waiting times of greater than 6 months were
associated with a higher total mean cost. Costs were estimated in terms of medical
costs, societal costs and personal costs. The authors conclude that waits of six
months and longer are costing New Zealand society in a variety of ways, including
financially.
Key messages regarding orthopaedics
 Orthopaedics is the largest and most expensive specialty in the UK
 There is a lack of evidence in terms of cost effectiveness /cost utility of
orthopaedic interventions
 Hip and knee arthroplasty are quality of life enhancing
 Age is no obstacle to positive surgical outcomes
 Patients value being able to influence the timing of surgery
 Patients seem to prefer active management even when evidence indicates little
difference between active and conservative management The length of time
patients wait is not determined by quality of life
 The length of time patients wait is not determined by quality of life
 There is conflicting evidence in terms of affects on quality of life whilst waiting
for surgery
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5.3
General surgery
5.3.1
Factors affecting acceptability of waiting for general surgery
Studies indicate that the factors which affect the acceptability of waiting times for
general surgery are similar to those described previously in this report. People with
more severe symptoms desire surgery more quickly35 and early information about the
duration of the delay could promote acceptance of waiting37. A questionnaire survey74
that included patients in the participants, conducted in The Netherlands, showed that
patients supported prioritisation based on clinical need but not on non-clinical need,
for example prioritising healthcare workers. Patients assigned different maximum
waits to different conditions prioritising hernia repair and gallstone surgery over
varicose vein surgery.
A Welsh survey75 found that healthcare staff and patients believed that level of pain,
rate of deterioration of disease, level of distress and level of disability should be the
deciding factors in prioritising patients for elective surgery. Participants felt that age,
ability to pay, cost of treatment, evidence of cost effectiveness, existence of
dependents and self inflicted ill health should have no influence on prioritising
patients. These findings are interesting as patients whose treatment falls outside
normal commissioning arrangements may be assessed under exceptional treatment
arrangements. Cost-effectiveness of treatments will be considered and other factors
such as dependents may be considered in terms of the societal cost of the person
not being treated. Access to some treatments may be predicated on patients
stopping smoking or losing weight as these actions are likely to both increase the
success of the treatment and reduce the chances of complications or failure. This
approach may however be viewed by some as judgemental or discrimininatory.
5.3.2
Is waiting for general surgery harmful?
Studies indicate that patients suffer adverse psychological outcomes whilst waiting
for surgery, especially if the length of wait is unknown. Oudhoff37 concludes that
patients waiting for a range of general surgical procedures, experience a prolonged
period of decreased health which affects them both psychologically and socially.
However there are limitations to this study, particularly the low response rate which
may indicate those who were unhappy with their care chose to respond. A New
Zealand study41 concluded that lengthy waits for surgery represented a burden in
terms of living with the unrelieved severe symptoms and poor health-related quality
of life.
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Key messages regarding general surgery
 Healthcare staff and the public support prioritisation of waiting based on clinical
need
 Neither healthcare staff not public support prioritisation of treatment on cost
effectiveness
 Patients suffer an adverse psychological impact whilst waiting
 Patients who perceive that they have more severe symptoms desire surgery
more quickly
 There is some evidence that waiting causes a societal cost.
6
Conclusions
There is no international consensus about what constitutes an ‘excessive’ wait
despite attempts to determine optimum waiting times for different surgical
procedures.
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.
Successful attempts to tackle waiting times have adopted a ‘whole systems’
approach rather than viewing the waiting list as a backlog to be tackled. Patients are
tolerant of short to moderate waits, with waits up to 3 months seen as acceptable but
no longer than 6 months. Giving information about the length of the wait can enhance
acceptability as can allowing patients to influence the timing of their procedure.
There is evidence that the public support prioritisation of healthcare by clinical need
but are not concerned with the cost effectiveness of treatments and do not support
age restrictions on treatment or exclusion based on lifestyle factors such as weight or
smoking.
Waiting time statistics give no information about the appropriateness of the wait.
Demographic factors such as age profile of the population, morbidity or socioeconomic factors do not appear to influence the size of waiting lists. The evidence in
relation to costs of waiting is unclear but there is some evidence that there is a
societal cost.
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
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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.
Because current information systems do not capture appropriate data it is not
possible to quantify the 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 in Wales would be problematic.
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7
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References
1. Welsh Assembly Government. An orthopaedic plan for Wales – getting Wales
moving. Cardiff: WAG; 2004. Available at:
https://www.wales.nhs.uk/documents/Orthopaedic-Plan.pdf [Accessed 10th May
2009]
2. Welsh Assembly Government. 2009 Access Project. WHC(2005)98. Cardiff: WAG;
2005. Available at: http://howis.wales.nhs.uk/doclib/WHC_2005_098.pdf [Accessed
10th May 2009]
3. Hurst J, Siciliani L. Tackling excessive waiting times for elective surgery: A
comparison of policies in twelve OECD countries. Paris: OECD; 2003. Available at:
http://www.oecd.org/dataoecd/24/32/5162353.pdf [Accessed 10th May 2009]
4. Jowell R et al. British social attitudes survey. Focussing on diversity. The 17th
report. London: Sage Publications Ltd; 2001.
5. Auditor General for Wales. NHS waiting times in Wales. Vol. 1. The scale of the
problem. Cardiff: NAO Wales; 2005. Available at:
http://www.wales.nhs.uk/documents/agw2004_9-i.pdf [Accessed 10th May 2009]
6. The Stockholm Institute. Impatient for change: European attitudes to healthcare
reform. London: The Stockholm Network; 2004. Cited in: Auditor General for Wales.
NHS waiting times in Wales. Cardiff: NAO for Wales; 2005
7. Welsh Assembly Government. Improving patient access. 2nd offer scheme. WHC
(2004)015. Cardiff: WAG; 2004. Available at: http://howis.wales.nhs.uk/doclib/whc2004-015-e.pdf [Accessed 10th May 2009]
8. Welsh Assembly Government. The introduction of the delivery and support unit
into NHS Wales. WHC(2005)097. Cardiff: WAG; 2005. Available at:
http://howis.wales.nhs.uk/doclib/WHC_2005_097.pdf [Accessed 10th May 2009]
9. Public Health Resource Unit. Appraisal tools. Website. [online]. Available at:
http://www.phru.nhs.uk/Pages/PHD/resources.htm [Accessed 10th May 2009]
10. Department of Health. The NHS plan. A plan for investment. A plan for reform.
Cm 4818-I. London: DoH; 2000. Available at:
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/document
s/digitalasset/dh_4055783.pdf [Accessed 10th May 2009]
11. Appleby J et al. Sustaining reductions in waiting times: identifying successful
strategies. Final report to the Department of Health. London: The King’s Fund; 2005.
Available at: http://www.kingsfund.org.uk/research/publications/sustaining.html
[Accessed 10th May 2009]
12. King’s Fund. An independent audit of the NHS under labour (1997-2005).
London: The King’s Fund; 2005. Available at:
Author: Geri Arthur, Specialty Registrar
Version: 1
Date: 061109
Page: 21 of 78
Status: Final
Intended Audience: WAG
National Public Health Service for Wales
Rapid review of the evidence on potential health
impact of waiting times initiatives in Wales
http://www.kingsfund.org.uk/research/publications/an_independent.html [Accessed
10th May 2009]
13. Welsh Assembly Government. Update on action to reduce hospital waiting times
and pressures on the NHS - HSS-20-02. Cardiff: WAG; 2002.
14. Welsh Assembly Government. Improving health in Wales. A plan for the NHS
with its partners. Cardiff: WAG; 2001. Available at:
http://www.wales.nhs.uk/publications/NHSStrategydoc.pdf [Accessed 10th May 2009]
15. Welsh Assembly Government. New waiting times strategy announced by Jane
Hutt. Press release 12th Jul 2001. Available at:
http://www.wales.nhs.uk/pressnotices/waiting-times-strat-announced-e.htm
[Accessed 16th Jun 2009]
16. Edwards, B. Review of orthopaedic services in Gwent. A report to the Welsh
Assembly. Cardiff: WAG; 2003. Available at:
https://www.angleseylhb.wales.nhs.uk/documents/BrainEdwardsReport.pdf
[Accessed 16th Jun 2009]
17. BBC News. Foreign surgeons’ letter row. Tuesday 7th Dec 2004. Available at:
http://news.bbc.co.uk/1/hi/wales/4076439.stm [Accessed 11th May 2009]
18. Welsh Assembly Government. Review of knee surgery carried out under the
second offer scheme in the NHS Treatment Centre, Weston. Cardiff: WAG; 2007.
Available at: http://www.wales.nhs.uk/newsitem.cfm?contentid=6171 [Accessed on
11th May 2009]
19. Welsh Assembly Government Oral – second offer scheme at Weston Area NHS
Trust. Cabinet statement 31st Jan 2007. Available at:
http://new.wales.gov.uk/about/cabinet/cabinetstatements/2007/1226567/?lang=en
[Accessed 22nd April 2009]
20. Welsh Assembly Government. An orthopaedic plan for Wales. A source
document. Cardiff: WAG; 2004. Available at:
http://www.wales.nhs.uk/documents/OrthopaedicPlan-SourceDocument.pdf
[Accessed 10th May 2009]
21. Welsh Assembly Government. The review of health and social care in Wales. The
report of the project team advised by Derek Wanless. Cardiff: WAG; 2003. Available
at: http://www.wales.nhs.uk/documents/wanless-review-e.pdf [Accessed 11th March
2009]
22. Welsh Assembly Government. Designed for life: creating world class health and
social care for Wales in the 21st century. Cardiff: WAG; 2005.
http://www.wales.nhs.uk/documents/designed-for-life-e.pdf [Accessed 11th Mar 2009]
23. Whitfield J. Why more than one in 10 people in Wales are waiting for treatment.
HSJ 2004; II4:10-11
Author: Geri Arthur, Specialty Registrar
Version: 1
Date: 061109
Page: 22 of 78
Status: Final
Intended Audience: WAG
National Public Health Service for Wales
Rapid review of the evidence on potential health
impact of waiting times initiatives in Wales
24. National Public Health Service for Wales. Access project 2009: predicted future
changes in orthopaedics in Wales. A horizon scanning exercise. Cardiff: NPHS;
2006. Available at:
http://www2.nphs.wales.nhs.uk:8080/healthserviceqdtdocs.nsf/($All)/65AAA4448E5A
AD3E80257230005AFC4F/$File/TeresaOrthopaedicsFinalrefs.doc?OpenElement
[Accessed 11th Mar 2009]
25. Auditor General for Wales. NHS waiting times: follow-up report. Cardiff: NAO
Wales; 2006. Available at:
http://www.wales.nhs.uk/documents/NHS_waiting_times_update.pdf [Accessed 11th
Mar 2009]
26. National Audit Office. Inappropriate adjustments to NHS waiting lists. London:
The Stationery Office; 2001. Available at:
http://www.nao.org.uk/publications/0102/inappropriate_adjustments_nhs.aspx?alread
ysearchfor=yes [Accessed 11th Mar 2009]
27. Auditor General for Wales. Making better use of NHS day surgery in Wales.
Cardiff: NAO Wales; 2006. Available at:
http://www.wales.nhs.uk/documents/WAO_Day_Surgery_Eng_web.pdf [Accessed
11th Mar 2009]
28. Welsh Assembly Government. Access 2009. Delivering a 26 week patient
pathway. WHC(2006)081. Cardiff: WAG; 2006. Available at:
http://howis.wales.nhs.uk/doclib/WHC(2006)081.pdf [Accessed 11th Mar 2009]
29. 2009 Access Project Team Delivery Support Unit, Health and Social Services
Department Welsh Assembly Government. Delivering a 26 week patient pathway. An
implementation framework. Cardiff: WAG; 2006.
30. Auditor General for Wales. Tackling delayed transfers of care across the whole
system – Overview report based on work in the Cardiff and vale of Glamorgan,
Gwent and Carmarthenshire health and social care communities. Cardiff: NAO
Wales; 2007. Available at:
http://www.wao.gov.uk/assets/englishdocuments/DToC_Overview_eng.pdf
[Accessed 11th Mar 2009]
31. Auditor General for Wales. Delayed transfers of care follow through. Cardiff: NAO
Wales; 2009. Available at:
http://www.wales.nhs.uk/documents/DToC_follow_through_eng.pdf [Accessed 11th
Mar 2009]
32. Welsh Assembly Government. Access project, 2008. Integrated delivery and
implementation plan. A framework for delivery 2008/09. WHC (2007)51. Cardiff:
WAG; 2007. Available at:
https://www.angleseylhb.wales.nhs.uk/documents/WHC(2007)051.pdf [Accessed 11th
Mar 2009]
33. Welsh Assembly Government. One Wales: A progressive agenda for the
government of Wales. An agreement between the Labour and Plaid Cymru Groups in
Author: Geri Arthur, Specialty Registrar
Version: 1
Date: 061109
Page: 23 of 78
Status: Final
Intended Audience: WAG
National Public Health Service for Wales
Rapid review of the evidence on potential health
impact of waiting times initiatives in Wales
the National Assembly. Cardiff: WAG, 2007. Available at:
http://wales.gov.uk/strategy/strategies/onewales/onewalese.pdf?lang=en [Accessed
11th Mar 2009]
34. Greer S. Devolution and divergence in UK health policies. BMJ 2009: 338:78
35. Godden S et al. Waiting list and waiting time statistics in Britain: a critical review.
Public Health 2009;123: 47-51
36. Martin RM et al 2003. NHS waiting lists and evidence of national or local failure:
analysis of health service data. BMJ 2003; 326: 188-92. Available at:
http://www.bmj.com/cgi/reprint/326/7382/188 [Accessed 11th Mar 2009]
37. Appelby J. Cutting NHS waiting times: identifying strategies for sustainable
reductions. London: King’s Fund; 2005. Available at:
http://www.kingsfund.org.uk/research/publications/cutting_nhs.html [Accessed 11th
Mar 2009]
38. Besley T, Bevan G, Burchardi K. Accountability and incentives: The impacts of
different regimes on hospital waiting times in England and Wales. London: London
School of Economics; 2008. Available at:
http://econ.lse.ac.uk/~tbesley/papers/nhs.pdf [Accessed 11th Mar 2009]
39. Siciliani L, Hurst J. 2004. Explaining waiting-time variations for elective surgery
across OECD countries. DELSA/ELSA/WD/HEA(2003)7. Paris: OECD; 2003.
Available at: http://www.oecd.org/dataoecd/31/10/17256025.pdf [Accessed 11th Mar
2009]
40. Kreindler SA. Watching your wait: evidence-informed strategies for reducing
health care wait times. Qual Manag Health Care 2008; 17:128-35
41. Derrett S, Paul C, Morris JM. Waiting for elective surgery: effects on health
related quality of life. Int J Qual Health Care 1999; 11: 47-57. Available at:
http://intqhc.oxfordjournals.org/cgi/reprint/11/1/47 [Accessed 11th Mar 2009]
42. Sanmartin C, Bertholet J-M, McIntosh CN. Determinants of unacceptable waiting
times for specialized services in Canada. Health Policy 2007; 2: e140-54. Available
at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2585450/pdf/policy-02-e140.pdf
[Accessed 11th Mar 2009]
43. Oudhoff, JD et al, 2007. Waiting for elective general surgery: impact on health
related quality of life and psychosocial consequences. BMC Public Health 2007; 7:
164. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1959190/pdf/14712458-7-164.pdf [Accessed 2nd Jun 2009]
44. Dunn E et al. Patient’s acceptance of waiting for cataract surgery: what makes a
wait too long? Soc Sci Med 1997; 44:1603-10
45. Lynch ME et al. 2008. A systematic review of the effect of waiting for treatment
for chronic pain. Pain 138: 97-116
Author: Geri Arthur, Specialty Registrar
Version: 1
Date: 061109
Page: 24 of 78
Status: Final
Intended Audience: WAG
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Rapid review of the evidence on potential health
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46. Sampalis J et al. Impact of waiting time on the quality of life of patients awaiting
coronary artery bypass grafting. CMAJ 2001; 165: 429-33. Available at:
http://www.cmaj.ca/cgi/reprint/165/4/429.pdf [Accessed 2nd Jun 2009]
47. Bell D et al, 2006. Does prolonging the time to testicular cancer surgery impact
long-term cancer control: a systematic review of the literature. Can J Urol 2006; 13:
Suppl 3:30-6
48. Saad F et al. Does prolonging the time to prostate cancer surgery impact longterm cancer control: a systematic review of the literature. Can J Urol 2006; 13: Suppl
3:16-24
49. Jewett M et al, 2006. Does prolonging the time to renal cancer surgery affect
long-term cancer control: a systematic review of the literature. Can J Urol 2006;13
:Suppl 3: 54-61
50. Fradet Y et al, 2006. Does prolonging the time to bladder cancer surgery affect
long-term cancer control: a systematic review of the literature. Can J Urol 2006; 13:
Suppl 3: 37-47
51. Anon. Waiting, quality and outcome. Bandolier 2001; 8(11). [online]. Available at:
http://www.medicine.ox.ac.uk/bandolier/painres/download/Bando093.pdf [Accessed
25th Mar 2009]
52. Anon. Testing the two-week rule. Bandolier 2006. Available at:
http://www.medicine.ox.ac.uk/bandolier/band147/b147-2.html [Accessed 25th Mar
2009]
53. Lewis NR, Le Jeune I, Baldwin DR. 2005. Under utilisation of the 2-week wait
initiative for lung cancer by primary care and its effects on the urgent referral
pathway. Br J Can 2005; 93:905-8. Available at:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2361660/pdf/93-6602798a.pdf
[Accessed 25th Mar 2009]
54. Thorne K, Hutchings HA, Elwyn G. The effects of the two-week rule on NHS
colorectal cancer diagnostic services: a systematic literature review. BMC Health Ser
Res 2006; 6: 43. Available at:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1479333/pdf/1472-6963-6-43.pdf
[Accessed 25th Mar 2009]
55. Potter S et al. Referral patterns, cancer diagnoses, and waiting times after
introduction of two week wait rule for breast cancer: prospective cohort study. BMJ
335; 288. Available at: http://www.bmj.com/cgi/reprint/335/7614/288 [Accessed 25th
Mar 2009]
56. Feldman, R. The cost of rationing medical care by insurance coverage and by
waiting. Health Econ 1994; 3: 361-72
57. Gravelle H. 2008. Is waiting-time prioritisation welfare improving? Health Econ
2008; 17:167-84
Author: Geri Arthur, Specialty Registrar
Version: 1
Date: 061109
Page: 25 of 78
Status: Final
Intended Audience: WAG
National Public Health Service for Wales
Rapid review of the evidence on potential health
impact of waiting times initiatives in Wales
58. Quan H, La Freniere R, Johnson D. Health service costs for patients on the
waiting lists. Can J Surg 2002; 45: 34-43
59. Rachlis MM. Public solutions to health care wait lists. Ottawa: Canadian Centre
for Policy Alternatives; 2005. Available at:
http://www.policyalternatives.ca/documents/National_Office_Pubs/2005/Health_Care
_Waitlists.pdf [Accessed 25th Mar 2009]
60. Lewis R, Appleby J. Can the English NHS meet the 18 week waiting list target? J
R Soc Med 2006; 99:10-13. Available at:
http://jrsm.rsmjournals.com/cgi/reprint/99/1/10 [Accessed 25th Mar 2009]
61. Appleby J, Harrison T. The war on waiting for hospital treatment. London: King’s
Fund; 2005. Available at:
http://www.kingsfund.org.uk/research/publications/the_war_on.html [Accessed 25th
Mar 2009]
62. McPherson K. Do patients’ preferences matter? BMJ 2009; 338:59
63. Anon. Influence of adherence to treatment and response of cholesterol on
mortality in the coronary drug project. NEJM 1980; 303: 1038- 41
64. Preference Collaborative Review Group. Patients’ preferences within randomised
trials: systematic review and patient level meta-analysis. BMJ 2008; 337: a1864.
Available at: http://www.bmj.com/cgi/content/full/337/oct31_1/a1864 [Accessed 25th
Mar 2009]
65. Lofvendahl S et al. Waiting for orthopaedic surgery: factors associated with
waiting times and patients’ opinion. Int J Qual Health Care 2005; 17:133-40
66. Ethgen O. Health-related quality of life in total hip and total knee arthroplasty. A
qualitative and systematic review of the literature. J Bone Joint Surg Am 2004; 86-A:
963-74
67. McGregor M, Atwood CV. Wait times at the MUHC: No 3. Fracture management.
Montreal: McGill University Health Centre; 2007. Available at:
http://www.mcgill.ca/files/tau/Wait_Time_Fractures_May2007_Final.pdf [Accessed
25th Mar 2009]
68. Hirvonen J et al. Health-related quality of life in patients waiting for major joint
replacement. A comparison between patients and population controls. Health and
Quality of Life Outcomes 2006; 4:3 Available at:
http://www.hqlo.com/content/pdf/1477-7525-4-3.pdf [Accessed 6th Jun 2009]
69. Peul WC et al. Prolonged conservative care versus early surgery in patients with
sciatica caused by lumbar disc herniation: two year results of a randomised
controlled trial. BMJ 2008; 336:1355-58. Available at:
http://www.bmj.com/cgi/reprint/bmj.a143v1 [Accessed 6th Jun 2009]
Author: Geri Arthur, Specialty Registrar
Version: 1
Date: 061109
Page: 26 of 78
Status: Final
Intended Audience: WAG
National Public Health Service for Wales
Rapid review of the evidence on potential health
impact of waiting times initiatives in Wales
70. Weinstein JN et al. Surgical vs non-operative treatment for lumbar disk
herniation: The Spine Patient Outcomes Research Trial (SPORT) Observational
Cohort. JAMA 2006 ; 296(20): 2451-59. Available at : http://jama.amaassn.org/cgi/reprint/296/20/2451 [Accessed 6th Jun 2009]
71. Gibson JN et al. Surgical interventions for lumbar disc prolapse. Cochrane
Database Syst Rev 2007, Issue 2. Available at:
http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD001350/pdf_fs.h
tml [Accessed 20th Jun 2009]
72. Fielden JM et al. Waiting for hip arthroplasty: Economic costs and health
outcomes. J Arthroplasty 2005; 20: 990-97
73. Brauer CA et al. Cost utility analyses in orthopaedic surgery. J Bone Joint Surg
Am 2005; 87: 1253-9
74. Oudhoff JP et al. The acceptability of waiting times for elective surgery and the
appropriateness of prioritising patients. BMC Health Serv Res 2007; 7:32. Available
at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1847814/pdf/1472-6963-7-32.pdf
[Accessed 20th June 2009]
75. Edwards RT et al. Clinical and lay preferences for the explicit prioritisation of
elective waiting lists: survey evidence from Wales. Health Policy 2003; 63: 229-37
Author: Geri Arthur, Specialty Registrar
Version: 1
Date: 061109
Page: 27 of 78
Status: Final
Intended Audience: WAG
National Public Health Service for Wales
Rapid review of the evidence on potential health
impact of waiting times initiatives in Wales
Appendix 1- Literature review search strategy
Waiting times initiatives review: Literature review
1. Search methodology
2. Review findings
TEAM UNDERTAKING REVIEW: Health and Social Care Quality for WAG
CONTACT PERSON: Nigel Monaghan, Geri Arthur
TOPIC: Public Health/population outcome benefits/ health gain of the Waiting Times
Initiative
PRINCIPAL RESEARCH QUESTION/OBJECTIVE:
To assess the population health outcome benefit of Waiting Times Initiatives
DATE :
1. METHODOLOGY
i)
Search strategy for identification of studies
Period of publication
MESH
Author: Geri Arthur, Specialty Registrar
Version: 1
2000- 2009
 Definition and use of Waiting times/
waiting lists – sometimes ambiguous.
 Databases use different terms around
some concepts e.g. outcome
Waiting Lists
Health Services Accessibility
Health Care Rationing
Time Factors
Morbidity
Mortality
Quality of Life
Value of Life
sickness impact profile
Outcome Assessment (Health Care)
Treatment Outcome
early treatment
delayed treatment
health gain
quality of life years
access to health services
Date: 061109
Page: 28 of 78
Status: Final
Intended Audience: WAG
National Public Health Service for Wales
Rapid review of the evidence on potential health
impact of waiting times initiatives in Wales
admissions management
patient waiting time
waiting list admissions
waiting list reductions
rationing
health rationing
health impact assessment
patient outcome
health outcomes
clinical outcomes
N.B. Specialities such as ENT, general
surgery, gynaecology, neurosurgery, plastic
surgery ophthalmology and urology were not
specified in search terms.
Electronic databases
√(tick as appropriate)
British Nursing Index
CINAHL
Clinical Evidence
Cochrane Library
√
EMBASE
Health
Technology
database
Assessment
HMIC
√
MEDLINE
√
PsycINFO
SCIE- Social Care
Meta search engines
Google/Google Scholar
SUMsearch
TRIP
Specialist web sites/portals
Bandolier
√
Best practice [E-library trial ]
Biomed Central
Cardiff University
libraries[Voyager]
&
Health
care
JBI-connect
Author: Geri Arthur, Specialty Registrar
Version: 1
Date: 061109
Page: 29 of 78
Status: Final
Intended Audience: WAG
National Public Health Service for Wales
Rapid review of the evidence on potential health
impact of waiting times initiatives in Wales
Map of Medicine
National
Library
Guidelines finder
for
Health
NICE
Government
documents
bodies/Official
1000 lives campaign
Audit Commission
Centre for Change & Innovation
Department of Health & Social
Services & Public Safety [DHSSPSNI] Northern Ireland
Department of Health [DH]
Health Committee
Healthcare Commission
National Audit Office
NHS Institute for Innovation and
Improvement
NHS modernisation agency
NLIAH
NPHS library database + Groupware
doc database
Scottish
Executive
Dept.[SEHD]
Health
Welsh Affairs committee
Welsh Audit Office
WHO
Specialist web sites/Research departments
AWARD
Health Foundation
Health
Services
Centre[Birmingham]
Management
Institute or Healthcare Improvement
King’s fund
MRCT
NCEPOD
Author: Geri Arthur, Specialty Registrar
Version: 1
Date: 061109
Page: 30 of 78
Status: Final
Intended Audience: WAG
National Public Health Service for Wales
Rapid review of the evidence on potential health
impact of waiting times initiatives in Wales
Nuffield Trust
Picker Institute
Sheffield
care
Research
–
Emergency
Sheffield University, Medical Care
Research Unit
UKCRN [cont’d from NRR]
Welsh Institute of Health & Social
Care
Professional bodies/associations
British Medical Association [BMA]
British Paramedic Association
College of Emergency medicine
Royal College of Anaesthetists
Royal College of GPs
Royal
College
of
Nursing
Emergency Care Association
–
Royal College of Physicians
Royal College of Surgeons
Royal Pharmaceutical Society
Hand searching journals
Last 6mths Electronic ToC
References from relevant studies
Some selective searching
√
ii) Selection criteria for inclusion of studies
Outcome measure(s)
This scoping search of high level evidence
on a couple of sources appear to indicate
that the key areas of literature likely to
help answer the question, will be around
the adverse effects of delayed treatment
rather than health gain , improved
outcomes from early treatment.
Study design/publication type
High level evidence -Stepped approach –
RCTs, meta-analysis, Systematic reviews,
literature review, PT=Reviews
Other inclusion/exclusion criteria
Exclude papers focussing on:
o
Author: Geri Arthur, Specialty Registrar
Version: 1
Waiting
Date: 061109
Page: 31 of 78
times
and
performance
Status: Final
Intended Audience: WAG
National Public Health Service for Wales
Rapid review of the evidence on potential health
impact of waiting times initiatives in Wales
indicators/management
o
Drug therapy/chemotherapy
o
Patient
satisfaction
/perception/willingness to travel.
o
Reasons for delayed treatment
o
Risk assessment models
o
Tools for assessing Quality of Life
o
Waiting times – relating to primary
care referrals
Include all specialities [though on the
whole majority of patients on the scheme
were orthopaedics]
Other specialities were ENT, general
surgery,
gynaecology,
neurosurgery,
plastic
surgery
ophthalmology
and
urology.
Language Limitations
English language only
How many papers found
37
Reference manager database
Yes [WaitingTimesHealthGain_HW_0309]
Saved searches for updates [ core
databases]
Yes [WaitListHealthGain]
Date of Search
18 March 2009
Search done by
Helen Wright, LKMS
2. REVIEW FINDINGS
(i) Quality Assessment
Study quality assessment
Data collection and analysis
How many papers included
How many papers excluded
RESULTS
CONCLUSIONS
Author: Geri Arthur, Specialty Registrar
Version: 1
Date: 061109
Page: 32 of 78
Status: Final
Intended Audience: WAG
National Public Health Service for Wales
Rapid review of the evidence on potential health
impact of waiting times initiatives in Wales
RECOMMENDATIONS
(if applicable)
PRACTICAL APPLICATION
RESOURCE IMPLICATIONS
KEY REFERENCES
REVIEW STATUS
Ongoing/Complete
(delete as appropriate)
DATE ISSUED
REVIEW DATE
Search history - Medline
1 *Waiting Lists/
1793
2 *Health Services Accessibility/sn, og, es, st, td, ec [Statistics &
Numerical Data, Organization & Administration, Ethics, Standards,
Trends, Economics]
5135
3 *Health Care Rationing/mt, ut, es, og, sn, ec, st, td [Methods,
Utilization, Ethics, Organization & Administration, Statistics &
Numerical Data, Economics, Standards, Trends]
1423
4 waiting times.mp.
1402
5 early treatment.mp.
5081
6 *Time Factors/
260
7 exp *"Patient Acceptance of Health Care"/
8 exp *Morbidity/
1429
9 exp Morbidity/
185002
10 exp *Mortality/
Author: Geri Arthur, Specialty Registrar
Version: 1
34696
15950
Date: 061109
Page: 33 of 78
Status: Final
Intended Audience: WAG
National Public Health Service for Wales
Rapid review of the evidence on potential health
impact of waiting times initiatives in Wales
11 exp Mortality/
135291
12 exp *"Quality of Life"/
25724
13 *sickness impact profile/
1744
14 *"Value of Life"/
634
15 health gain.mp.
242
16 exp *"Outcome Assessment (Health Care)"/mt, st, ut, og, td, sn,
ec
[Methods,
Standards,
Utilization,
Organization
&
Administration, Trends, Statistics & Numerical Data, Economics]
4494
17 exp *Treatment Outcome/
3236
18 *Patient Satisfaction/
11450
19 delayed treatment.mp.
831
20 6 or 4 or 1 or 3 or 19 or 2 or 5
15239
21 7 or 17 or 12 or 15 or 14 or 8 or 18 or 10 or 13 or 16 84703
22 21 and 20
950
23 limit 22 to (english language and humans)
883
24 limit 23 to yr="2000 - 2009"
727
25 limit 24 to (clinical trial, all or controlled clinical trial or
evaluation studies or government publications or meta analysis or
multicenter study or randomized controlled trial or "review" or
validation studies)
135
26 17 or 12 or 15 or 14 or 8 or 10 or 13 or 16
51212
27 26 and 20 287
28 limit 27 to (english language and humans)
255
29 limit 28 to (case reports or clinical trial, all or clinical trial or
comparative study or controlled clinical trial or evaluation studies
or meta analysis or multicenter study or randomized controlled trial
or "review" or validation studies)
99
30 limit 29 to yr="2000 - 2009"
85
31 from 30 keep 4-5, 9-10
Author: Geri Arthur, Specialty Registrar
Version: 1
4
Date: 061109
Page: 34 of 78
Status: Final
Intended Audience: WAG
National Public Health Service for Wales
Rapid review of the evidence on potential health
impact of waiting times initiatives in Wales
32 from 30 keep 14, 18, 20, 23, 27, 32-33...
11
33 from 30 keep 49, 51, 58, 68, 71, 74...
7
Search history - HMIC
1 exp Morbidity/
2066
2 exp Mortality/
3568
3 exp waiting lists/ or exp access to health services/ or exp
admissions management/ or exp patient waiting time/ or exp
waiting list admissions/ or exp waiting list reductions/
5621
4 exp patient waiting time/
1541
5 exp WAITING LISTS/ or exp PATIENT WAITING TIME/
2236
6 early treatment.mp.
50
7 delayed treatment.mp.
7
8 exp RATIONING/ or exp HEALTH RATIONING/
948
9 exp health gain/ or health impact assessment/
312
10 health gain/ or exp patient outcome/
3274
11 exp "quality of life"/ or exp quality adjusted life years/
1911
12 value of life.mp.
28
13 exp PATIENT SATISFACTION/
2167
14 exp HEALTH OUTCOMES/ or exp CLINICAL OUTCOMES/
1564
15 exp ACCESS TO HEALTH SERVICES/
3451
16 8 or 6 or 4 or 3 or 7 or 15 or 5
6502
17 11 or 1 or 13 or 10 or 9 or 12 or 2 or 14
13104
18 16 and 17 366
19 limit 18 to yr="2000 - 2009"
224
20 limit 19 to ((article or book or ccplan or chapter dh helmis or
circular or ejournal holding dh kf or euroinfo or himp or journal
holding dh kf or webpubl or website) and (article or book or ccplan
or cdrom or chapter or circular or circulars or dept pubs or
195
Author: Geri Arthur, Specialty Registrar
Version: 1
Date: 061109
Page: 35 of 78
Status: Final
Intended Audience: WAG
National Public Health Service for Wales
Rapid review of the evidence on potential health
impact of waiting times initiatives in Wales
deptseries or euroinfo or govt pub or govtdoc or govtseries or himp
or internatl or journal or kfpub or report or ssi report or stratplan or
thesis or trustdoc or webpubl or website))
21 from 20 keep 1-195
195
22 1 or 2
081
23 22 and 16
Author: Geri Arthur, Specialty Registrar
Version: 1
85
Date: 061109
Page: 36 of 78
Status: Final
Intended Audience: WAG
National Public Health Service for Wales
Rapid review of the evidence on potential health
impact of waiting times initiatives in Wales
Appendix 2- Evidence levels (Modified from NICE Guideline
Methodology Manual)
Level of Evidence
1++
Type of evidence
High-quality meta-analyses, systematic reviews of
RCTs, or
RCTs with a very low risk of bias
1+
Well-conducted meta-analyses, systematic
reviews of RCTs,or RCTs with a low risk of bias
1-
Meta-analyses, systematic reviews of RCTs, or
RCTs with a high risk of bias
2++
High-quality systematic reviews of case–control or
cohort studies. High-quality case–control or cohort
studies with a very low risk of confounding, bias,
or chance and a high probability that the
relationship is causal
2+
Well-conducted case–control or cohort studies
with a low risk of confounding, bias, or chance
and a moderate probability that the relationship is
causal
2-
Case–control or cohort studies with a high risk of
confounding bias, or chance and a significant risk
that the relationship is not causal
3
Non-analytic studies (for example, case reports,
case series)
4
Expert opinion, formal consensus
Author: Geri Arthur, Specialty Registrar
Version: 1
Date: 061109
Page: 37 of 78
Status: Final
Intended Audience: WAG
National Public Health Service for Wales
Appendix 3
Study
1. Welsh Assembly
Government. An
orthopaedic plan for
Wales Getting Wales
moving. Cardiff: WAG;
2004
Potential health effects of recent national waiting
times initiatives in Wales – a rapid review of the
evidence (Draft)
Evidence table
Population / Setting
Intervention / Aim
Wales NHS,
orthopaedic
services
Policy
Author: Geri Arthur Specialty Registrar
Version: 0a
Date:
Page: 38 of 78
Outcomes
Results
Design
In 1999, 1356 pts waiting over 18/12, April Strategic
2004 9 pts, however number waiting for 1st document/
outpatient appt has risen. Says committed expert opinion
substantial funds for SE Wales as waits are
longest. Identified an activity/capacity gap and
differing service models and capacity in
different areas.
Key actions:
 Managing demand – prevention, point of
contact treatment, alternative referral pathway
 Using our capacity efficiently – trauma
management, wait list management, bed and
pt flow management, theatre utilisation,
discharge and rehab
 Using our staff effectively – work differently,
extended roles, GP with a special interest,
increase in numbers trained
 Adding capacity – build on existing NHS
services (local expertise where possible),
protect from trauma, culture of working
differently and rethinking pathway
 Informing the process – robust, timely data,
secondary analysis
Drivers include: demography – population is
growing & elderly increasing; epidemiology –
elderly are highest users of health & social
care; trauma – knock on effect on elective
Status: Draft
Intended Audience:
Evidence
level
4
National Public Health Service for Wales
Study
Population / Setting
Potential health effects of recent national waiting
times initiatives in Wales – a rapid review of the
evidence (Draft)
Intervention / Aim
Outcomes
Results
Design
Evidence
level
care; demand – increasing, level of referrals
exceeds activity. Latent need is hard to
quantify; activity – Wales has a lower crude
hip replacement rate than other countries in
Europe, greatest gap is in the SE and there
are gaps between LHBs; capacity –
inadequate but not being well utilised, lack of
GP capacity. Long average length of stay
The report outlined key actions in the above
areas and allocated priority levels and who
should act, WAG, Trust or LHB.
2. Welsh Assembly
Government. 2009
Access project.
WHC(2005)98. Cardiff:
WAG; 2005
NHS Wales
Author: Geri Arthur Specialty Registrar
Version: 0a
Not applicable
Date:
Page: 39 of 78
Not
applicable
Plan also outlines responsibilities for WAG,
LHBs, Trusts, GPs and patients themselves.
Not all areas will require additional funding but
there will be new investment.
Significant challenges for NHS Wales in
delivering the 2009 access targets. These are:
 Continuing to implement good practice
across the whole patient pathway, thus
maximising current capacity
 Achieving balance in the capacity and
pathways for unscheduled care and demand
management, reducing any adverse impacts
on elective care
 Securing new capacity as efficiently as
possible
 Developing new ways of working to reduce
the total patient pathway especially at
outpatient follow up stage
Status: Draft
Intended Audience:
Policy
-
National Public Health Service for Wales
Study
Population / Setting
Potential health effects of recent national waiting
times initiatives in Wales – a rapid review of the
evidence (Draft)
Intervention / Aim
3. Hurst J, Siciliani L.
Tackling excessive
waiting times for elective
surgery: A comparison of
policies in twelve OECD
countries. Paris:OECD;
2003
OECD countries
Comparison of
waiting time
policies in
OECD countries
4. Jowell R et al. British
social attitudes survey.
Focussing on diversity.
The 17th report. London:
Sage Publications Ltd;
2001.
UK
Not applicable
5. Auditor General for
Wales. NHS waiting
times in Wales. Cardiff:
NAO Wales; 2005.
Waiting times of
patients in Wales
Author: Geri Arthur Specialty Registrar
Version: 0a
Not applicable
Date:
Page: 40 of 78
Outcomes
Results
 Ensuring there is a robust performance
management and support framework in place.
 At worst waiting times can lead to
deterioration in health, loss of utility and extra
cost
 Waiting times tend to form in countries
which combine public health insurance and
constraints on surgical capacity
 Constraints on capacity prevent supply
meeting demand
 Non-price rationing in the form of waiting
lists takes over from price rationing
 Optimum waiting times will not be zero, it
may be cost effective to maintain short queues
 Maximum waiting time guarantees may
conflict with clinical prioritisation
Design
Expert opinion
4
-
Looks at a
range of
opinions
 Waiting for specialist assessment and
waiting for elective surgery are considered to
be the first and second most important NHS
failings
Survey
-
 Wales spends more than England per head
on health but Welsh have to wait longer for
appointments. In June 2004, 7,105 patients
had been waiting over 18 months for OP appt,
and 1,447 IP/DC (better than 2002 when waits
were at their longest). Policy variation and the
way waiting times are measured across the
Audit
Status: Draft
Intended Audience:
Evidence
level
(3600
respondents a
year)
3/4
National Public Health Service for Wales
Study
Population / Setting
Potential health effects of recent national waiting
times initiatives in Wales – a rapid review of the
evidence (Draft)
Intervention / Aim
Outcomes
Results
home nations, difficult to compare. Variation
across Wales, SE longest. “The current
waiting time situation in Wales in inequitable,
both within Wales and in comparison to the
situation in England and Scotland. Causes are
rising GP referrals, emergency and medical
pressures; also inefficiencies such as long
ALOS, long intervals between bed usage and
proportionally fewer patients treated as day
cases compared to E & S
 Significance of waiting times – “the time
patients have to wait for treatment is very
important to the users of the NHS”
 The 2 measures used for waiting times
cover only a proportion of total NHS activity in
Wales. At that time maximum combined wait
was 36 months against 13 in England and 15
in Scotland
 Cardiac targets met, no information on 10
day cancer target but quick audit looks like not
met
 Diagnostic and therapy services have not
traditionally been measured and form a hidden
waiting time. Being addressed via “Diagnostic
Services Strategy”
 Wanless states that Wales does not use its
capacity efficiently
 In contrast to E & S, little protected elective
capacity, also delayed discharge and DTOC
 WAG criticised for not providing clear
targets. Performance management
Author: Geri Arthur Specialty Registrar
Version: 0a
Date:
Page: 41 of 78
Status: Draft
Intended Audience:
Design
Evidence
level
National Public Health Service for Wales
Study
Population / Setting
Potential health effects of recent national waiting
times initiatives in Wales – a rapid review of the
evidence (Draft)
Intervention / Aim
Outcomes
Results
Design
Evidence
level
arrangements have not been effective in
reducing waits. There is a concern that the
system rewards failure e.g. non-recurrent
funding for initiatives and tolerated number of
breaches. Strong positive correlation between
trusts expenditure and proportion of patients
waiting over 18 months. Initiatives were
treating the symptoms – the wait, rather than
the cause
Recommendations
 WAG should take steps to reduce inequities
in access to health services and drive
accountability of LHBs for WT; publish more
detailed data; publish cancer waits; waiting list
management rigorous; extend partial booking;
expand OP innovations; demand management
role by LHBs; continue focus on diagnostics;
maximise access to diagnostics, etc
 Better management of WT funding
 WAG should only provide additional funding
if local capacity maximised
6. The Stockholm
Institute, Impatient for
change: European
attitudes to healthcare
reform.2004. Cited in:
Auditor General. NHS
waiting times in Wales.
Cardiff: NAO Wales;
2005
Europe
Author: Geri Arthur Specialty Registrar
Version: 0a
Assess public’s
opinions about
healthcare
Date:
Page: 42 of 78
In early 2004, the Stockholm Network
commissioned Populus to survey the views of
8,000 citizens across Britain, the Czech
Republic, France, Germany, Italy, the
Netherlands, Spain and Sweden. Our aim was
to get a representative
geographical sweep of opinion about the future
of healthcare and what Europeans really
understand by terms commonly
Status: Draft
Intended Audience:
Survey / expert
opinion
-
National Public Health Service for Wales
Study
Population / Setting
Potential health effects of recent national waiting
times initiatives in Wales – a rapid review of the
evidence (Draft)
Intervention / Aim
7. Welsh Assembly
Government. Improving
patient access – 2nd offer
scheme.
WHC(2004)015. Cardiff:
WAG; 2004.
NHS Wales
Not applicable
8. Welsh Assembly
Government. The
Introduction of the
delivery and support unit
into NHS Wales.
WHC(2005)097. Cardiff:
WAG; 2005
NHS Wales
Not applicable
9 Public Health
Not applicable
Not applicable
Author: Geri Arthur Specialty Registrar
Version: 0a
Date:
Page: 43 of 78
Outcomes
Results
used by politicians across Europe, such as
‘patient choice’.
Conclusion: European healthcare systems are
living on borrowed time. Population ageing, the
rising costs of medical technology and more
demanding customers have produced chronic
underfunding, which will only worsen as time
passes. Unless European health systems are
reformed rapidly and decisively the
consequences will be dire: longer waiting lists,
much stricter rationing decisions, discontented
medical staff fleeing the profession, a decline
in pharmaceutical innovation and, worst of all,
more ill health for Europe’s patients.
Guidance on amendments to ‘Second offer’
scheme
Not
The Delivery and Support Unit (DSU)
introduced to support organisations that are
experiencing difficulty in delivering targets or
sustaining expected levels of performance
services they deliver. The
DSU resources are finite and it will concentrate
expertise in specific areas. Support provided
by the DSU will be focused on targets
identified as critical areas of delivery in 2006 /
2007. These areas are set out in this circular.
Tools designed to help critically appraise
Status: Draft
Intended Audience:
Design
Evidence
level
Policy
document
-
Policy
document
-
Not applicable
-
National Public Health Service for Wales
Study
Resource Unit. Appraisal
tools. Website. [online].
10. Department of
Health. The NHS plan: a
plan for investment, a
plan for reform. London:
DOH; 2000
Population / Setting
Potential health effects of recent national waiting
times initiatives in Wales – a rapid review of the
evidence (Draft)
Intervention / Aim
Outcomes
applicable
UK NHS
Not applicable
11. King’s Fund.
Sustaining reductions in
waiting times: identifying
successful strategies.
London: King’s Fund;
2005.
UK NHS
To isolate the
factors which
lead to
sustainable
reductions in
waiting times
12. King’s Fund. An
independent audit of the
UK NHS
Assess whether
the Labour
Author: Geri Arthur Specialty Registrar
Version: 0a
Date:
Page: 44 of 78
Not
applicable
Results
research as part of the Critical Appraisal Skills
Programme
Public wanted to see:
• more and better paid staff using new ways of
working
• reduced waiting times and high quality care
centred on patients
• improvements in local hospitals and
surgeries.
The NHS is a 1940s system operating in
a 21st century world. It has:
• a lack of national standards
• old-fashioned demarcations between staff
and barriers between services
• a lack of clear incentives and levers to
improve performance
• over-centralisation and disempowered
patients.
Work is in 3 parts
 Sustaining reductions in waiting timeidentifying successful strategies
 The impact of waiting times targets on
clinical treatment priorities
 A framework for system-based information
requirements for the management of the
supply of elective care
 No single answer as to why waiting times
vary
 Targets met on spending, with large
increases in investment but queries over
Status: Draft
Intended Audience:
Design
Evidence
level
Strategic
document
-
Review/ Expert
opinion
4
Audit/review
4
National Public Health Service for Wales
Study
Population / Setting
NHS under labour (19972005). London: King’s
Fund; 2005
Potential health effects of recent national waiting
times initiatives in Wales – a rapid review of the
evidence (Draft)
Intervention / Aim
government has
delivered targets
and reforms
13. Welsh Assembly
Government. Update on
action to reduce hospital
waiting times and
pressures on the NHS.
Cardiff: WAG; 2002
Author: Geri Arthur Specialty Registrar
Version: 0a
Outcomes
Results
Evidence
level
productivity
 Achieved huge progress in waiting lists and
access to care
 Substantially met targets in cancer, heart
disease and mental health however these
were already on downward trajectory
 Increase in some types of hospital bed and
in staff, good progress on modernising NHS
facilities, however figures use headcounts not
WTE
 Public satisfaction with NHS fluctuates,
some improvement in life expectancy
Paul Williams report, follow-on to the Capacity
Working Group Report published in 2000. The
key themes: of report were:
 The need for a whole systems approach to
deal with demand and the tensions between
elective and emergency work.
 All sectors needed to work more efficiently
to reduce unnecessary admissions and tackle
delayed transfers of care.
 Workforce issues should be considered and
new ways of working developed.
 Good practice should be shared and rolled
out.
In response to Members comments, Paul
Williams made the following points:
 Recommended bed occupancy levels were
85%. In some hospitals, medical bed
occupancy was currently running at 98%.
Date:
Page: 45 of 78
Design
Status: Draft
Intended Audience:
Minutes of
meeting
-
National Public Health Service for Wales
Study
Population / Setting
Potential health effects of recent national waiting
times initiatives in Wales – a rapid review of the
evidence (Draft)
Intervention / Aim
Outcomes
Results
 The solution was not simply a question of
increasing bed numbers; not all hospitals
needed extra beds. There were a number of
other ways of using existing beds more
efficiently, for example reducing the number of
patients in bed waiting for tests or drugs, and
improving day surgery rates.
 The report recommended that each local
health board worked with its trusts and local
authority to identify the most problematic
areas and channel resources to achieve a
more balanced system.
 There were problems in Gwent particularly
with orthopaedic surgery. The Trust was
looking at strategic solutions such as having a
‘cold unit’ for elective orthopaedic surgery, as
major trauma otherwise took priority.
 Large hospitals seemed to work in isolation
and did not recognise the key role that
community hospitals could play. Trusts should
plan how they utilise their total bed stock and
available community resources to provide
effective solutions to the care problems of
patients.
 Community hospitals had a high number of
GP beds and needed operational policies to
work with GPs to use these more effectively.
 Targets were necessary, but trusts should
be empowered to achieve them in the way
most appropriate to their circumstances.
Author: Geri Arthur Specialty Registrar
Version: 0a
Date:
Page: 46 of 78
Status: Draft
Intended Audience:
Design
Evidence
level
National Public Health Service for Wales
Study
14. Welsh Assembly
Government. Improving
health in Wales. A plan
Potential health effects of recent national waiting
times initiatives in Wales – a rapid review of the
evidence (Draft)
Population / Setting
Intervention / Aim
NHS Wales
Not applicable
Not applicable
Not applicable
for the NHS with its
partners Cardiff: WAG;
2001
15. Welsh Assembly
Government. New
waiting times strategy
announced by Jane Hutt.
Press release 12th Jul
2001
Author: Geri Arthur Specialty Registrar
Version: 0a
Date:
Page: 47 of 78
Outcomes
Results
The Plan is written against a background of an
increase in health funding; the document
states that the Welsh
Assembly’s budget provides a 7.7% increase
in health funding for 2001-02 with further
increases of 7.6% and
7.9% in its indicative budgets for the
subsequent two years. This takes the health
budget from £2,620m in
1999-2000 to £3,601m in 2003-04.
The Plan outlines the Assembly’s commitment
to rebuild and improve the health service in
Wales, to develop
innovative and effective ways of improving
citizens’ health, and to make primary care the
engine which drives constant improvement in
the service.
"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.
"That is why we are focusing on waiting times.
Today I am announcing targets based around
waiting times and improvements in the
patient’s experience. Patients want tangible
changes. What I want for them is more clarity
Status: Draft
Intended Audience:
Design
Policy
document
Press release
Evidence
level
-
National Public Health Service for Wales
Study
16. Edwards, B.
Review of orthopaedic
services in Gwent. A
report to the Welsh
Assembly. Cardiff:
WAG; 2003
Population / Setting
Gwent, Wales,
orthopaedic
services
Author: Geri Arthur Specialty Registrar
Version: 0a
Potential health effects of recent national waiting
times initiatives in Wales – a rapid review of the
evidence (Draft)
Intervention / Aim
To review
functioning of
orthopaedic
services in
Gwent
Date:
Page: 48 of 78
Outcomes
Results
Design
and certainty about when they can expect
treatment. I want shorter waiting times in
priority areas, and systems that give them
earlier, clearer information on when they will be
treated.
There are four elements to the strategy which
are:
 Shorter waiting times in priority areas More
certainty and choice for patients
 Better reporting
 Better information
 Current lists in Gwent too long – up to 3 Expert opinion
years.
 Patients being added to lists quicker than
they are seen – getting worse
 Not enough capacity to handle future
demand
 Existing bed capacity used for emergencies
and taken up by DToCs
 Orthopaedic service badly affected by
surges in emergency medical admissions and
work flows interrupted by patients who don’t
turn up.
 Joint replacements in Wales significantly
below England
 Operating theatre practices need to be more
flexible.
 Demand on orthopaedic services could be
better managed. E.g. treated by other
 Needs a whole health community solution
Recommended:
Status: Draft
Intended Audience:
Evidence
level
4
National Public Health Service for Wales
Study
Population / Setting
Potential health effects of recent national waiting
times initiatives in Wales – a rapid review of the
evidence (Draft)
Intervention / Aim
Outcomes
Results
 Tighter management of wait
services e.g. theatres
 Capacity issues addressed
17. BBC News. Foreign
surgeons’ letter row.
Tuesday 7th Dec 2004
18. Welsh Assembly
Not applicable
Not applicable
NHS Wales
Not applicable
Government. Review
of knee surgery carried
out under the second
offer scheme in the
NHS Treatment
Centre, Weston.
Cardiff: WAG; 2007
19. Welsh Assembly
Government, 31st Jan
2007. Oral – Second
Offer Scheme At Weston
Author: Geri Arthur Specialty Registrar
Version: 0a
Date:
Page: 49 of 78
Design
list
and
A Welsh health trust has apologised after a
letter, apparently from a surgeon, warned
patients about the "quality" of foreign surgeons
working at an English hospital.
The unsigned letter had "concerns" about the
treatment offered to Cardiff patients in Westonsuper-Mare.
Only five of 73 patients later turned up for
appointments.
News story
Patients from South Wales who underwent
knee surgery at Weston were offered
reassurances following a review of their
treatment.
More than 600 patients were sent to Weston
NHS Treatment Centre for orthopaedic surgery
under the Second Offer Scheme, a Welsh
Assembly Government policy which allowed
the NHS in Wales to provide alternative
treatments for a range of conditions.
The vast majority of the 683 patients were
transferred from the orthopaedic waiting list at
Cardiff and Vale NHS Trust to Weston
Report recommended that all patients who
were sent to Weston for knee surgery under
the second-offer scheme should have their xrays reviewed. As a precaution, the second-
News story
Status: Draft
Intended Audience:
Evidence
level
Cabinet
statement
-
-
National Public Health Service for Wales
Study
Population / Setting
Potential health effects of recent national waiting
times initiatives in Wales – a rapid review of the
evidence (Draft)
Intervention / Aim
Area NHS Trust.
Available at:
http://new.wales.gov.uk/a
bout/cabinet/cabinetstate
ments/2007/1226567/?la
ng=en [Accessed on
22nd April 2009]
20. Welsh Assembly
Government Oral –
second offer scheme
at Weston Area NHS
Trust. Cabinet
statement 31st Jan
2007.
Outcomes
Results
Design
Evidence
level
offer team has also decided that all patients
who went to Weston for orthopaedic surgery of
any sort should have their x-rays reviewed.
While the only concerns to date relate to knee
surgery, all patients who have had joint surgery
at Weston will be offered a radiological review.
Approx 384 patients have been referred for
knee surgery, 157 for hip surgery and 152 for
other orthopaedic procedures.
Wales NHS,
orthopaedic
services
Author: Geri Arthur Specialty Registrar
Version: 0a
Policy document
Date:
Page: 50 of 78
 Plan to change orthopaedic services and
deliver improved access over the next 10
years.
 Background: Continual reductions in
orthopaedic waiting times targets in England
and a recent European Court ruling on undue
delay provide further imperative.
 Late 90s, a series of HA reviews of
orthopaedics services
 WAG report giving recommendations for
services in SE Wales (Salter)
 2000/01, WAG asked Has to produce 3 year
orthopaedic waiting time plan
 2000 WAG establishes the Innovations in
Care team to encourage innovation and best
practice. These plans have had limited impact
on sustainability
 Jan 2001 Improving Health in Wales set out
clear delivery criteria for reducing long waits.
Wales residents should wait no longer than
other UK residents
Status: Draft
Intended Audience:
Strategic
document/
expert opinion
4
National Public Health Service for Wales
Study
Population / Setting
Potential health effects of recent national waiting
times initiatives in Wales – a rapid review of the
evidence (Draft)
Intervention / Aim
Outcomes
Results
Design
Evidence
level
 May 2000 £40 million for health
communities to tackle long waits
 June 2001 £12 million package to reduce
maximum wait for inpatient/DC orthopaedics
to 18 months by July 2002
 Additional wait list money allocated in
2002/3 and 2003/4. Non-recurrent and has
had limited ongoing impact.
 Interim plan: targeted, phased investment in
additional capacity, extending number of
registrar places, re-establishing academic
chair in orthopaedics, continue IiC program,
ring-fence beds for orthopaedic surgery.
 £5 million recurrently and a capital
investment of £10 million for St Woolos and
Llandough hospitals.
 Current population is just over 2.9 million,
will rise by 41,000 over next 10 years.
21. Welsh Assembly
NHS Wales
Government. The
review of health and
social care in Wales.
The report of the
project team advised
by Derek Wanless.
Cardiff: WAG; 2003
Author: Geri Arthur Specialty Registrar
Version: 0a
To examine how
resources can
be transformed
into reform and
improved
performance
Date:
Page: 51 of 78
“Current position in Wales is worse than in the
UK as a whole, reflecting trends evident over
decades.
Wales does not get as much out of its
spending as it should; in health, for example, it
now places unsustainable pressure on its
acute sector.
The impact extends into social care. Long
hospital waiting lists and assessments
without subsequent social service provision are
the unacceptable consequences and are
symptoms of the deep underlying problems
Status: Draft
Intended Audience:
Expert opinion
4
National Public Health Service for Wales
Study
22. Welsh Assembly
Population / Setting
Potential health effects of recent national waiting
times initiatives in Wales – a rapid review of the
evidence (Draft)
Intervention / Aim
Not applicable
Not applicable
UK NHS
Assess
differences
between English
and Welsh NHS
Government. Designed
for life: creating world
class health and social
care for Wales in the
21st century. Cardiff:
WAG, 2005
23. Whitfield J. Why
more than one in 10
people in Wales are
waiting for treatment.
HSJ 2004; II4:10-11
Author: Geri Arthur Specialty Registrar
Version: 0a
Date:
Page: 52 of 78
Outcomes
Results
needing to be faced.
Capacity problems intensify and, particularly in
the case of the workforce, the danger is that
present gaps will widen. Capacity planning
needs realistic long-term thinking and a
recognition of the need that every pound spent
must be as productive as possible.
Currently, people working in health and social
care try hard to keep up with demand but the
system in which they operate does not make
success easier. It lets them down”.
Designed for life distinguished five groups of
people within the general population and four
levels of care to address the needs of these
groups.
Community services were to be greatly
strengthened and the primary care team
extended, it stated that: “to continue the
wholesale transformation of services and their
delivery, a new and effective planning system
for health and social care is required”.
 Feels that Wales NHS looks like England’s
would have done without targets
 In terms of performance Wales and England
are diverging
 States that the argument that Wales has a
sicker and older population doesn’t stand up if
you compare it to a similar English region
such as the north east.
 Author cites the Audit Commission which
Status: Draft
Intended Audience:
Design
Evidence
level
Policy
document
-
Expert opinion
4
National Public Health Service for Wales
Study
Population / Setting
Potential health effects of recent national waiting
times initiatives in Wales – a rapid review of the
evidence (Draft)
Intervention / Aim
Outcomes
Results
Design
Evidence
level
states that capacity is not the issue, but rather
that the existing capacity is under chronic
unnecessary pressure.
24. National Public
Health Service for
Wales. Access project
2009: predicted future
changes in orthopaedics
in Wales. A horizon
scanning exercise.
Cardiff: NPHS; 2006
Orthopaedic
interventions
focussing on
Wales
Horizon
scanning
exercise in
relation to
predicting
changes in
orthopaedic
demand and
management
-
 Demand for orthopaedic services is rising in
Wales as the population ages
 NHS capacity is increasing but there is a
long backlog of activity
 Orthopaedic services vary n terms of
organisation and efficiency
 Predicting the future of orthopaedic services
is complex
 Technological improvements can result in
better outcomes but also increase costs
 Up to 50% of the UK population will require
orthopaedic surgery at some point in their life
 Wales has a higher rate of emergency
trauma admissions and lower rate of elective
admissions than England
 The validity of routine data in orthopaedics
is questionable
 Epidemiological data on the frequency of
orthopaedic procedures is rare
Literature
review
2/3
25. Auditor General for
Wales. NHS waiting
times: follow-up report.
Cardiff: NAO Wales;
2006
Follow up to
earlier waiting
times report to
review progress
Not applicable
-
 Found that the NHS in Wales had made
considerable progress in reducing long waits
and addressing their causes within a clear
strategic context. And there are important
known risks that need to be addressed to
deliver the ambitious 2009 target and sustain
performance thereafter.
Review/ expert
opinion
4
Author: Geri Arthur Specialty Registrar
Version: 0a
Date:
Page: 53 of 78
Status: Draft
Intended Audience:
National Public Health Service for Wales
Study
Population / Setting
Potential health effects of recent national waiting
times initiatives in Wales – a rapid review of the
evidence (Draft)
Intervention / Aim
Outcomes
Results
Design
Evidence
level
 Asks WAG to ensure that no inappropriate
activity or manipulation of data caused by
trusts focussing on the target.
 Need longer term objectives to sustain
performance
 By March 2006 only 15 patients waited >1yr
for OP and 10 patients over 18 months. No
wait over 1yr for elective inpatient treatment
 Audit Committees report shows that Wales
has sufficient capacity, it just has to be used
better.
26. National Audit Office.
Inappropriate
adjustments to NHS
waiting lists. London:
The Stationery Office;
2001
UK NHS trusts
Further
assessment of
accuracy and
management of
waiting lists in
trusts previously
identified as
having made
inappropriate
adjustments
 Found that 9 English NHS trusts
inappropriately adjusted their waiting lists
affecting nearly 6000 patients
 In 5 trusts, issues only came to light
following patient, health authority, MP
complaints or adverse publicity. 4 trusts self
identified
 4 trusts held an internal enquiry and 5 an
external inquiry
 At 4 trusts, 7 staff were suspended. Four
Chief or Deputy Chief Executives (3 of whom
were suspended) resigned or had left,
receiving compensation payments totalling
£260,000 covered by confidentiality clauses.
 Four suspended staff have been reemployed within the NHS, only one case had
their compensation clawed back as a result
Audit/expert
opinion
4
27. Auditor General for
Wales NHS
Assess usage of
 Where appropriate DS delivers benefits for
Audit/ expert
3/4
Author: Geri Arthur Specialty Registrar
Version: 0a
Date:
Page: 54 of 78
Status: Draft
Intended Audience:
National Public Health Service for Wales
Study
Population / Setting
Wales. Making better
use of NHS day surgery
in Wales. Cardiff: NAO
Wales; 2006.
Author: Geri Arthur Specialty Registrar
Version: 0a
Potential health effects of recent national waiting
times initiatives in Wales – a rapid review of the
evidence (Draft)
Intervention / Aim
day surgery
Date:
Page: 55 of 78
Outcomes
Results
Design
patients undergoing elective surgery reduces
opinion
ALOS, lowering costs to NHS and risk of HAI.
Rates in Wales lower than England and much
less than 75% (thought to be achievable).
Situation is improving but rates still low and
barriers need to be tackled.
 0% in 99/00 to 60% in 03/04 (due largely to
cataracts).Range in Wales is 47 – 79%. Some
caution with figures due to non-adherence to
the 23.59 rule.
 No clear assembly strategy, guidance on
day surgery (2004) released without a WHC.
 The expansion of day surgery is constrained
by competing demands for beds, adequacy of
recovery and opening hours of day surgery
units. Common practice to admit the night
before to ensure bed available, mainly as
clinicians concerned about cancellations.
 Discharge processes for day surgery are
variable
 Staffing levels in Welsh day surgery units
are higher than England and NI but
productivity is lower.
 Capacity is not an issue in most trusts to
increasing DS.
 An additional 558 cases a month could be
accommodated if all units increased activity to
upper quartile in units in E,W&NI.
 DS beds often used for inappropriate
procedures e.g. Fully equipped theatres for
minor surgery.
Status: Draft
Intended Audience:
Evidence
level
National Public Health Service for Wales
Study
Population / Setting
Potential health effects of recent national waiting
times initiatives in Wales – a rapid review of the
evidence (Draft)
Intervention / Aim
Outcomes
Results
Design
Evidence
level
 Theatres were scheduled to be used for 25
ours a week on average but actually used for
14 hours. Time lost because of gaps/
cancelled lists. Recovery beds/chairs used
inefficiently. Cardiff and Vale ambulatory care
unit not fully utilised due to funding shortfall.
 Designed for life plans 85% of surgery will
require stay of less than 48 hours.
Recommendations:
 Patients listed for DS by default and
clinicians have to change them to other.
 Performance measurement systems should
capture all short stay procedures.
 Patients educated about benefits of day
surgery.
 Commissioning should encourage greater
day surgery provision.
 Staff need appropriate training to expand
the type of surgery done as DS.
 Patients require post-discharge telephone
follow-up.
28. Welsh Assembly
Government. Access
2009. Delivering a 26
week patient pathway.
WHC(2006)081. Cardiff:
WAG; 2006
.
Wales NHS
Author: Geri Arthur Specialty Registrar
Version: 0a
Not applicable
Date:
Page: 56 of 78
 March 2005 the First Minister announced
that by December 2009, no patient in Wales
will wait more than 26 weeks from GP referral
to treatment, including waiting for diagnostic
tests and therapies.
 12 months by March 20056
 months March 2007
 Currently WAG report waiting times
separately for outpatients, inpatients, dayStatus: Draft
Intended Audience:
Policy
document
-
National Public Health Service for Wales
Study
Population / Setting
Potential health effects of recent national waiting
times initiatives in Wales – a rapid review of the
evidence (Draft)
Intervention / Aim
Outcomes
Results
Design
Evidence
level
cases and certain diagnostic tests and therapy
services.
 Most challenged specialties are;
orthopaedics, general surgery and ENT,
accounting for 63% of all waits for IP/DC
procedures (30th Sept 2006) and 37% of OP
waits
 For diagnostics tests; MRI, echo, nonobstetric ultrasounds, SALT
29. 2009 Access Project
Team Delivery Support
Unit, Health and Social
Services Department
Welsh Assembly
Government. Delivering
a 26 week patient
pathway. An
implementation
framework. Cardiff:WAG;
2006
NHS Wales
Not applicable
30. Auditor General for
Wales. Tackling delayed
transfers of care across
the whole system –
Overview report based
on work in the Cardiff
and vale of Glamorgan,
Gwent and
Carmarthenshire health
and social care
NHS Wales
Assess impact
of work on
delayed
transfers of care
(DToC) in
named regions
of Wales
Author: Geri Arthur Specialty Registrar
Version: 0a
Date:
Page: 57 of 78
-
The framework covers:
 Tackling waiting times
 The challenge of achieving the pathway
 The principles and definitions covering the
pathway, including the interim targets to be
achieved
 The implementation strategy
Policy
document
-
 The direct cost of bed days occupied by
DToCs across Wales was £69 million in 06/07,
at marginal cost up to £27 million could be
released.
 There are local agreements which lead to
undercounting of DToCs.
 Delays in restarting care packages that
were frozen on admission
 Problems in determining eligibility for CHC,
Audit / expert
opinion
4
Status: Draft
Intended Audience:
National Public Health Service for Wales
Study
Population / Setting
Potential health effects of recent national waiting
times initiatives in Wales – a rapid review of the
evidence (Draft)
Intervention / Aim
communities. Cardiff:
NAO Wales; 2007.
31. Auditor General for
Outcomes
Results
Design
Evidence
level
causing tension between health and social
care.
 Significant capacity issues in EMI provision
 Budgetary pressures have led to problems
being passed around
 Some areas have instituted Section 33
agreements, taking advantage of budget
flexibilities.
 Joint commissioning arrangements between
health and social care as required by the older
peoples NSF
NHS Wales
Wales. Delayed
transfers of care follow
through. Cardiff: NAO
Wales; 2009
Author: Geri Arthur Specialty Registrar
Version: 0a
Follow-up on
previous report
on delayed
transfers of
care.
Date:
Page: 58 of 78
 Seminar in Nov 2008, attendees from
Cardiff, Vale of Glamorgan & Gwent with
external speakers from Scotland & England.
Concluded that there has been positive
progress which can only lead to sustainable
improvement if partner organisations seize
longer term opportunities. Partner
organisations are taking DToCs more
seriously and improving how they work
together both strategically and operationally.
States that WAG could do more to provide a
robust national framework with an integrated
approach across health and social care.
 Main decrease between 06/07 and 07/08
was reduction in mental health DToCs. Bed
days lost fell by 24% and delayed transfers by
20%. Cardiff reported 42% of the total bed
days lost due to DToCs.
 “There are strategic visions for promoting
Status: Draft
Intended Audience:
Re-audit
-
National Public Health Service for Wales
Study
Population / Setting
Potential health effects of recent national waiting
times initiatives in Wales – a rapid review of the
evidence (Draft)
Intervention / Aim
Outcomes
Results
Design
Evidence
level
independence but at a local and national level,
there is little evidence of robust long to
medium-term planning to turn these visions
into reality.”
 “…the Assembly Government has not yet
provided a clear overall direction to tackle the
whole systems problems that can be
manifested by delayed transfers of care”
 Different performance indicators for health
and social care, theses problems are typified
by local agreements which represent a
number of the codes for types of delays and
mask the true extent of the problem.
 Little progress in the Unified Assessment
Process, which remains overly bureaucratic
and inadequately supported by electronic
solutions.
 Recommendations: single targets across
health and social care; mechanisms to share
human and financial resources more easily;
clear shared performance indicators; greater
flexibility, especially the need for shorter
interim CHC to support re-ablement
32. Welsh Assembly
Government. Access
project, 2008. Integrated
delivery and
implementation plan. A
framework for delivery
2008/09. WHC (2007)51.
NHS Wales
Author: Geri Arthur Specialty Registrar
Version: 0a
Implementation
of the Access
2009 aims
Date:
Page: 59 of 78
 Analysis of backlog shows that approx
39,000 additional outpatients will need to be
seen and 7,000 additional inpatient /DC
compared to 2007/8. Orthopaedics and ENT
have the greatest OP volumes with
orthopaedics, ophthalmology and gynaecology
requiring the highest levels of inpatient/DC
Status: Draft
Intended Audience:
Strategic
document
-
National Public Health Service for Wales
Study
Population / Setting
Potential health effects of recent national waiting
times initiatives in Wales – a rapid review of the
evidence (Draft)
Intervention / Aim
Cardiff: WAG; 2007
Author: Geri Arthur Specialty Registrar
Version: 0a
Outcomes
Results
activity.
 Trusts have made progress in reporting
systems
 Closed by admission (patients receive
elective treatment) at 26 weeks = 57%
 Closed by other (treated in outpatients or
not necessary) = 61%
 Pathway transformation work underway
 One Wales (2007) set out the requirement
to eliminate the use of the independent sector
by the NHS by 2011.
 June 2007, the 2009 Access Project
published its Integrated Delivery and
Implementation Plan under WHC(20067)051.
 Outpatient data up to 28th Feb 2008 shows
volumes well above the trajectory line
 Orthopaedics is above the trajectory; ENT
has reduced but is still above the trajectory
 Clearance time – the time it takes to treat all
patients on a named wait list. Total number of
pts waiting divided by average weekly activity.
 Orthopaedics has 25,000 on list and a
clearance time 10 weeks
 Neurosurgery is >30 weeks (due to case
mix)
 No formal definition of demand, only major
impact on demand is GP referrals which have
slightly reduced from Jan 2006 to Jan 2008,
with some variance on a specialty basis.
 6.2% increase in outpatient activity requires
an extra 39,712 patients to be seen in 08/09
Date:
Page: 60 of 78
Status: Draft
Intended Audience:
Design
Evidence
level
National Public Health Service for Wales
Study
Potential health effects of recent national waiting
times initiatives in Wales – a rapid review of the
evidence (Draft)
Population / Setting
Intervention / Aim
33. Welsh Assembly
Government. One
Wales: A progressive
agenda for the
government of Wales. An
agreement between the
Labour and Plaid Cymru
Groups in the National
Assembly. Cardiff: WAG,
2007
Wales
Not applicable
34. Greer S. Devolution
and divergence in UK
health policies. BMJ
2009: 338:78
UK NHS
Explores how
political variation
n the UK nations
has led to
differences in
health systems
Author: Geri Arthur Specialty Registrar
Version: 0a
Date:
Page: 61 of 78
Outcomes
Not
applicable
Results
 Labour and Plaid Cymru formed a coalition
government and produced a joint manifesto
document. Chapter dealing with health stated
that there would be a moratorium on existing
proposals for change at community hospital
level and that district general hospital service
changes would not be implemented until all
relevant associated community services were
in place.
 They would support changes where there
was local agreement on the way forward but
where there was contention they would
proceed on the basis of the best evidence.
They also planned to revisit and revise
proposals which reconfigure individual
services through single site solutions.
 The document signalled an end to the
internal market principles and pledged to
eliminate the use of private sector hospitals by
the NHS by 2011 in Wales.
Author sees Wales as most radical innovator,
concentrating on public health. Focussed on
health not the NHS. Local government more
influential than elsewhere. Feels policy limited
by localism and fragmentation.
English policy was to make NHS more of a
market.
Problems with both systems as they did not fit
the legacies of NHS systems.
The four systems are heading in different
Status: Draft
Intended Audience:
Design
Evidence
level
Strategic
document
-
Expert opinion
4
National Public Health Service for Wales
Study
Population / Setting
Potential health effects of recent national waiting
times initiatives in Wales – a rapid review of the
evidence (Draft)
Intervention / Aim
Outcomes
Results
Design
Evidence
level
directions with ever more distinct working
cultures.
35. Godden S, et al.
Waiting list and waiting
time statistics in Britain:
a critical review. Public
Health 2009;123: 47-51
UK NHS
Description and
evaluation of
data used to
compile waiting
list information
-
Issues identified in relation to:
 Data quality: determines who appears on
list
 Omissions and exclusions: statistics
provide only partial view of patient experience
 Hidden waits: part of wait not measures
 Emphasis on achieving targets: increases
pressure on trusts and implication for data
accuracy
 Purpose of statistics: no single method ideal
for all purposes
 Interpretation: clinical need should be the
main determinant of time waited, yet that
information is not collected.
Review
4
36. Martin RM et al 2003.
NHS waiting lists and
evidence of national or
local failure: analysis of
health service data. BMJ
2003; 326: 188-98.
NHS hospital
trusts in England,
patients waiting
for general, ENT,
ophthalmic or
trauma and
orthopaedic
surgery
Investigate
national
distribution of
waiting and
association with
markers of NHS
capacity, activity
in private sector
and need
Number of
people
waiting
longer than 6
months,
characteristic
s of trusts
with large
numbers
waiting
 Between 52-83% of patients waiting longer
than 6 months were found in 25% of the trusts
 There was little evidence to show that
capacity or private sector activity were
associated with longer waits
 Increased waiting with increased numbers
of anaesthetists
 Markers of deprivation were inversely
associated with long waits
Routine data
analysis
2-/3
37. Appelby J. Cutting
NHS waiting times:
identifying strategies for
UK NHS
Research
summary of
recent King’s
Factors which emerged as important in
sustaining reductions:
 A sustained focus on the task,
Expert opinion
4
Author: Geri Arthur Specialty Registrar
Version: 0a
Date:
Page: 62 of 78
Status: Draft
Intended Audience:
National Public Health Service for Wales
Study
Population / Setting
sustainable reductions.
London: King’s Fund;
2005
Potential health effects of recent national waiting
times initiatives in Wales – a rapid review of the
evidence (Draft)
Intervention / Aim
Outcomes
Results
Fund work on
waiting
organisationally and through management and
clinical effort
 An understanding of the nature of waiting
lists and how they form part of a whole system
of care
 The importance of detailed information,
analysis, forecasting, monitoring and planning
 The development of appropriate capacity
Design
Evidence
level
38. Besley T, Bevan G,
Burchardi K.
Accountability and
incentives: The impacts
of different regimes on
hospital waiting times in
England and Wales.
London: London School
of Economics; 2008.
UK NHS
Compare impact
of waiting time
policies in
England and
Wales
 Prior to 2001 England and Wales had
similar policies
 After 2001, English hospitals that failed to
meet targets were ‘named and shamed’
 In Wales failure was perceived to bring
extra resources
 Waiting times in England did reduce in
comparison to Wales
 Some evidence in England of shuffling
patients to meet targets which may increase
mean waits
Case
study/expert
opinion
3/4
39. Siciliani L, Hurst J.
2004. Explaining waitingtime variations for
elective surgery across
OECD countries.
DELSA/ELSA/WD/HEA(
2003)7. Paris: OECD;
2003
OECD countries
Comparative
analysis of two
country groups.
One group using
policy to
address
concerns, other
not
 Not all OECD countries report significant
waiting times
 Negative association between waiting times
and capacity
 Higher level of health spending is
systematically associated with lower waiting
times
 Availability of doctors most significant
negative association with waiting
 Low availability of acute care beds
Comparative
study
3
Author: Geri Arthur Specialty Registrar
Version: 0a
Date:
Page: 63 of 78
Status: Draft
Intended Audience:
National Public Health Service for Wales
Study
Population / Setting
Potential health effects of recent national waiting
times initiatives in Wales – a rapid review of the
evidence (Draft)
Intervention / Aim
Outcomes
Results
Design
Evidence
level
significantly associated with waiting
 Activity based funding in hospitals may
reduce waits
40. Kreindler SA.
Watching your wait:
evidence-informed
strategies for reducing
health care wait times.
Qual Manag Health Care
2008; 17:128-35
Health systems
Investigating
effective
strategies to
manage waiting
lists
41. Derrett S, Paul C,
Morris JM. Waiting for
elective surgery: effects
on health related quality
of life. Int J Qual Health
Care 1999; 11: 47-57
People on waiting
list for
prostatectomy or
hip or knee joint
replacement in
Otago region
New Zealand
Describe
experiences of
those waiting for
admission for
elective surgery
42. Sanmartin C,
Bertholet J-M, McIntosh
Respondents to a
national survey
Identification of
the
Author: Geri Arthur Specialty Registrar
Version: 0a
Date:
Page: 64 of 78
Assessment
of severity of
condition and
opinions
about waiting
Need to address the root causes of waiting,
usually poorly designed systems rather than
an absolute lack of capacity. The 7 problems
identified were:
 Too much complexity in the booking
process
 Inefficient methods of scheduling patients
 Excess steps and avoidable delays
 Poor use of human resources
 Doing the right thing at the wrong place
 Traffic jams
 People who should not be on the waiting list
 Assumptions and caveats
Literature
review
3
 Participants had more sever symptoms and
poorer quality of life than the general New
Zealand population
 Condition specific or general quality of life
did not deteriorate during wait
 People with more severe symptoms desire
surgery faster
 Lengthy waiting for surgery represents a
burden in terms of living with symptoms and
poor quality of life
Crosssectional
2-
 Between 17 and 29% of patients felt their
wait was unacceptable
Survey
2-/3
Status: Draft
Intended Audience:
National Public Health Service for Wales
Study
Potential health effects of recent national waiting
times initiatives in Wales – a rapid review of the
evidence (Draft)
Population / Setting
Intervention / Aim
CN. Determinants of
unacceptable waiting
times for specialized
services in Canada.
Health Policy 2007; 2:
e140-54.
on who had
accessed
specialist
services in
Canada
determinants of
unacceptable
waits for
specialised
healthcare
43. Oudhoff, JD et al,
2007. Waiting for elective
general surgery: impact
on health related quality
of life and psychosocial
consequences. BMC
Public Health 2007; 7:
164.
Patients in
surgical
departments of
27 general
hospitals across
the Netherlands
Assess the
impact of
waiting for
elective surgery
Europe
Assess the
acceptability of
wait times to
44. Dunn E et al.
Patient’s acceptance of
Author: Geri Arthur Specialty Registrar
Version: 0a
Date:
Page: 65 of 78
Outcomes
Results
Design
Evidence
level
 Most individuals waited less than 3 months
 Between 10-19% indicated waiting had
affected their lives
 Longer waits or an adverse event while
waiting were significantly associated with
reporting the wait as unacceptable
 The role of socio-economic and
demographic factors was variable
 Individuals with lower education were less
likely to find waiting unacceptable
 Patients aged under 65 were more likely to
find waiting unacceptable
Quality of life,
general
health
perceptions,
psychological
consequence
s, social
consequence
s, waiting
time
 In each group the waiting period involved
worse general health perceptions, quality of
life problems, and raised anxiety levels as
compared to after surgery
 Emotional reactions were most negative to
waiting in those with gall stones
 Prior information about the wait duration
reduced negative reactions
 Social activities were affected in 39-48% of
patients
 18-23% of employed patients reported work
problems during the wait
 Quality of life was not affected in 18-23% of
patients
Cross
sectional
questionnaire
and post-op
follow up
2-
 Anticipated wait time is strongest predictor
of patients tolerance for wait
 Patient dissatisfaction increased with the
Prospective
cohort
2-
Status: Draft
Intended Audience:
National Public Health Service for Wales
Study
Population / Setting
waiting
for
cataract
surgery: what makes a
wait too long? Soc Sci
Med 1997; 44:1603-10
Potential health effects of recent national waiting
times initiatives in Wales – a rapid review of the
evidence (Draft)
Intervention / Aim
Outcomes
patients in
relation to
cataract surgery
Results
Design
Evidence
level
duration of anticipated wait
 Patients were accepting of waits up to 3
months and considered waits in excess of 6
months excessive
 Patients with low tolerance of waits had
greater self-reported vision difficulty
 Acceptance of waiting not associated with
clinical visual acuity or socio-demographic
characteristics
45. Lynch ME et al.
2008. A systematic
review of the effect of
waiting for treatment for
chronic pain. Pain 138:
97-116
Studies on
waiting for
treatment on
chronic pain
To assess the
relationship
between waiting
times, health
status and
health outcomes
-
 Patients experience a significant
deterioration in health related quality of life
and psychological well-being during the 6
months from referral to treatment
 Unknown at what point deterioration begins
as results mixed but some as low as 5 weeks
 Concluded that waits in excess of 6 months
were unacceptable
Systematic
review
1+
46. Sampalis J et al.
Impact of waiting time on
the quality of life of
patients awaiting
coronary artery bypass
grafting. CMAJ 2001;
165: 429-33
Patients
registered for
coronary bypass
grafting from 3
hospitals in
Montreal, Canada
Assess impact
on quality of life
of patients
waiting for
coronary bypass
grafting
Quality of life,
pain,
frequency of
symptoms,
rates of
complications
, death
 Patients waiting longer than 97 days or
more had significantly reduced physical
functioning, vitality, social functioning and
general health
 At 6 months post-surgery, those who waited
>97 days had reduced physical functioning,
physical role, vitality, mental health, general
health
 Incidence of complications significantly
greater inpatients with longer waits
 Longer waits were associated with
increasing likelihood of not returning to work
Prospective
cohort
2-
Author: Geri Arthur Specialty Registrar
Version: 0a
Date:
Page: 66 of 78
Status: Draft
Intended Audience:
National Public Health Service for Wales
Potential health effects of recent national waiting
times initiatives in Wales – a rapid review of the
evidence (Draft)
Study
Population / Setting
Intervention / Aim
47. Bell D et al, 2006.
Does prolonging the time
to testicular cancer
surgery impact long-term
cancer control: a
systematic review of the
literature. Can J Urol
2006; 13: Suppl 3:30-6
Studies and
guideline
/consensus
documents that
evaluated wait
time for testicular
cancer surgery
To assess if
waiting time for
testicular cancer
surgery affects
long-term
cancer control
Postoperative
clinical
outcomes
including
survival
 Limited evidence on median wait, one study
in UK showed 30 days from GP referral
 National and international guidelines
recommend a maximum wait of between 2 -4
weeks for all cancer surgery
 Epidemiological evidence unclear in terms
of surgical delay and overall survival
Systematic
review
1+
48. Saad F et al. Does
prolonging the time to
prostate cancer surgery
impact long-term cancer
control: a systematic
review of the literature.
Can J Urol 2006; 13:
Suppl 3:16-24
Studies and
guideline
/consensus
documents that
evaluated wait
time for prostate
cancer surgery
To assess if
waiting time for
prostate cancer
surgery affects
long-term
cancer control
Postoperative
clinical
outcomes
including
survival
 Median wait times varied from 42 days to
244 days
 National and international guidelines
recommend a maximum wait of between 2 -4
weeks for all cancer surgery
 Epidemiological evidence unclear in terms
of surgical delay of 3 months or more and
effect on PSA recurrence free survival
Systematic
review
1+
49. Jewett M et al, 2006.
Does prolonging the time
to renal cancer surgery
affect long-term cancer
control: a systematic
review of the literature.
Can J Urol 2006;13
:Suppl 3: 54-61
Studies and
guideline
/consensus
documents that
evaluated wait
time for renal
cancer suregry
To assess if
waiting time for
renal cancer
surgery affects
long-term
cancer control
Postoperative
clinical
outcomes
including
survival
 Median wait times varied from 26 days to 82
days
 National and international guidelines
recommend a maximum wait of between 2 -4
weeks for all cancer surgery
 There were no epidemiological studies
evaluating the association between surgical
delay and clinical outcome
Systematic
review
1+
50. Fradet Y et al, 2006.
Does prolonging the time
to bladder cancer
Studies and
guideline
/consensus
To assess if
waiting time for
bladder cancer
Postoperative
clinical
 Median wait times varied from 29 days to
164 days
 National and international guidelines
Systematic
review
1+
Author: Geri Arthur Specialty Registrar
Version: 0a
Date:
Page: 67 of 78
Outcomes
Results
Status: Draft
Intended Audience:
Design
Evidence
level
National Public Health Service for Wales
Study
Potential health effects of recent national waiting
times initiatives in Wales – a rapid review of the
evidence (Draft)
Population / Setting
Intervention / Aim
surgery affect long-term
cancer control: a
systematic review of the
literature. Can J Urol
2006; 13: Suppl 3: 37-47
documents that
evaluated wait
time for bladder
cancer
surgery affects
long-term
cancer control
51. Anon. Waiting,
quality and outcome.
Bandolier 2001; 8(11).
Commentary on
47 – see above
Not applicable
52. Anon. Testing the
Commentary on
an audit on
patients from
Nottingham with
lung cancer
Commentary on
systematic review
on effectiveness
of two week wait
rule for colorectal
cancer referrals
Assess effect of
Department of
Health
guidelines on
two week
cancer referral
two-week rule.
Bandolier 2006.
Author: Geri Arthur Specialty Registrar
Version: 0a
Date:
Page: 68 of 78
Outcomes
outcomes
including
survival
Results
recommend a maximum wait of between 2 -4
weeks for all cancer surgery
 Mixed results on the effects of delayed
surgery
 Studies that looked at a 3 month delay and
tumour grade showed a poorer tumour grade
Comments that studies on the effects of
waiting time appear to be rare. An ethics
committee would be unlikely to approve an
RCT, so only have observational studies as
evidence.
Author believes that the strength of the study
was its inclusivity and confirms that ill people
go downhill if not treated quickly
Study One
 Before guidelines almost every case was an
urgent referral (98%)
 After the guidelines, 60% were under the
two week wait rule and 40% were urgent,
 Referrals increased substantially but
detected cancers did not
 Times between referral and diagnosis and
treatment were the same or worse
Study Two
 12% of referrals had colorectal cancer,
those referred under the two week rule 10%
had cancer
 Most patients were seen by the hospital
within two weeks
 No difference in cancer staging dependent
on referral mechanism
Status: Draft
Intended Audience:
Design
Evidence
level
Expert opinion
4
Expert opinion
based on an
audit and a
systematic
review
4
National Public Health Service for Wales
Study
Population / Setting
Potential health effects of recent national waiting
times initiatives in Wales – a rapid review of the
evidence (Draft)
Intervention / Aim
Outcomes
Results
Design
Evidence
level
Concludes that neither study show
improvement caused by two week rule
53. Lewis NR, Le Jeune
I, Baldwin DR. 2005.
Under utilisation of the 2week wait initiative for
lung cancer by primary
care and its effects on
the urgent referral
pathway. Br J Can 2005;
93:905-8.
Patients in
Nottingham
referred with
suspected lung
cancer
Examine
referrals before
and after the
Department of
Health
guidelines on
cancer referrals
54. Thorne K, Hutchings
HA, Elwyn G. The effects
of the two-week rule on
NHS colorectal cancer
diagnostic services: a
systematic literature
review. BMC Health Ser
Res 2006; 6: 43.
Studies of
patients referred
for possible
colorectal cancer
between 200 2003
To assess
impact of two
week cancer
referral rule
55. Potter S et al.
Referral patterns, cancer
diagnoses, and waiting
times after introduction of
two week wait rule for
breast cancer:
prospective cohort study.
BMJ 335; 288.
All patients
referred to a
Bristol breast
clinic between
1999 and 2005
To assess the
long term impact
of the two week
wait rule for
breast cancer
referral patterns
Author: Geri Arthur Specialty Registrar
Version: 0a
Date:
Page: 69 of 78
 Before guidelines almost all cases were
urgent referrals
 After guidelines this was 60% as a two
week referral, 40% as urgent
 The number of referrals increased, the
number of cancers detected and the stage at
which they were detected did not change
 Time from referral to diagnosis and
treatment was the same or increased
Audit
3/4
Number of
cancers
detected,
stage of
cancer,
length of wait
 Overall 12% of patients referred had cancer
detected
 Of those referred under the two week rule
10% had cancer detected
 Most patients were seen by a hospital
specialist in under two weeks
 No difference in staging of cancer
dependent on method of referral
Systematic
review
2-
Number,
route,
outcome of
referrals from
primary care,
waiting times
for routine
and urgent
appointments
 Annual number of referrals increased by 9%
over 7 years
 Routine referrals decreased by 24%
 2 week wait referrals increased by 42%
 Percentage of patients diagnosed with
cancer in the two week wait group decreased
from 12.8% to 7.7%
 Number of cancers detected in routine
group increased from 2.5% to 5.3%
Prospective
cohort
2+
Status: Draft
Intended Audience:
National Public Health Service for Wales
Study
Population / Setting
Potential health effects of recent national waiting
times initiatives in Wales – a rapid review of the
evidence (Draft)
Intervention / Aim
Outcomes
Results
Design
Evidence
level
 27% of patient with cancer are currently
referred in the non-urgent group
 Waiting times for routine referral have
increased over time
56. Feldman, R. The cost
of rationing medical care
by insurance coverage
and by waiting. Health
Econ 1994; 3: 361-72
Healthcare
provision
To assess two
methods of
reducing risk in
relation to
purchase of
medical care.
First is
’complete
insurance’ and
the second
rationing by
waiting time
57. Gravelle H. 2008. Is
waiting-time prioritisation
welfare improving?
Health Econ 2008;
17:167-84
Healthcare
To assess the
optimal way to
use waiting
times to allocate
a fixed supply of
treatment
58. Quan H, La Freniere
R, Johnson D. Health
service costs for patients
on the waiting lists. Can
J Surg 2002; 45: 34-43
Patients from
Calgary regional
health authority
waiting for
particular surgery,
To assess if the
cost of heath
services a\re
increased by
delay in surgery
Author: Geri Arthur Specialty Registrar
Version: 0a
Date:
Page: 70 of 78
Costs
Costs
 ‘Complete insurance corresponds to US
model. Rationing by waiting corresponds to
UK model.
 First system may lead to over utilisation of
resources which is not offset by
underutilisation of the uninsured
 The latter model has been estimated to cost
between $541 - $828 per family in 1984
dollars.
 Both systems result in costly mis-allocation
of resources
Economic
analysis/
Expert opinion
3/4
Investigates whether prioritisation is welfare
improving when benefit of treatment is made
up of 2 components, one of which is not visible
to the healthcare provider.
Study indicates that prioritisation (shorter waits
for higher benefit) is welfare improving in some
scenarios
Economic
model
3
 Median wait for joint surgery was longer
than for other disciplines
 Total per patient physician costs decreased
after surgery
 Seeing the procedure specialist more than
Retrospective
cohort study
2-
Status: Draft
Intended Audience:
National Public Health Service for Wales
Study
Population / Setting
Potential health effects of recent national waiting
times initiatives in Wales – a rapid review of the
evidence (Draft)
Intervention / Aim
that is:
cholesystectomy,
discectomy,
hysterectomy,
total knee or total
hip replacement
Outcomes
Results
Design
Evidence
level
once pre-operatively was associated with a
greater decrease in post-op physician claim
costs
 Longer waits were not associated with more
physician claims or prescription claims for
over 65s in the year before or after surgery
 No evidence to suggest that longer waits
associated with greater health service
expenditure
59. Rachlis MM. Public
solutions to health care
wait lists. Ottawa:
Canadian Centre for
Policy Alternatives;
2005..
Canadian
healthcare
Not applicable
 The healthcare system should establish
more specialised short-stay surgical clinics in
the public sector
 Lessons learned from queue management
theory should be adopted
 Shift minor and low risk procedures to short
stay public specialised clinics
 Backlog clearance is usually a temporary
fix: If intermittent capacity/demand
mismatches cause waiting lists then they will
reappear after the backlog is temporarily
cleared
Expert opinion
4
60. Lewis R, Appleby J.
Can the English NHS
meet the 18 week
waiting list target? J R
Soc Med 2006; 99:10-13
England NHS
To assess if 18
week waiting
target can be
met
 Central targets appear to be effective in
focussing NHS attention as long as
underpinned by rewards/sanctions
 The use of targets has been ‘remarkably’
successful’
 New 18 week target is total wait’ which is
more in tune with what people want
 Evidence about whether waiting targets
Expert opinion
4
Author: Geri Arthur Specialty Registrar
Version: 0a
Date:
Page: 71 of 78
Status: Draft
Intended Audience:
National Public Health Service for Wales
Study
Population / Setting
Potential health effects of recent national waiting
times initiatives in Wales – a rapid review of the
evidence (Draft)
Intervention / Aim
Outcomes
Results
Design
Evidence
level
distorted priorities is unclear
 If targets become more demanding may
reduce flexibility of hospitals
 Additional costs to reduce waiting may be
out of proportion to benefits gained
61. Appleby J, Harrison
T. The war on waiting for
hospital treatment.
London: King’s Fund;
2005.
UK NHS
Not applicable
62. McPherson K. Do
patients’ preferences
matter? BMJ 2009;
338:59
Commentary on a
meta-analysis
Original study
was a metaanalysis of
studies
assessing
affects of patient
preference on
outcome of
treatment
Author: Geri Arthur Specialty Registrar
Version: 0a
Date:
Page: 72 of 78
Effect size of
treatment
Describes phases of the labour government’s
‘War on Waiting’.
1. (1997-2000)Concentration on reducing the
numbers waiting
2. (2000-2004)Increased funding and targets
on waiting
3. (2005-2008) 18 week target
Author states that government needs to further
develop:
 Its objectives for waiting lists
 The policies that will achieve these
objectives
 Its understanding of the overall health
system and, within that, what causes waiting
Expert opinion
4
 Patients who received their preferred
treatment did better than those who were
indifferent or not allocated to their preference
 Preference had little effect on attrition
 Effect might be explained by people with
strong preferences refusing to be randomised
 Related to placebo effect possibly
Expert opinion
4
Status: Draft
Intended Audience:
National Public Health Service for Wales
Study
Potential health effects of recent national waiting
times initiatives in Wales – a rapid review of the
evidence (Draft)
Population / Setting
Intervention / Aim
Outcomes
Results
63. Anon. Influence of
adherence to treatment
and response of
cholesterol on mortality
in the coronary drug
project. NEJM 1980;
303: 1038- 41
Fully randomised
studies that
examined the
impact of patient
preference on
attrition and
outcome
64. Preference
Collaborative Review
Group. Patients’
preferences within
randomised trials:
systematic review and
patient level metaanalysis. BMJ 2008; 337:
a1864
65. Lofvendahl S et al.
Waiting for orthopaedic
surgery: factors
associated with waiting
times and patients’
opinion. Int J Qual Health
Care 2005; 17:133-40
Preferences for
treatment
Effect of
treatment,
clinical
outcome,
attrition rates
 Patients randomised to their preferred
treatment had a greater standardised effect
 Effects the same for people allocated to
their undesired treatment and those who were
indifferent
 No difference in attrition between patients
who had their desired treatment and those
who were indifferent
 Those who received their preferred
treatment appeared to have better outcomes
but this was not statistically significant
Meta-analysis
1-
Included studies
of fully
randomised
preferences
To assess effect
of preference on
clinical
outcomes and
attrition
Treatment
effect size,
clinical
outcome,
attrition
Systematic
review
1+
Orthopaedic
patients from 10
Swedish hospitals
To assess
waiting times
and identify
factors in
variation
Length of
time waited,
socioeconom
ic variables,
hospital type,
quality of life,
opinion about
waiting
 Patients who were randomised to their
preferred treatment had a standardised effect
size greater than that of those who were
indifferent to the treatment assignment
 Participants who received their preferred
treatment also did better than participants who
did not receive their preferred treatment
although this was not statistically significant
 No difference was found in attrition between
patients allocated to their preference and
those who were indifferent
 Longest waits in hip replacement group
 Socioeconomic variables were not
determinants in waiting other than working
status in the back surgery group
 Shorter waits for county/district hospital
rather than university/regional hospital
 Patients with better health related quality of
life had longer waits for knee surgery
Retrospective
cohort
2-
Author: Geri Arthur Specialty Registrar
Version: 0a
Date:
Page: 73 of 78
Status: Draft
Intended Audience:
Design
Evidence
level
National Public Health Service for Wales
Study
Population / Setting
Potential health effects of recent national waiting
times initiatives in Wales – a rapid review of the
evidence (Draft)
Intervention / Aim
Outcomes
Results
Design
Evidence
level
 The length of wait was a significant
predictor of the acceptability of the wait
 Patients influence over surgery date
affected their opinion about the waiting time
66. Ethgen O. Healthrelated quality of life in
total hip and total knee
arthroplasty. A qualitative
and systematic review of
the literature. J Bone
Joint Surg Am 2004; 86A: 963-74
Studies including
patients with total
hip or knee
arthroplasties
Review
literature for
outcomes in hip
and knee
arthroplasty in
terms of quality
of life
 Overall hip and knee arthroplasties were
found to be effective in terms of improvement
in health related quality of life
 Age not found to be an obstacle to effective
surgery
 Men appear to benefit more than women
 When improvements were found to be
modest, co-morbidities played a role
 Total hip arthroplasty appears to return
function more than knee procedures
 Primary surgery offers greater improvement
than revision
 Patients with poorer peri-operative health
related quality of life were more likely to
experience greater improvement
Systematic
review
2++
67. McGregor M, Atwood
CV. Wait times at the
MUHC: No 3. Fracture
management. Montreal:
McGill University Health
Centre; 2007
Patients requiring
surgery for
fracture
management
To provide
guidance on
optimum waits
for fracture
surgery
 Conflicting evidence about timing of surgery
to hip fractures. Author states it is probable
but not proven that delay leads to increased
mortality
 Some evidence that delay, >24 hours, in
surgery on ankle and tibial fractures may
result in increased complications and longer
hospital stays
 No evidence that prompt treatment has an
adverse effect.
Systematic
review
2++
Author: Geri Arthur Specialty Registrar
Version: 0a
Date:
Page: 74 of 78
Status: Draft
Intended Audience:
National Public Health Service for Wales
Study
Population / Setting
Potential health effects of recent national waiting
times initiatives in Wales – a rapid review of the
evidence (Draft)
Intervention / Aim
Outcomes
Results
Design
Evidence
level
 Authors state that reducing delays results in
less pain, facilitation of surgical planning,
improved morale and more efficient bed usage
68. Hirvonen J et al.
Health-related quality of
life in patients waiting for
major joint replacement.
A comparison between
patients and population
controls. Health and
Quality of Life Outcomes
2006; 4:3
Patients awaiting
major joint
replacement due
to osteoarthritis
Assessing
quality of life
whilst waiting for
surgery and
after
69. Peul WC et al.
Prolonged conservative
care versus early surgery
in patients with sciatica
caused by lumbar disc
herniation: two year
results of a randomised
controlled trial. BMJ
2008; 336:1355-58.
Patients with
sciatica in nine
Dutch hospitals
Assess early
surgery against
conservative
treatment
70. Weinstein JN et al.
Surgical vs nonoperative treatment for
lumbar disk herniation:
The Spine Patient
Patients with
lumbar
intervertebral disc
herniation treated
at 13 spine clinics
Assess standard
open
discectomy
against
conservative
Author: Geri Arthur Specialty Registrar
Version: 0a
Date:
Page: 75 of 78
 Patients quality of life did not appear to
deteriorate whilst waiting
 Patients did have a significantly worse
quality of life than population controls
Case control
2-
Following
surgery, at
one year and
at two years
 44% of patients assigned to conservative
treatment eventually required surgery
 Improvement in leg pain was faster for
those assigned to early surgery
 Short term benefit was no longer significant
by six months and difference continued to
narrow over time
 Patient satisfaction in both groups
decreased slightly between one and two years
 At two years 20% of all patients reported an
unsatisfactory outcome
RCT
1-
Changes in
quality of life,
pain and
physical
function and
 At 3 months patients who chose surgery
had greater improvement in pain, physical
function and disability
 These differences narrowed at two years
 Patients in both groups improved
Prospective
cohort study
2-
Status: Draft
Intended Audience:
National Public Health Service for Wales
Study
Potential health effects of recent national waiting
times initiatives in Wales – a rapid review of the
evidence (Draft)
Population / Setting
Intervention / Aim
in 11 US states
management
disability
71. Gibson JN et al.
Surgical interventions for
lumbar disc prolapse.
Cochrane Database Syst
Rev 2007, Issue 2
Randomised and
quasi-randomised
(QRCT) trials of
the surgical
management of
lumbar disc
prolapse
Assess the
effects of
surgical
intervention for
the treatment of
lumbar disc
prolapse
42 RCT
2 QRCTs
 Surgical discectomy for selected patients
with sciatica due to lumbar disc prolapse
provides faster relief from the acute attack
than conservative management
 Lifetime affects on the natural history of the
underlying disc disease are unclear
 Micro-discectomy gives broadly comparable
results to open discectomy
 Evidence on other minimally invasive
techniques is unclear
72. Fielden JM et al.
Waiting for hip
arthroplasty: Economic
costs and health
outcomes. J Arthroplasty
2005; 20: 990-97
Patients waiting
for total hip
arthroplasty in
New Zealand
To determine
the economic
and health costs
of waiting for
total hip
arthroplasty
Costs in New
Zealand
dollars and
quality of life
measure
Prospective
 Mean wait was 5.1 months at a mean cost
cohort study
of NZ$4,305 per person
 Waiting more than 6 months was associated
with higher mean cost than waiting less than 6
months
 Longer waits meant poorer physical function
pre-operatively.
 Quality of life improved from pre to postoperatively
 Those with poor initial health status showed
greatest improvement on the disease specific
health status tool
 Those with better health status preoperatively had better absolute outcomes at 6
Outcomes Research
Trial (SPORT)
Observational Cohort.
JAMA 2006 ; 296(20):
Outcomes
Results
Design
Evidence
level
2451-59.
Author: Geri Arthur Specialty Registrar
Version: 0a
Date:
Page: 76 of 78
Status: Draft
Intended Audience:
Systematic
review
2++
2-
National Public Health Service for Wales
Study
Population / Setting
Potential health effects of recent national waiting
times initiatives in Wales – a rapid review of the
evidence (Draft)
Intervention / Aim
Outcomes
Results
Design
Evidence
level
months
 Conclude that longer waits for total hip
arthroplasty incur greater economic costs and
deterioration in physical function while waiting
 Studies varied substantially
 Studies on cost-utility analysis in
orthopaedics were of a lower standard than in
other areas of medicine
 Number of studies has increased but the
quality has not improved over time
 For the majority of interventions studied the
cost utility ratio was below the commonly used
threshold of $50,000 per quality adjusted life
year for acceptable cost effectiveness
Literature
review
2+
Ascertain what
is an acceptable
wait
 Participants endorsed prioritisation of
patients based on clinical need but not on
ability to benefit
 Acceptable waiting times ranged between 2
and 25 weeks dependent on disorder, severity
of physical and psychosocial problems
Survey
3/4
Elicit
preferences of
health
professional and
public in relation
to prioritisation
of waiting
 Professional and lay support for a more
explicit system of rationing elective care by
waiting list.
 Surveyed groups felt that level of pain,
deterioration of disease. Level of
distress/disability should play most influential
role
Postal survey
4
73. Brauer CA et al. Cost
utility analyses in
orthopaedic surgery. J
Bone Joint Surg Am
2005; 87: 1253-9
Studies on
orthopaedic cost
utility analysis
To determine if
sub-specialties
are represented,
the cost utility
ratios that have
been used and
the quality of the
literature
74. Oudhoff JP et al. The
acceptability of waiting
times for elective surgery
and the appropriateness
of prioritising patients.
BMC Health Serv Res
2007; 7:32.
Health
professionals in
the Netherlands
75. Edwards RT et al.
Clinical and lay
preferences for the
explicit prioritisation of
elective waiting lists:
survey evidence from
Wales. Health Policy
UK NHS
Author: Geri Arthur Specialty Registrar
Version: 0a
Date:
Page: 77 of 78
37 studies
Status: Draft
Intended Audience:
National Public Health Service for Wales
Study
Population / Setting
Potential health effects of recent national waiting
times initiatives in Wales – a rapid review of the
evidence (Draft)
Intervention / Aim
2003; 63: 229-37
Author: Geri Arthur Specialty Registrar
Version: 0a
Outcomes
Results
Groups agreed that age, ability to pay, cost of
treatment, evidence of cost effectiveness,
existence of dependents and self inflicted ill
health should not influence patient priority
Date:
Page: 78 of 78
Status: Draft
Intended Audience:
Design
Evidence
level