J R Soc Med 2004;97:119-120
doi:10.1258/jrsm.97.3.119
© 2004 Royal Society of Medicine
Generic waiting lists for routine spinal surgery
P Leach MRCS
SA Rutherford AFRCS
AT King FRCS
JRS Leggate FRCS
Department of Neurosurgery, Hope Hospital, Salford, Manchester M6 8HD,
UK
Correspondence to: Paul Leach E-mail:
leachy100{at}hotmail.com
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SUMMARY
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National Health Service Hospitals are under pressure to reduce
waiting
lists within the constraints of a limited infrastructure.
We implemented two
systems to reduce waiting times for elective
non-complex spinal surgery. The
first of these was the introduction
of managed generic waiting lists for both
initial outpatient
appointments and subsequent surgery. Thereafter, the MRI
booking
system was integrated with outpatient review appointments. Times
from
referral to first outpatient appointment and from scan
to outpatient review
and time on waiting list for surgery were
analysed before and after
implementation of these changes.
Despite constant unit capacity there was a global decrease in waiting
times. Before introduction of the generic waiting list, 37% of listed patients
waited for more than 9 months; this figure fell to zero. Time from scan to
outpatient review was 185 days before integration, 30 days after.
Changes of this sort demand a quorum of consultants who will accept each
others' recommendations. The generic waiting list will have impact only when
there are large disparities in waiting times for different consultants.
Targets are met at the expense of continuity of care.
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INTRODUCTION
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The global trend within the National Health Service over the
past decade
has been of lengthening waiting times as outdated
systems struggle to cope
with increased demand and expectation.
The Government has adopted a target
driven system to address
the most obvious shortcomings, often without
providing resources
to cope with an increased throughput.
According to The NHS
Plan1 the
maximum waiting time for a routine outpatient appointment will be 3 months,
the maximum waiting time for inpatient treatment will be 6 months and the
maximum wait for any stage of treatment will be 3 months. These are to be
achieved in a staged process, culminating at the end of 2008.
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METHODS
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All neurosurgical services within Greater Manchester were amalgamated
to
the Hope Hospital site in Salford in May 2001, and this is
the time when our
data collection begins. To reduce waiting
times, we employed two strategies.
First, managed generic waiting
lists were introduced for both initial
outpatient appointments
and dates for surgery. Subsequently the computerized
MR booking
system was integrated with outpatient review appointments.
The managed generic outpatient waiting list begins with a consultant
screening all new GP referred spinal cases to assess their suitability for a
pooled waiting list. They are then allocated to the next available appointment
irrespective of who the consultant might be. The managed generic surgical
waiting list works by a similar process. When consultants list a patient for
elective non-complex spinal surgery, they indicate whether the patient should
remain under their care or enter a pooled waiting list. The pooled patients
are then allocated dates for surgery sequentially. The integration of the MR
appointment system with outpatient follow-up entails regular secretarial
review of which patients are to be scanned. As soon as these appointments are
allocated, ring-fenced outpatient review appointments are provided.
We compared data collected before and after implementation of these two new
systems. The outcome measures were time from referral to first outpatient
appointment, time from scan to outpatient review and time on waiting list for
surgery.
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RESULTS
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Figure 1 shows times to
first neurosurgical outpatient examination.
The number of patients waiting
more than 26 weeks fell to zero
and the number waiting more than 13 weeks
declined greatly.
After introduction of the integrated MR follow-up system,
the
mean wait from MR scan to outpatient review fell from 185 days
to 31 days.
At the time of introduction of the generic waiting
list for elective surgery,
37% of listed patients had been waiting
for more than 9 months. The number is
currently zero (
Figure 2).
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DISCUSSION
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The introduction of these systems has dramatically reduced waiting
times
within our unit for each stage of the referral process.
However, the waiting
list figures alone paint an incomplete
picture. The first potential difficulty
we faced with the generic
waiting list was in establishing a quorum of
consultants within
our unit prepared to accept the underlying premise of
possible
discontinuity in patient care. Of the ten neurosurgical consultants,
seven
agreed to the principle of operating on the basis of a colleague's
recommendation.
When such a system was proposed in the Birmingham
ophthalmology
unit, for cataract surgery, most of the consultants had
reservations.
In our experience, as in Birmingham, nearly all patients are happy with the
system when it is explained to them that their wait will be shorter and that
the operation can be carried out by any appropriately trained neurosurgeon.
The general practitioners have not been formally consulted, but many were
already referring patients to the department rather than a named specialist.
The second hurdle to be surmounted was agreement on which patients were
appropriate for the pooled waiting list. The criteria include first-time
referrals, clear-cut signs or symptoms of cervical or lumbar neural
compromise, and no obvious underlying disease that might require spinal
fixation (e.g. rheumatoid arthritis). It was therefore agreed that the generic
list should only incorporate patients who needed non-complex spinal surgery of
the sort practised by all neurosurgeons. The reason this system has been so
successful in our unit is the previous disparity between the waiting times for
our various consultants. This allowed reallocation of the longest waiters to
the consultants with the shortest lists. A disadvantage of the generic waiting
list is the occasional difference of opinion between consultants on the need
for treatment. Consultants are operating on patients they have not assessed in
an outpatient clinic. We know of only one case, thus far, in which a
consultant declined to perform the listed operation. The consultant who
originally listed the patient performed the operation on the same admission.
The system relies on good communication and flexibility at consultant
level.
Disadvantages of these innovations include difficulties in the initial set
up, a modest increase in secretarial workload and an occasional lack of
continuity of care at consultant level. The great advantage of these schemes
is that they are cost neutral but effective in helping to meet government
targets. Clearly, waiting times are not a measure of what matters
most—namely, clinical outcome. An ideal system would preserve continuity
of care, but strategies of this sort are likely to be increasingly applied in
the target-driven NHS.
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Acknowledgments
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We acknowledge the invaluable contributions made by Dawn Wood
(Assistant
Service Manager for Neurosciences) and Gemma Halliday
(Neurosurgical
Secretary).
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REFERENCES
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- Department of Health. The NHS Plan: A Plan for
Investment, a Plan for Reform. Norwich: Stationery Office,2000
- Ramchandani M, Mirza S, Sharma A, et al. Pooled cataract
waiting lists: views of hospital consultants, general practitioners and
patients. J R Soc Med2002; 95:598
–600[Abstract/Free Full Text]
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SUMMARY
INTRODUCTION
0–12 weeks;
13–26 weeks; 
26+ weeks; 
introduction of a
generic waiting list for elective spinal surgery