Managing Waiting Times: A Good Practice Guide

MANAGING WAITING TIMES: A GOOD PRACTICE GUIDE

CHAPTER FOUR
THE NHS BOARD

Low treatment rates or a high level of demand may be contributory factors to lengthy waiting times. In order to manage demand in relation to need and deliver care of an appropriate level and case-mix, Health Boards should consider the following actions:

• The appropriateness of referral rates for specific specialities should be assessed by NHS Boards in partnership with primary and secondary care and benchmarked against comparative populations. Intervention rates for selected procedures should also be benchmarked against comparative populations.

• Where appropriate, referral practice and intervention rates should be protocol driven, taking account of local health needs assessment and existing guidelines from NHS Quality Improvement Scotland, including SIGN guidelines.

• NHS Boards, in partnership with general practice, should review significant variations in referral levels between different general practices, or groups of general practices, with a view to benchmarking expected referral levels.

• Access to outpatient and consultative services for those from deprived communities, and those from the most vulnerable groups in society, should be reviewed and where access is perceived to be inadequate, targets should be set for improvement. Rates for patient failure to attend for appointment or admission should be audited in relation to deprivation.

• The public health contribution to improving waiting times should support the best balance between meeting need, managing demand and providing appropriate healthcare resources.

It is recommended that when agreeing activity levels to deliver waiting time standards, the following factors should be taken into consideration:

1. It should be determined if activity levels are appropriate to deliver the agreed waiting time standards. "Roll-over agreements" should not be employed in a manner that activity levels of the previous year are simply confirmed as activity levels for the following year.

2. Where appropriate, it should be determined at speciality or sub-speciality level if activity levels are appropriate to deliver a specific waiting time standard. The process of "bottom line agreements" should not be employed where increases in activity in one area are simply offset against decreases in activity in another area. An example of this would be off-setting an increase in emergency activity against a decrease in elective activity. Similarly, increases in activity in one speciality should not be off-set against decreases in activity in another speciality unless it is clear this is appropriate and waiting time standards will be maintained.

3. Where appropriate, annual activity targets should be phased to take account of seasonal variations in demand and capacity. Elective activity for most specialities should generally be lower in the winter period while emergency activity is generally higher in the winter period. Some specialities however, do not suffer from large seasonal fluctuations and this is particularly the case for day case services.

4. Outpatient appointments should not be utilised as a proxy for demand or for need. Outpatient referrals may be significantly higher than appointments leading to increasing waiting times. In addition, low appointment rates may mask unmet need which has not resulted in referral to hospital.

Planning to maintain waiting time standards should be part of an overall integrated and linked planning process. Action to deliver waiting time standards should complement and not detract from action to deliver other targets, for instance around the management of emergency care and chronic conditions.

The NHS Board should provide leadership in analysing and in managing the entire waiting time pathway from referral to completion of treatment. The aim should be to ensure that patient care does not become fragmented with the patient subjected to a series of consecutive waiting times which are poorly understood and reported.

In completing service strategies and reviews, NHS Boards should take full account of the requirement to improve waiting times. Strategic plans should underpin the delivery of agreed national and local waiting time standards.

Each NHS Board should have an executive director with specific responsibility for waiting times and the Board should receive regular reports covering progress towards national and local standards.