OECD Health Policy Studies

2074-319X (online)
2074-3181 (print)
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This series of publications analyses the organisation and performance of health systems, and factors explaining performance variations. Studies are conducted on such topics as co-ordination of care, pharmaceutical pricing, long-term care and disability, health workforce and international migration of health workers, information and communications technologies in health care, and the economics of prevention. 
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Waiting Time Policies in the Health Sector

Waiting Time Policies in the Health Sector

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Edited By:Luigi Siciliani, Michael Borowitz, Valerie Moran
04 Feb 2013
9789264179080 (PDF) ;9789264179066(print)

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Over the past decade, many OECD countries have introduced new policies to tackle excessive waiting times for elective surgery with some success. However, in the wake of the recent economic downturn and severe pressures on public budgets, waiting times times may rise again, and it is important to understand which policies work.  In addition, the European Union has introduced new regulations to allow patients to seek care in other member states, if there are long delays in treatment.   This book provides a framework to understand why there are waiting lists for elective surgery in some OECD countries and not in others. It also describes how waiting times are measured in OECD countries, which differ widely, and makes recommendations for best practice. Finally, it reviews different policy approaches to tackling excessive waiting times. Some countries have introduced guarantees to patients that they will not wait too long for treatment. These policies work only if they are accompanied by sanctions on health providers to ensure the guarantee is met or if they allow greater choice of health-care providers including the private sector. Many countries have also introduced policies to expand supply of surgical services, but these policies have generally not succeeded in the long-term in bringing down waiting times. Given the increasing demand for elective surgery, some countries have experimented with policies to improve priorisation of who is entitled to elective surgery. These policies are promising, but difficult to implement.
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  • Foreword

    Long waiting times for health services is a prominent health policy issue in many OECD countries. This issue was the focus of an earlier OECD project carried out in 2001-04. Since then many new policies have been introduced to decrease waiting times. This book critically evaluates these policies and presents detailed information on the experience of countries and information on waiting times. This book will help policy makers who are confronting the issue of increased waiting times for elective treatments. It will help national experts to compare their policies with several other OECD countries and to identify latest developments. The focus on elective treatments reflects the policy focus of countries over the past decade, but waiting times are also prevalent in other parts of the health system – in receiving primary care, emergency care, and cancer treatment – where their effects may well be more deleterious to health outcomes.

  • Executive summary

    In many OECD countries, long waiting times for health care services is an important health policy issue. A recent OECD survey revealed problems with waiting times in almost all OECD countries including primary care, out-patient specialist care, emergency care, cancer care and elective (non-emergency) care. More than half of OECD countries have long waiting times for elective treatments, and these waiting times are often a contentious political issue.

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    • Waiting times for health care: A conceptual framework

      This chapter provides a conceptual framework for understanding the role of waiting lists and waiting times in the health sector, with a special focus on hospital services. It emphasises demand-side and supply-side factors that influence excessive waiting times, and in particular the critical role of doctors in determining the demand for care. It then briefly describes the health policy significance of waiting times across the OECD countries, and the extent to which this is associated with health spending and the supply of hospital beds and doctors. There is a negative association between waiting times and the availability of curative care beds, and to a lesser extent with public health expenditure per capita. It then briefly reviews the empirical evidence on the effect of waiting times on health outcomes. This suggests that long waiting times can have a detrimental impact on health outcomes for more urgent procedures, like coronary bypass, but less so for less urgent ones, like elective hip replacement, where the evidence is mixed. It also highlights the recent empirical literature, which suggests that waiting times for publicly funded patients may be longer for individuals with lower socioeconomic status, making waiting times a less equitable allocation mechanism than currently perceived.

    • Measuring waiting times across OECD countries

      The measurement of waiting times varies widely across OECD countries. This chapter gives an overview of different measures of patients’ experience of waiting using examples from several countries. Common measures are the in-patient waiting time (from specialist addition to the list to treatment), the out-patient waiting time (from general practitioner referral to specialist visit) and the referral-to-treatment (from GP referral to treatment). Reported figures include the mean waiting times, the waiting time at different percentiles of the distribution (at the 50th percentile, i.e. the median, the 80th, 90th or 95th percentile), and the number of patients waiting more than a threshold waiting time, for example, three, six or nine months. Waiting times are reported in most countries by procedure (e.g. hip and knee replacement, cataract surgery) or by specialty (e.g. ophthalmology, orthopedics). They refer mainly to two distributions: i) the distribution of waiting times of patients treated in a given period (for example, a financial year); ii) the distribution of waiting times of the patients on the list at a point in time (a census date). Most information on waiting times is available from administrative databases from countries where waiting times are a significant policy issue, and less so from survey data.

    • A review of waiting times policies in 13 OECD countries

      This chapter reviews various policy tools that countries have used to tackle excessive waiting times in 13 countries: Australia, Canada, Denmark, Finland, Ireland, Italy, Netherlands, New Zealand, Norway, Portugal, Spain, Sweden and the United Kingdom. The most common policy is some form of maximum waiting time guarantee. Increasingly, such guarantees are backed with targets set for providers and sanctions if these targets are not met. The guarantees often go hand-in-hand with choice, competition and an increase in supply (in the public and/or the private sector). These policies have generally been successful in bringing down waiting times. In contrast, most attempts to increase supply temporarily in order to decrease waiting times have had only a limited effect. A better approach may be to condition increases in supply on simultaneous reductions in waiting times. Demand-side policies attempt to define more rigorous clinical thresholds for treatment. However, it has proved difficult to implement such thresholds. The most promising approaches link waiting time guarantees to different categories of clinical need, also referred to as waiting time prioritisation. An alternative demand-side approach is to encourage private health insurance to shift demand from the public to the private sector, though this has generally not proven successful in reducing waiting times.

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  • Expand / Collapse Hide / Show all Abstracts Review of waiting times policies: Country case studies

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    • Australia

      In Australia, lowering waiting times for elective surgery has been a policy focus over the last two decades. Initially, the focus at the national level was on subsidising private health insurance with the aim of shifting demand from public to private hospitals. More recently, policies have shifted to directly expanding public hospital capacity and providing financial incentives to states for achieving lower waiting times. Despite these expensive efforts, waiting times barely changed, with the median even increasing slightly. Australia’s states manage the public hospitals, and there are large variations in waiting time across the states. There is some evidence that state-based programmes are more effective than national ones, but their impacts have been short-lived. Several features of the current system for managing waiting lists may contribute to long waiting times, including the wide discretion given to specialists in assigning urgency to patients on the waiting list.

    • Canada

      This chapter outlines the main characteristics of the Canadian health care delivery system, traces the development of unacceptably long patient waiting times for care and examines public concern about the viability of Canadian Medicare. While individual jurisdictions addressed the problem of waiting times with limited success, federal provincial and territorial leaders collaborated in the development of a pan-Canadian approach to reduce waiting times in the context of the 2004 10-Year Plan to Strengthen Health Care. Reductions in waiting times are presented as are the results of statutory parliamentary reviews of progress.

    • Denmark

      Waiting times for hospital treatment have been on the political agenda in Denmark for a long time, and various measures have been taken since the 1990s to deal with the problem directly, including systematic monitoring and reporting, the introduction of maximum waiting times coupled with the free choice of hospital for somatic and psychiatric patients, a short maximum waiting time guarantee for life-threatening diseases coupled with care packages for cancer and heart diseases and extra-activity targeted hospital grants. There are good reasons to believe that these policies have reduced waiting times. In addition, a range of other measures may indirectly have affected waiting times, such as a general increase in spending on health care, the strong commitment to general practitioners as gate-keepers, the increased use of activity-based hospital reimbursement, the increasing use of private health insurance and private hospitals, and a shift from in-patient to out-patient activity. A maximum waiting time for diagnosis is currently being contemplated. The waiting time experienced for surgery has been reduced from about 12 weeks in 2001 to 7.6 weeks in 2011.

    • Finland

      A National Health Care Guarantee was introduced into Finnish law in 2005. The guarantee defines maximum waiting times for hospital and primary care services, including dental care. To support the guarantee, uniform grounds for access to non-emergency care were introduced.After the establishment of the guarantee, waiting times for hospital care have become shorter, although the development has been bumpy and characterised by a rubber band phenomenon. The Supervisory Agency has given several hospital districts that failed to comply with the guarantee orders to improve, often accompanied by the threat of penalty fines. Consequently, waiting times have shortened considerably, but the situation deteriorated again when the threat of fines was removed. Regional variations in accessibility still exist.Research is limited as to the broader range of consequences of the guarantee, e.g. whether resources have been allocated from chronic patient groups in need of repeated hospital care to patients to be admitted for the first time. The economic consequences of the reform have not been calculated in detail.The observed reductions in waiting times may partly be explained by other parallel trends in the health sector, e.g. increased diversity in the production of services and increasing freedom of choice.

    • Ireland

      Long waiting times to access health services have characterised the Irish health sector from the early 1990s. These waiting times may in part arise from the complex interaction of public and private finance and delivery that is characteristic of the Irish health services. The major policy initiatives implemented to reduce waiting times have been in the form of additional dedicated funding. Maximum waiting time targets were also introduced, but these were not accompanied by penalties for non-fulfilment. While the first major policy initiative – the Waiting List Initiative – granted additional funding to public hospitals, its successor – the National Treatment Purchase Fund – instead channelled funding predominantly to private hospitals. Recently, a new Special Delivery Unit has been established in order to reduce waiting times for scheduled and unscheduled care in Irish hospitals by adopting an approach based on performance management and capacity building.

    • Italy

      In Italy, waiting time is a critical issue for out-patient specialist care and diagnostic services, and it is being tackled by national plans issued in the last decade. Most regions improved patients’ access through better information on waiting times, process re-engineering and the creation of unified booking centres. In addition, important prioritisation criteria have been piloted to manage waiting time based on clinical criteria and professional judgment (for example, the Homogenous Waiting Groups pilots). However, actual policies, including the implementation of national legislation, vary across the regions, with some of them very active and others often lagging behind. Policies on co-payments, intramoenia dual practice and voluntary insurance also have substantial effects on waiting time. National and regional co-payments have likely reduced waiting time via the reduction of demand for national health services, but rather broad exemption criteria have limited their effect on the more affluent and healthier part of the population. The expansion of intramoenia dual practice and the promotion of additional private health insurance could undermine access to the NHS basic health care package: the former may encourage doctors to build up long lists in their public practices so as to maintain demand for their private practice, whereas the latter may worsen equity of access to the NHS services.

    • The Netherlands

      In the Netherlands, hospital waiting times increased during the 1990s as a result of the introduction of fixed budgets and capacity constraints for specialists, complementing the fixed global hospital budgets already introduced in the 1980s. Though the resulting waiting lists were still small compared to other OECD countries, public discontent initiated government action. Over the years 2000-11 policies included a change from fixed budgets to activity-based funding, for both hospitals and specialists, and increased competition among hospitals. All together these measures resulted in a strong reduction of waiting times. In 2011, mean expected waiting times for almost all surgical procedures were below five weeks, which is well under the generally agreed norm of 6-7 weeks. Waiting lists are thus no longer an important policy concern. Dutch policy makers are now primarily concerned about the rapid growth in health care expenditure as a result of a combination of hospitals’ and specialists’ incentives for extra production and insurers’ limited countervailing power. Hence, new powerful supply-side constraints are being introduced in 2012. These constraints may cause waiting times to increase in the coming years, especially for more complex surgical procedures that are subject to price regulations.

    • New Zealand

      Long waiting lists, and hence long waiting times, for elective surgery have been a key feature of the New Zealand health system for many years. During the past 18 years, New Zealand governments have implemented a formal set of priority setting policies for elective services, prioritising which patients can be treated within available resources in a timely way. This chapter reflects on these policies, identifying failures and successes and key issues for the future. The chapter emphasises the need for the country’s governments to ensure overall equity of access to elective services, a major policy goal that is yet to be achieved. There is also a need to improve our understanding of the performance of priority setting tools through further research and evaluation, and to provide further information publicly on how the priority-setting system for elective services actually works and the implications of current policy settings for New Zealanders’ overall access to elective services. This is particularly important given the lack of available information on how many patients miss out on care altogether and what happens to their quality of life as a result.

    • Norway

      Norway has a predominantly public health care sector. Municipalities have the responsibility for primary care, while specialist health care is organised in regional health authorities owned by the central government. These regional authorities are responsible for specialist health care for the population in their catchment areas, and they own the main providers. There is a system of referral to specialist care, with primary care physicians as gate keepers. The reduction of waiting times in specialist health care has been considered a major political challenge. National guidelines have been developed, which stipulate maximum medically acceptable waiting times for the patients for a range of diagnoses. These vertical and individualised prioritisation rules make the Norwegian system for waiting time regulation quite unique. The chapter details the organisation of the health care sector, and we report some results from empirical analyses of developments in waiting times for specialist health care.

    • Portugal

      Waiting lists and waiting times have been an issue for the Portuguese National Health Service (NHS) for a long time. Over the years, several special programmes have attempted to solve the problem. But only after 2005, with the creation of the SIGIC, a waiting time and waiting list management system, do we observe a consistent decrease in waiting times for surgical intervention. The new management system is based on a centralised electronic platform and on a set of rules that allows patients to move within the health system. It also allows for activity-based funding at the margin for hospitals that show the ability to treat more patients in waiting list. Target (maximum) waiting times were set from the start, and then updated to more demanding values after three years of operation. The SIGIC system allows the transfer of patients to another hospital (either public or private) when 75% of the maximum waiting time is reached. The creation of the IT platform on a centralized basis, under a unified set of rules and procedures and with direct access to hospital data, was key to ensuring a detailed knowledge of waiting lists and waiting times across providers, across procedures and across time. This also allowed for more detailed information to be provided to patients (who now have a frequently updated estimate of the likely moment of intervention). The SIGIC has provided a solution for the problem of excessive waiting times whereas earlier programmes that simply provided additional funds for additional activity had failed.

    • Spain

      This chapter first reviews the criteria for managing health care waiting lists in Spain and the country’s experience with them. We then consider challenges to the management of health care delivery, and suggest some key issues for policy discussion and the notion of what a waiting list actually is. Data is provided to ascertain the scale of the waiting lists and times, including for comparative purposes. The chapter critically evaluates the policies in place and contains some suggestions for policy reform.

    • Sweden

      Waiting times have been a salient problem in the Swedish health care system since the 1980s. Various initiatives have been taken at the national level since then to come to terms with this problem. The most prominent initiative has been the implementation of waiting time guarantees that set out specific time limits within which patients are to be treated. The last two decades display a pattern of temporarily reduced waiting times due to the guarantees. However, the current guarantee, designed in 2005, seems to have had a more positive, long-term effect on waiting times. More patients than before are receiving treatment and surgery within 90 days. The current guarantee, which was made statutory in 2010, is economically supported by the Queue Billion programme. The economic policy tools were weaker for the earlier guarantees, whereas the Queue Billion provides clear economic incentives for the individual clinics to cut waiting times. There is, however, a need for more thorough research to assess the causal mechanisms behind the reduced waiting times. Economic incentives, administrative interventions such as cleaning the waiting lists, and the purchase of services from other producers are mentioned in some counties as causes of the improvements.

    • United Kingdom

      Waiting times for elective hospital treatment have traditionally been a very high political priority in the United Kingdom, and there have been numerous initiatives over the last twenty years designed to tackle them. The most successful was the system of waiting time targets, under which all National Health Service organisations were given very clear maximum waiting times.In England in 2009, a new NHS Constitution established a guarantee of a maximum wait of 18 weeks from initial referral to a specialist until eventual treatment. This has been accompanied by a shift of emphasis away from centrally specified targets towards patient choice.Scotland performs well in comparison to the other countries of the United Kingdom, but recent relaxation of the zero-tolerance approach to violations of the targets has been associated with deteriorating waiting times performance. Frequent revisions of the measurement of waiting times and the publication of increasingly complex statistics on performance make it difficult to track consistent trends. The ultimate aims of waiting times policy in Scotland have not been evaluated.

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