Workshop Rs Transportasi Pasien

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 Date: 061109 Status: Final

Version: 1 Page: 1 of 78 Intended Audience: WAG
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.

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.

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.
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.

1 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 Assembly 5. 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 2004 6
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 Europe 3;
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.

2 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 UK 11. 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 waiting 12 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
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 established 7, 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.
4.5 Wales Audit Office report on waiting times

By 2005, the Wales Audit Office report on waiting times 5 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 Wanless 21 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 established 8 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 NPHS 24, 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 report 25 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 targets 26. 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
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 report 30 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 delivery 32 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
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
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
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. OECD 3 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. Sanmartin 42 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 socio-
economic 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 cross-
sectional 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 al 44, who
looked specifically at cataract surgery waits. They found waits of three months or less

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

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. Lewis 60 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 McPherson 62 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 study 63 where mortality
was 35% lower from coronary heart disease in participants who took their placebo
versus those who did not. He discusses a recent study 64 where the treatment effect
for patients randomised to their preferred treatment were greater than in those
indifferent to treatment assignment.
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
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 study 65 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 fractures 67 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 study 68 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 management 69 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 study 70,
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 review 71 of surgical
interventions for disc prolapse indicated that discectomy produced better outcomes
than placebo but only four trials had compared discectomy with conservative
management. The authors conclude that discectomy for carefully selected patients
provides faster relief than conservative treatment

Another prospective cohort study on hip arthroplasty 72 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

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 waiting 37. 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. Oudhoff 37 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.

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.
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 socio-
economic 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
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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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 2000- 2009

 Definition and use of Waiting times/
waiting lists – sometimes ambiguous.
 Databases use different terms around
some concepts e.g. outcome
Waiting Lists
MESH 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

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 Assessment
database
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 & Health care
libraries[Voyager]
JBI-connect

Map of Medicine
National Library for Health
Guidelines finder
NICE
Government bodies/Official
documents
1000 lives campaign
Audit Commission
Centre for Change & Innovation
Department of Health & Social
Services & Public Safety [DHSSPS-
NI] 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 Health Dept.
[SEHD]
Welsh Affairs committee
Welsh Audit Office
WHO
Specialist web sites/Research departments

AWARD
Health Foundation
Health Services Management
Centre[Birmingham]
Institute or Healthcare Improvement
King’s fund
MRCT
NCEPOD
Nuffield Trust

Picker Institute
Sheffield Research – Emergency
care
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 Waiting times and performance
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 Yes [WaitListHealthGain]
databases]
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
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 & 5135
Numerical Data, Organization & Administration, Ethics, Standards,
Trends, Economics]
3 *Health Care Rationing/mt, ut, es, og, sn, ec, st, td [Methods, 1423
Utilization, Ethics, Organization & Administration, Statistics &
Numerical Data, Economics, Standards, Trends]
4 waiting times.mp. 1402
5 early treatment.mp. 5081
6 *Time Factors/ 260
7 exp *"Patient Acceptance of Health Care"/ 34696
8 exp *Morbidity/ 1429
9 exp Morbidity/ 185002
10 exp *Mortality/ 15950
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, 4494
ec [Methods, Standards, Utilization, Organization &
Administration, Trends, Statistics & Numerical Data, Economics]
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 135

evaluation studies or government publications or meta analysis or
multicenter study or randomized controlled trial or "review" or
validation studies)
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 99

comparative study or controlled clinical trial or evaluation studies
or meta analysis or multicenter study or randomized controlled trial
or "review" or validation studies)
30 limit 29 to yr="2000 - 2009" 85
31 from 30 keep 4-5, 9-10 4
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 5621

admissions management/ or exp patient waiting time/ or exp
waiting list admissions/ or exp waiting list reductions/
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 195

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
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 85

Appendix 2- Evidence levels (Modified from NICE Guideline

Methodology Manual)
Level of Evidence
Type of evidence
1++ 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

National Public Health Service for Wales Potential health effects of recent national waiting
times initiatives in Wales – a rapid review of the
evidence (Draft)
Appendix 3 Evidence table
Study Population / Setting Intervention / Aim Outcomes Results Design Evidence

level
1. Welsh Assembly Wales NHS, Policy In 1999, 1356 pts waiting over 18/12, April Strategic 4
Government. An orthopaedic 2004 9 pts, however number waiting for 1st document/
orthopaedic plan for services outpatient appt has risen. Says committed expert opinion
Wales Getting Wales substantial funds for SE Wales as waits are
moving. Cardiff: WAG; longest. Identified an activity/capacity gap and
2004 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
Author: Geri Arthur Specialty Registrar Date: Status: Draft

Version: 0a Page: 38 of 78 Intended Audience:
evidence (Draft)

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.
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.
2. Welsh Assembly NHS Wales Not applicable Not Significant challenges for NHS Wales in Policy -
Government. 2009 applicable delivering the 2009 access targets. These are:
Access project.  Continuing to implement good practice
WHC(2005)98. Cardiff: across the whole patient pathway, thus
WAG; 2005 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

evidence (Draft)

level
 Ensuring there is a robust performance
management and support framework in place.
3. Hurst J, Siciliani L. OECD countries Comparison of  At worst waiting times can lead to Expert opinion 4
Tackling excessive waiting time deterioration in health, loss of utility and extra
waiting times for elective policies in cost
surgery: A comparison of OECD countries  Waiting times tend to form in countries
policies in twelve OECD which combine public health insurance and
countries. Paris:OECD; constraints on surgical capacity
2003  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
4. Jowell R et al. British UK Not applicable Looks at a  Waiting for specialist assessment and Survey -
social attitudes survey. range of waiting for elective surgery are considered to (3600
Focussing on diversity. opinions be the first and second most important NHS respondents a
The 17th report. London: failings year)
Sage Publications Ltd;
2001.
5. Auditor General for Waiting times of Not applicable -  Wales spends more than England per head Audit 3/4
Wales. NHS waiting patients in Wales on health but Welsh have to wait longer for
times in Wales. Cardiff: appointments. In June 2004, 7,105 patients
NAO Wales; 2005. 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
evidence (Draft)

level
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

evidence (Draft)

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 Europe Assess public’s In early 2004, the Stockholm Network Survey / expert -
Institute, Impatient for opinions about commissioned Populus to survey the views of opinion
change: European healthcare 8,000 citizens across Britain, the Czech
attitudes to healthcare Republic, France, Germany, Italy, the
reform.2004. Cited in: Netherlands, Spain and Sweden. Our aim was
Auditor General. NHS to get a representative
waiting times in Wales. geographical sweep of opinion about the future
Cardiff: NAO Wales; of healthcare and what Europeans really
2005 understand by terms commonly

evidence (Draft)

level
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.
7. Welsh Assembly NHS Wales Not applicable Guidance on amendments to ‘Second offer’ Policy -
Government. Improving scheme document
patient access – 2nd offer
scheme.
WHC(2004)015. Cardiff:
WAG; 2004.
8. Welsh Assembly NHS Wales Not applicable The Delivery and Support Unit (DSU) Policy -
Government. The introduced to support organisations that are document
Introduction of the experiencing difficulty in delivering targets or
delivery and support unit sustaining expected levels of performance
into NHS Wales. services they deliver. The
WHC(2005)097. Cardiff: DSU resources are finite and it will concentrate
WAG; 2005 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.
9 Public Health Not applicable Not applicable Not Tools designed to help critically appraise Not applicable -
evidence (Draft)

level
Resource Unit. Appraisal applicable research as part of the Critical Appraisal Skills
tools. Website. [online]. Programme
10. Department of UK NHS Not applicable Not Public wanted to see: Strategic -
Health. The NHS plan: a applicable • more and better paid staff using new ways of document
plan for investment, a working
plan for reform. London: • reduced waiting times and high quality care
DOH; 2000 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.
11. King’s Fund. UK NHS To isolate the Work is in 3 parts Review/ Expert 4
Sustaining reductions in factors which  Sustaining reductions in waiting time- opinion
waiting times: identifying lead to identifying successful strategies
successful strategies. sustainable  The impact of waiting times targets on
London: King’s Fund; reductions in clinical treatment priorities
2005. waiting times  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
12. King’s Fund. An UK NHS Assess whether  Targets met on spending, with large Audit/review 4
independent audit of the the Labour increases in investment but queries over

evidence (Draft)

level
NHS under labour government has productivity
(1997-2005). London: delivered targets  Achieved huge progress in waiting lists and
King’s Fund; 2005 and reforms 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
13. Welsh Assembly Paul Williams report, follow-on to the Capacity Minutes of -
Government. Update on Working Group Report published in 2000. The meeting
action to reduce hospital key themes: of report were:
waiting times and  The need for a whole systems approach to
pressures on the NHS. deal with demand and the tensions between
Cardiff: WAG; 2002 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%.
evidence (Draft)

level
 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.

evidence (Draft)

level
14. Welsh Assembly NHS Wales Not applicable The Plan is written against a background of an Policy -
Government. Improving increase in health funding; the document document
health in Wales. A plan states that the Welsh
for the NHS with its Assembly’s budget provides a 7.7% increase
partners Cardiff: WAG; in health funding for 2001-02 with further
2001 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.
15. Welsh Assembly Not applicable Not applicable "Waiting lists are heavily influenced by the Press release
Government. New decisions of those responsible for referring and
waiting times strategy treating and at any time can include both
announced by Jane Hutt. people who do not need care and omit others
Press release 12th Jul who do. If performance is measured solely on
2001 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
evidence (Draft)

level
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
16. Edwards, B. Gwent, Wales, To review  Current lists in Gwent too long – up to 3 Expert opinion 4
Review of orthopaedic orthopaedic functioning of years.
services in Gwent. A services orthopaedic  Patients being added to lists quicker than
report to the Welsh services in they are seen – getting worse
Gwent  Not enough capacity to handle future
Assembly. Cardiff:
WAG; 2003 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:
evidence (Draft)

level
 Tighter management of wait list and
services e.g. theatres
 Capacity issues addressed
17. BBC News. Foreign A Welsh health trust has apologised after a News story -
surgeons’ letter row. letter, apparently from a surgeon, warned
Tuesday 7th Dec 2004 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 Weston-
super-Mare.
Only five of 73 patients later turned up for
appointments.
18. Welsh Assembly Not applicable Not applicable Patients from South Wales who underwent News story
Government. Review knee surgery at Weston were offered
of knee surgery carried reassurances following a review of their
out under the second treatment.
More than 600 patients were sent to Weston
offer scheme in the
NHS Treatment Centre for orthopaedic surgery
NHS Treatment under the Second Offer Scheme, a Welsh
Centre, Weston. Assembly Government policy which allowed
Cardiff: WAG; 2007 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
19. Welsh Assembly NHS Wales Not applicable Report recommended that all patients who Cabinet -
Government, 31st Jan were sent to Weston for knee surgery under statement
2007. Oral – Second the second-offer scheme should have their x-
Offer Scheme At Weston rays reviewed. As a precaution, the second-

evidence (Draft)

level
Area NHS Trust. offer team has also decided that all patients
Available at: who went to Weston for orthopaedic surgery of
http://new.wales.gov.uk/a any sort should have their x-rays reviewed.
bout/cabinet/cabinetstate While the only concerns to date relate to knee
ments/2007/1226567/? surgery, all patients who have had joint surgery
lang=en [Accessed on at Weston will be offered a radiological review.
22nd April 2009] Approx 384 patients have been referred for
knee surgery, 157 for hip surgery and 152 for
other orthopaedic procedures.
20. Welsh Assembly Wales NHS, Policy document  Plan to change orthopaedic services and Strategic 4
Government Oral – orthopaedic deliver improved access over the next 10 document/
second offer scheme services years. expert opinion
at Weston Area NHS  Background: Continual reductions in
Trust. Cabinet orthopaedic waiting times targets in England
statement 31st Jan and a recent European Court ruling on undue
delay provide further imperative.
2007.
 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

evidence (Draft)

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 To examine how “Current position in Wales is worse than in the Expert opinion 4
Government. The resources can UK as a whole, reflecting trends evident over
review of health and be transformed decades.
social care in Wales. into reform and Wales does not get as much out of its
improved spending as it should; in health, for example, it
The report of the
performance now places unsustainable pressure on its
project team advised acute sector.
by Derek Wanless. The impact extends into social care. Long
Cardiff: WAG; 2003 hospital waiting lists and assessments
without subsequent social service provision are
the unacceptable consequences and are
symptoms of the deep underlying problems

evidence (Draft)

level
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”.
22. Welsh Assembly Not applicable Not applicable Designed for life distinguished five groups of Policy -
Government. people within the general population and four document
Designed for life: levels of care to address the needs of these
creating world class groups.
Community services were to be greatly
health and social care
strengthened and the primary care team
for Wales in the 21st extended, it stated that: “to continue the
century. Cardiff: WAG, wholesale transformation of services and their
2005 delivery, a new and effective planning system
for health and social care is required”.
23. Whitfield J. Why UK NHS Assess  Feels that Wales NHS looks like England’s Expert opinion 4
more than one in 10 differences would have done without targets
people in Wales are between English  In terms of performance Wales and England
waiting for treatment. and Welsh NHS are diverging
HSJ 2004; II4:10-11  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

evidence (Draft)

level
states that capacity is not the issue, but rather
that the existing capacity is under chronic
unnecessary pressure.
24. National Public Orthopaedic Horizon -  Demand for orthopaedic services is rising in Literature 2/3
Health Service for Wales. interventions scanning Wales as the population ages review
Access project 2009: focussing on exercise in  NHS capacity is increasing but there is a
predicted future changes Wales relation to long backlog of activity
in orthopaedics in Wales. predicting  Orthopaedic services vary n terms of
A horizon scanning changes in organisation and efficiency
exercise. Cardiff: NPHS; orthopaedic  Predicting the future of orthopaedic services
2006 demand and is complex
management  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
25. Auditor General for Follow up to Not applicable -  Found that the NHS in Wales had made Review/ expert 4
Wales. NHS waiting earlier waiting considerable progress in reducing long waits opinion
times: follow-up report. times report to and addressing their causes within a clear
Cardiff: NAO Wales; review progress strategic context. And there are important
2006 known risks that need to be addressed to
deliver the ambitious 2009 target and sustain
performance thereafter.
evidence (Draft)

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. UK NHS trusts Further  Found that 9 English NHS trusts Audit/expert 4
Inappropriate assessment of inappropriately adjusted their waiting lists opinion
adjustments to NHS accuracy and affecting nearly 6000 patients
waiting lists. London: management of  In 5 trusts, issues only came to light
The Stationery Office; waiting lists in following patient, health authority, MP
2001 trusts previously complaints or adverse publicity. 4 trusts self
identified as identified
having made  4 trusts held an internal enquiry and 5 an
inappropriate external inquiry
adjustments  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 re-
employed within the NHS, only one case had
their compensation clawed back as a result
27. Auditor General for Wales NHS Assess usage of  Where appropriate DS delivers benefits for Audit/ expert 3/4
evidence (Draft)

level
Wales. Making better day surgery patients undergoing elective surgery reduces opinion
use of NHS day surgery ALOS, lowering costs to NHS and risk of HAI.
in Wales. Cardiff: NAO Rates in Wales lower than England and much
Wales; 2006. 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.

evidence (Draft)

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 Wales NHS Not applicable  March 2005 the First Minister Policy -
Government. Access announced that by December 2009, no patient document
2009. Delivering a 26 in Wales will wait more than 26 weeks from
week patient pathway. GP referral to treatment, including waiting for
WHC(2006)081. Cardiff: diagnostic tests and therapies.
WAG; 2006  12 months by March 20056
. 8 months March 2007
 Currently WAG report waiting times
separately for outpatients, inpatients, day-
evidence (Draft)

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, non-
obstetric ultrasounds, SALT
29. 2009 Access Project NHS Wales Not applicable The framework covers: Policy -
Team Delivery Support  Tackling waiting times document
Unit, Health and Social  The challenge of achieving the pathway
Services Department  The principles and definitions covering the
Welsh Assembly pathway, including the interim targets to be
Government. Delivering achieved
a 26 week patient  The implementation strategy
pathway. An
implementation
framework. Cardiff:WAG;
2006
30. Auditor General for NHS Wales Assess impact -  The direct cost of bed days occupied by Audit / expert 4
Wales. Tackling delayed of work on DToCs across Wales was £69 million in 06/07, opinion
transfers of care across delayed at marginal cost up to £27 million could be
the whole system – transfers of care released.
Overview report based (DToC) in  There are local agreements which lead to
on work in the Cardiff named regions undercounting of DToCs.
and vale of Glamorgan, of Wales  Delays in restarting care packages that
Gwent and were frozen on admission
Carmarthenshire health  Problems in determining eligibility for CHC,

evidence (Draft)

level
and social care causing tension between health and social
communities. Cardiff: care.
NAO Wales; 2007.  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
31. Auditor General for NHS Wales Follow-up on  Seminar in Nov 2008, attendees from Re-audit -
Wales. Delayed previous report Cardiff, Vale of Glamorgan & Gwent with
transfers of care follow on delayed external speakers from Scotland & England.
through. Cardiff: NAO transfers of Concluded that there has been positive
care. progress which can only lead to sustainable
Wales; 2009
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

evidence (Draft)

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 NHS Wales Implementation  Analysis of backlog shows that approx Strategic -
Government. Access of the Access 39,000 additional outpatients will need to be document
project, 2008. Integrated 2009 aims seen and 7,000 additional inpatient /DC
delivery and compared to 2007/8. Orthopaedics and ENT
implementation plan. A have the greatest OP volumes with
framework for delivery orthopaedics, ophthalmology and gynaecology
2008/09. WHC (2007)51. requiring the highest levels of inpatient/DC

evidence (Draft)

level
Cardiff: WAG; 2007 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
evidence (Draft)

level
33. Welsh Assembly Wales Not applicable Not  Labour and Plaid Cymru formed a coalition Strategic -
Government. One applicable government and produced a joint manifesto document
Wales: A progressive document. Chapter dealing with health stated
agenda for the that there would be a moratorium on existing
government of Wales. proposals for change at community hospital
An agreement between level and that district general hospital service
the Labour and Plaid changes would not be implemented until all
Cymru Groups in the relevant associated community services were
National Assembly. in place.
Cardiff: WAG, 2007  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.
34. Greer S. Devolution UK NHS Explores how Author sees Wales as most radical innovator, Expert opinion 4
and divergence in UK political variation concentrating on public health. Focussed on
health policies. BMJ n the UK nations health not the NHS. Local government more
2009: 338:78 has led to influential than elsewhere. Feels policy limited
differences in by localism and fragmentation.
health systems 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

evidence (Draft)

level
directions with ever more distinct working
cultures.
35. Godden S, et al. UK NHS Description and - Issues identified in relation to: Review 4
Waiting list and waiting evaluation of  Data quality: determines who appears on
time statistics in Britain: data used to list
a critical review. Public compile waiting  Omissions and exclusions: statistics
Health 2009;123: 47-51 list information 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.
36. Martin RM et al 2003. NHS hospital Investigate Number of  Between 52-83% of patients waiting longer Routine data 2-/3
NHS waiting lists and trusts in England, national people than 6 months were found in 25% of the trusts analysis
evidence of national or patients waiting distribution of waiting  There was little evidence to show that
local failure: analysis of for general, ENT, waiting and longer than 6 capacity or private sector activity were
health service data. BMJ ophthalmic or association with months, associated with longer waits
2003; 326: 188-98. trauma and markers of NHS characteristic  Increased waiting with increased numbers
orthopaedic capacity, activity s of trusts of anaesthetists
surgery in private sector with large  Markers of deprivation were inversely
and need numbers associated with long waits
waiting
37. Appelby J. Cutting UK NHS Research Factors which emerged as important in Expert opinion 4
NHS waiting times: summary of sustaining reductions:
identifying strategies for recent King’s  A sustained focus on the task,
evidence (Draft)

level
sustainable reductions. Fund work on organisationally and through management and
London: King’s Fund; waiting clinical effort
2005  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
38. Besley T, Bevan G, UK NHS Compare impact  Prior to 2001 England and Wales had Case 3/4
Burchardi K. of waiting time similar policies study/expert
Accountability and policies in  After 2001, English hospitals that failed to opinion
incentives: The impacts England and meet targets were ‘named and shamed’
of different regimes on Wales  In Wales failure was perceived to bring
hospital waiting times in extra resources
England and Wales.  Waiting times in England did reduce in
London: London School comparison to Wales
of Economics; 2008.  Some evidence in England of shuffling
patients to meet targets which may increase
mean waits
39. Siciliani L, Hurst J. OECD countries Comparative  Not all OECD countries report significant Comparative 3
2004. Explaining waiting- analysis of two waiting times study
time variations for country groups.  Negative association between waiting times
elective surgery across One group using and capacity
OECD countries. policy to  Higher level of health spending is
DELSA/ELSA/WD/HEA( address systematically associated with lower waiting
2003)7. Paris: OECD; concerns, other times
2003 not  Availability of doctors most significant
negative association with waiting
 Low availability of acute care beds
evidence (Draft)

level
significantly associated with waiting
 Activity based funding in hospitals may
reduce waits
40. Kreindler SA. Health systems Investigating Need to address the root causes of waiting, Literature 3
Watching your wait: effective usually poorly designed systems rather than review
evidence-informed strategies to an absolute lack of capacity. The 7 problems
strategies for reducing manage waiting identified were:
health care wait times. lists  Too much complexity in the booking process
Qual Manag Health Care  Inefficient methods of scheduling patients
2008; 17:128-35  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
41. Derrett S, Paul C, People on waiting Describe Assessment  Participants had more sever symptoms and Cross- 2-
Morris JM. Waiting for list for experiences of of severity of poorer quality of life than the general New sectional
elective surgery: effects prostatectomy or those waiting for condition and Zealand population
on health related quality hip or knee joint admission for opinions  Condition specific or general quality of life
of life. Int J Qual Health replacement in elective surgery about waiting did not deteriorate during wait
Care 1999; 11: 47-57 Otago region  People with more severe symptoms desire
New Zealand surgery faster
 Lengthy waiting for surgery represents a
burden in terms of living with symptoms and
poor quality of life
42. Sanmartin C, Respondents to a Identification of  Between 17 and 29% of patients felt their Survey 2-/3
Bertholet J-M, McIntosh national survey the wait was unacceptable
CN. Determinants of on who had determinants of  Most individuals waited less than 3 months
evidence (Draft)

level
unacceptable waiting accessed unacceptable  Between 10-19% indicated waiting had
times for specialized specialist waits for affected their lives
services in Canada. services in specialised  Longer waits or an adverse event while
Health Policy 2007; 2: Canada healthcare waiting were significantly associated with
e140-54. 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
43. Oudhoff, JD et al, Patients in Assess the Quality of life,  In each group the waiting period involved Cross 2-
2007. Waiting for elective surgical impact of general worse general health perceptions, quality of sectional
general surgery: impact departments of waiting for health life problems, and raised anxiety levels as questionnaire
on health related quality 27 general elective surgery perceptions, compared to after surgery and post-op
of life and psychosocial hospitals across psychological  Emotional reactions were most negative to follow up
consequences. BMC the Netherlands consequence waiting in those with gall stones
Public Health 2007; 7: s, social  Prior information about the wait duration
164. consequence reduced negative reactions
s, waiting  Social activities were affected in 39-48% of
time patients
 18-23% of employed patients reported work
problems during the wait
 Quality of life was not affected in 18-23% of
patients
Europe Assess the  Anticipated wait time is strongest predictor Prospective 2-

44. Dunn E et al. acceptability of of patients tolerance for wait cohort
Patient’s acceptance of wait times to  Patient dissatisfaction increased with the
waiting for cataract patients in duration of anticipated wait
evidence (Draft)

level
relation to  Patients were accepting of waits up to 3
surgery: what makes a cataract surgery months and considered waits in excess of 6
wait too long? Soc Sci months excessive
Med 1997; 44:1603-10  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. Studies on To assess the -  Patients experience a significant Systematic 1+
2008. A systematic waiting for relationship deterioration in health related quality of life review
review of the effect of treatment on between waiting and psychological well-being during the 6
waiting for treatment for chronic pain times, health months from referral to treatment
chronic pain. Pain 138: status and  Unknown at what point deterioration begins
97-116 health outcomes as results mixed but some as low as 5 weeks
 Concluded that waits in excess of 6 months
were unacceptable
46. Sampalis J et al. Patients Assess impact Quality of life,  Patients waiting longer than 97 days or Prospective 2-
Impact of waiting time on registered for on quality of life pain, more had significantly reduced physical cohort
the quality of life of coronary bypass of patients frequency of functioning, vitality, social functioning and
patients awaiting grafting from 3 waiting for symptoms, general health
coronary artery bypass hospitals in coronary bypass rates of  At 6 months post-surgery, those who waited
grafting. CMAJ 2001; Montreal, Canada grafting complications >97 days had reduced physical functioning,
165: 429-33 , death 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

evidence (Draft)

level
47. Bell D et al, 2006. Studies and To assess if Post-  Limited evidence on median wait, one study Systematic 1+
Does prolonging the time guideline waiting time for operative in UK showed 30 days from GP referral review
to testicular cancer /consensus testicular cancer clinical  National and international guidelines
surgery impact long-term documents that surgery affects outcomes recommend a maximum wait of between 2 -4
cancer control: a evaluated wait long-term including weeks for all cancer surgery
systematic review of the time for testicular cancer control survival  Epidemiological evidence unclear in terms
literature. Can J Urol cancer surgery of surgical delay and overall survival
2006; 13: Suppl 3:30-6
48. Saad F et al. Does Studies and To assess if Post-  Median wait times varied from 42 days to Systematic 1+
prolonging the time to guideline waiting time for operative 244 days review
prostate cancer surgery /consensus prostate cancer clinical  National and international guidelines
impact long-term cancer documents that surgery affects outcomes recommend a maximum wait of between 2 -4
control: a systematic evaluated wait long-term including weeks for all cancer surgery
review of the literature. time for prostate cancer control survival  Epidemiological evidence unclear in terms
Can J Urol 2006; 13: cancer surgery of surgical delay of 3 months or more and
Suppl 3:16-24 effect on PSA recurrence free survival
49. Jewett M et al, 2006. Studies and To assess if Post-  Median wait times varied from 26 days to 82 Systematic 1+
Does prolonging the time guideline waiting time for operative days review
to renal cancer surgery /consensus renal cancer clinical  National and international guidelines
affect long-term cancer documents that surgery affects outcomes recommend a maximum wait of between 2 -4
control: a systematic evaluated wait long-term including weeks for all cancer surgery
review of the literature. time for renal cancer control survival  There were no epidemiological studies
Can J Urol 2006;13 cancer suregry evaluating the association between surgical
:Suppl 3: 54-61 delay and clinical outcome
50. Fradet Y et al, 2006. Studies and To assess if Post-  Median wait times varied from 29 days to Systematic 1+
Does prolonging the time guideline waiting time for operative 164 days review
to bladder cancer /consensus bladder cancer clinical  National and international guidelines
surgery affect long-term documents that surgery affects outcomes recommend a maximum wait of between 2 -4

evidence (Draft)

level
cancer control: a evaluated wait long-term including weeks for all cancer surgery
systematic review of the time for bladder cancer control survival  Mixed results on the effects of delayed
literature. Can J Urol cancer surgery
2006; 13: Suppl 3: 37-47  Studies that looked at a 3 month delay and
tumour grade showed a poorer tumour grade
51. Anon. Waiting, quality Commentary on Not applicable Comments that studies on the effects of Expert opinion 4
and outcome. Bandolier 47 – see above waiting time appear to be rare. An ethics
2001; 8(11). 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
52. Anon. Testing the Commentary on Assess effect of Study One Expert opinion 4
two-week rule. an audit on Department of  Before guidelines almost every case was an based on an
Bandolier 2006. patients from Health urgent referral (98%) audit and a
Nottingham with guidelines on  After the guidelines, 60% were under the systematic
lung cancer two week two week wait rule and 40% were urgent, review
Commentary on cancer referral  Referrals increased substantially but
systematic review detected cancers did not
on effectiveness  Times between referral and diagnosis and
of two week wait treatment were the same or worse
rule for colorectal Study Two
cancer referrals  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
Concludes that neither study show
evidence (Draft)

level
improvement caused by two week rule
53. Lewis NR, Le Jeune Patients in Examine  Before guidelines almost all cases were Audit 3/4
I, Baldwin DR. 2005. Nottingham referrals before urgent referrals
Under utilisation of the 2- referred with and after the  After guidelines this was 60% as a two
week wait initiative for suspected lung Department of week referral, 40% as urgent
lung cancer by primary cancer Health  The number of referrals increased, the
care and its effects on guidelines on number of cancers detected and the stage at
the urgent referral cancer referrals which they were detected did not change
pathway. Br J Can 2005;  Time from referral to diagnosis and
93:905-8. treatment was the same or increased
54. Thorne K, Hutchings Studies of To assess Number of  Overall 12% of patients referred had cancer Systematic 2-
HA, Elwyn G. The effects patients referred impact of two cancers detected review
of the two-week rule on for possible week cancer detected,  Of those referred under the two week rule
NHS colorectal cancer colorectal cancer referral rule stage of 10% had cancer detected
diagnostic services: a between 200 - cancer,  Most patients were seen by a hospital
systematic literature 2003 length of wait specialist in under two weeks
review. BMC Health Ser  No difference in staging of cancer
Res 2006; 6: 43. dependent on method of referral
55. Potter S et al. All patients To assess the Number,  Annual number of referrals increased by 9% Prospective 2+
Referral patterns, cancer referred to a long term impact route, over 7 years cohort
diagnoses, and waiting Bristol breast of the two week outcome of  Routine referrals decreased by 24%
times after introduction of clinic between wait rule for referrals from  2 week wait referrals increased by 42%
two week wait rule for 1999 and 2005 breast cancer primary care,  Percentage of patients diagnosed with
breast cancer: referral patterns waiting times cancer in the two week wait group decreased
prospective cohort study. for routine from 12.8% to 7.7%
BMJ 335; 288. and urgent  Number of cancers detected in routine
appointments group increased from 2.5% to 5.3%
 27% of patient with cancer are currently
evidence (Draft)

level
referred in the non-urgent group
 Waiting times for routine referral have
increased over time
56. Feldman, R. The cost Healthcare To assess two Costs  ‘Complete insurance corresponds to US Economic 3/4
of rationing medical care provision methods of model. Rationing by waiting corresponds to analysis/
by insurance coverage reducing risk in UK model. Expert opinion
and by waiting. Health relation to  First system may lead to over utilisation of
Econ 1994; 3: 361-72 purchase of resources which is not offset by
medical care. underutilisation of the uninsured
First is  The latter model has been estimated to cost
’complete between $541 - $828 per family in 1984
insurance’ and dollars.
the second  Both systems result in costly mis-allocation
rationing by of resources
waiting time
57. Gravelle H. 2008. Is Healthcare To assess the Investigates whether prioritisation is welfare Economic 3
waiting-time prioritisation optimal way to improving when benefit of treatment is made model
welfare improving? use waiting up of 2 components, one of which is not visible
Health Econ 2008; times to allocate to the healthcare provider.
17:167-84 a fixed supply of Study indicates that prioritisation (shorter waits
treatment for higher benefit) is welfare improving in some
scenarios
58. Quan H, La Freniere Patients from To assess if the Costs  Median wait for joint surgery was longer Retrospective 2-
R, Johnson D. Health Calgary regional cost of heath than for other disciplines cohort study
service costs for patients health authority services a\re  Total per patient physician costs decreased
on the waiting lists. Can waiting for increased by after surgery
J Surg 2002; 45: 34-43 particular surgery, delay in surgery  Seeing the procedure specialist more than
that is: once pre-operatively was associated with a
cholesystectomy,
evidence (Draft)

level
discectomy, greater decrease in post-op physician claim
hysterectomy, costs
total knee or total  Longer waits were not associated with more
hip replacement 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 Canadian Not applicable  The healthcare system should establish Expert opinion 4
solutions to health care healthcare more specialised short-stay surgical clinics in
wait lists. Ottawa: the public sector
Canadian Centre for  Lessons learned from queue management
Policy Alternatives; theory should be adopted
2005..  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
60. Lewis R, Appleby J. England NHS To assess if 18  Central targets appear to be effective in Expert opinion 4
Can the English NHS week waiting focussing NHS attention as long as
meet the 18 week target can be underpinned by rewards/sanctions
waiting list target? J R met  The use of targets has been ‘remarkably’
Soc Med 2006; 99:10-13 successful’
 New 18 week target is total wait’ which is
more in tune with what people want
 Evidence about whether waiting targets
distorted priorities is unclear
evidence (Draft)

level
 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 UK NHS Not applicable Describes phases of the labour government’s Expert opinion 4
T. The war on waiting for ‘War on Waiting’.
hospital treatment. 1. (1997-2000)Concentration on reducing the
London: King’s Fund; numbers waiting
2005. 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
62. McPherson K. Do Commentary on a Original study Effect size of  Patients who received their preferred Expert opinion 4
patients’ preferences meta-analysis was a meta- treatment treatment did better than those who were
matter? BMJ 2009; analysis of indifferent or not allocated to their preference
338:59 studies  Preference had little effect on attrition
assessing  Effect might be explained by people with
affects of patient strong preferences refusing to be randomised
preference on  Related to placebo effect possibly
outcome of
treatment
63. Anon. Influence of Fully randomised Preferences for Effect of  Patients randomised to their preferred Meta-analysis 1-

evidence (Draft)

level
adherence to treatment studies that treatment treatment, treatment had a greater standardised effect
and response of examined the clinical  Effects the same for people allocated to
cholesterol on mortality impact of patient outcome, their undesired treatment and those who were
in the coronary drug preference on attrition rates indifferent
project. NEJM 1980; attrition and  No difference in attrition between patients
303: 1038- 41 outcome 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
64. Preference Included studies To assess effect Treatment  Patients who were randomised to their Systematic 1+
Collaborative Review of fully of preference on effect size, preferred treatment had a standardised effect review
Group. Patients’ randomised clinical clinical size greater than that of those who were
preferences within preferences outcomes and outcome, indifferent to the treatment assignment
randomised trials: attrition attrition  Participants who received their preferred
systematic review and treatment also did better than participants who
patient level meta- did not receive their preferred treatment
analysis. BMJ 2008; 337: although this was not statistically significant
a1864  No difference was found in attrition between
patients allocated to their preference and
those who were indifferent
65. Lofvendahl S et al. Orthopaedic To assess Length of  Longest waits in hip replacement group Retrospective 2-
Waiting for orthopaedic patients from 10 waiting times time waited,  Socioeconomic variables were not cohort
surgery: factors Swedish hospitals and identify socioeconom determinants in waiting other than working
associated with waiting factors in ic variables, status in the back surgery group
times and patients’ variation hospital type,  Shorter waits for county/district hospital
opinion. Int J Qual quality of life, rather than university/regional hospital
Health Care 2005; opinion about  Patients with better health related quality of
17:133-40 waiting life had longer waits for knee surgery
 The length of wait was a significant
evidence (Draft)

level
predictor of the acceptability of the wait
 Patients influence over surgery date
affected their opinion about the waiting time
66. Ethgen O. Health- Studies including Review  Overall hip and knee arthroplasties were Systematic 2++
related quality of life in patients with total literature for found to be effective in terms of improvement review
total hip and total knee hip or knee outcomes in hip in health related quality of life
arthroplasty. A qualitative arthroplasties and knee  Age not found to be an obstacle to effective
and systematic review of arthroplasty in surgery
the literature. J Bone terms of quality  Men appear to benefit more than women
Joint Surg Am 2004; 86- of life  When improvements were found to be
A: 963-74 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
67. McGregor M, Atwood Patients requiring To provide  Conflicting evidence about timing of surgery Systematic 2++
CV. Wait times at the surgery for guidance on to hip fractures. Author states it is probable but review
MUHC: No 3. Fracture fracture optimum waits not proven that delay leads to increased
management. Montreal: management for fracture mortality
McGill University Health surgery  Some evidence that delay, >24 hours, in
Centre; 2007 surgery on ankle and tibial fractures may
result in increased complications and longer
hospital stays
 No evidence that prompt treatment has an
adverse effect.
 Authors state that reducing delays results in
evidence (Draft)

level
less pain, facilitation of surgical planning,
improved morale and more efficient bed usage
68. Hirvonen J et al. Patients awaiting Assessing  Patients quality of life did not appear to Case control 2-
Health-related quality of major joint quality of life deteriorate whilst waiting
life in patients waiting for replacement due whilst waiting for  Patients did have a significantly worse
major joint replacement. to osteoarthritis surgery and quality of life than population controls
A comparison between after
patients and population
controls. Health and
Quality of Life Outcomes
2006; 4:3
69. Peul WC et al. Patients with Assess early Following  44% of patients assigned to conservative RCT 1-
Prolonged conservative sciatica in nine surgery against surgery, at treatment eventually required surgery
care versus early surgery Dutch hospitals conservative one year and  Improvement in leg pain was faster for
in patients with sciatica treatment at two years those assigned to early surgery
caused by lumbar disc  Short term benefit was no longer significant
herniation: two year by six months and difference continued to
results of a randomised narrow over time
controlled trial. BMJ  Patient satisfaction in both groups
2008; 336:1355-58. decreased slightly between one and two years
 At two years 20% of all patients reported an
unsatisfactory outcome
70. Weinstein JN et al. Patients with Assess standard Changes in  At 3 months patients who chose surgery Prospective 2-
Surgical vs non- lumbar open quality of life, had greater improvement in pain, physical cohort study
operative treatment for intervertebral disc discectomy pain and function and disability
lumbar disk herniation: herniation treated against physical  These differences narrowed at two years
The Spine Patient at 13 spine clinics conservative function and  Patients in both groups improved
Outcomes Research in 11 US states management disability

evidence (Draft)

level
Trial (SPORT)
Observational Cohort.
JAMA 2006 ; 296(20):
2451-59.
71. Gibson JN et al. Randomised and Assess the 42 RCT  Surgical discectomy for selected patients Systematic 2++
Surgical interventions for quasi-randomised effects of 2 QRCTs with sciatica due to lumbar disc prolapse review
lumbar disc prolapse. (QRCT) trials of surgical provides faster relief from the acute attack
Cochrane Database Syst the surgical intervention for than conservative management
Rev 2007, Issue 2 management of the treatment of  Lifetime affects on the natural history of the
lumbar disc lumbar disc underlying disc disease are unclear
prolapse prolapse  Micro-discectomy gives broadly comparable
results to open discectomy
 Evidence on other minimally invasive
techniques is unclear
72. Fielden JM et al. Patients waiting To determine Costs in New  Mean wait was 5.1 months at a mean cost Prospective 2-
Waiting for hip for total hip the economic Zealand of NZ$4,305 per person cohort study
arthroplasty: Economic arthroplasty in and health costs dollars and  Waiting more than 6 months was associated
costs and health New Zealand of waiting for quality of life with higher mean cost than waiting less than 6
outcomes. J Arthroplasty total hip measure months
2005; 20: 990-97 arthroplasty  Longer waits meant poorer physical function
pre-operatively.
 Quality of life improved from pre to post-
operatively
 Those with poor initial health status showed
greatest improvement on the disease specific
health status tool
 Those with better health status pre-
operatively had better absolute outcomes at 6
months
evidence (Draft)

level
 Conclude that longer waits for total hip
arthroplasty incur greater economic costs and
deterioration in physical function while waiting
73. Brauer CA et al. Cost Studies on To determine if 37 studies  Studies varied substantially Literature 2+
utility analyses in orthopaedic cost sub-specialties  Studies on cost-utility analysis in review
orthopaedic surgery. J utility analysis are represented, orthopaedics were of a lower standard than in
Bone Joint Surg Am the cost utility other areas of medicine
2005; 87: 1253-9 ratios that have  Number of studies has increased but the
been used and quality has not improved over time
the quality of the  For the majority of interventions studied the
literature cost utility ratio was below the commonly used
threshold of $50,000 per quality adjusted life
year for acceptable cost effectiveness
74. Oudhoff JP et al. The Health Ascertain what  Participants endorsed prioritisation of Survey 3/4
acceptability of waiting professionals in is an acceptable patients based on clinical need but not on
times for elective surgery the Netherlands wait ability to benefit
and the appropriateness  Acceptable waiting times ranged between 2
of prioritising patients. and 25 weeks dependent on disorder, severity
BMC Health Serv Res of physical and psychosocial problems
2007; 7:32.
75. Edwards RT et al. UK NHS Elicit  Professional and lay support for a more Postal survey 4
Clinical and lay preferences of explicit system of rationing elective care by
preferences for the health waiting list.
explicit prioritisation of professional and  Surveyed groups felt that level of pain,
elective waiting lists: public in relation deterioration of disease. Level of
survey evidence from to prioritisation distress/disability should play most influential
Wales. Health Policy of waiting role
2003; 63: 229-37 Groups agreed that age, ability to pay, cost of
evidence (Draft)

level
treatment, evidence of cost effectiveness,
existence of dependents and self inflicted ill
health should not influence patient priority


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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

Author: Geri Arthur, Specialty Registrar Date: 061109 Status: Final

4 The political and policy context 6

5 Results of the literature search 10

5.1 Waiting times 10

5.3 General surgery 18

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

Acknowledgement to the National Public Health Service for Wales to be stated.

Author: Geri Arthur, Specialty Registrar Date: 061109 Status: Final

Results of review of scientific literature

The evidence in terms of physical implications for patients caused by waiting is

Author: Geri Arthur, Specialty Registrar Date: 061109 Status: Final

Patients may suffer adverse psychological outcomes as a result of waiting. Those

Because current information systems do not capture appropriate data it is not

Author: Geri Arthur, Specialty Registrar Date: 061109 Status: Final

Inefficiencies in health services have been blamed including: poor management of

Author: Geri Arthur, Specialty Registrar Date: 061109 Status: Final

4 The political and policy context

4.2 Orthopaedic services

A review of orthopaedic service in Gwent16 published in 2003, indicated there were

4.3 Second offer scheme

4.4 Orthopaedic plan for Wales

4.5 Wales Audit Office report on waiting times

4.6 Delivery Support Unit and Designed for life

4.7 Data and day surgery

4.8 26 week patient pathways

4.9 Delayed transfers of care

4.10 Providing care in NHS facilities

5 Results of the literature review

5.1.1 What causes waiting lists?

One criticism of waiting statistics is that they include no information about

An analysis of waiting times in the UK looked at the impacts of different regimes on

associated with longer waits. There is likely to be a different explanation, the

5.1.2 Factors affecting acceptability of waiting

Author: Geri Arthur, Specialty Registrar Date: 061109 Status: Final

5.1.3 Is waiting harmful?

5.1.4 Health economics of waiting

Author: Geri Arthur, Specialty Registrar Date: 061109 Status: Final

A review by Rachlis59 looks at solutions to waits, particularly in Canada. He suggests

5.1.5 Patient preference

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

 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

 Providing information about length of wait can increase acceptability

 Patient’s perception of their condition rather than the professional’s assessment

 Patients exercising preference may positively influence outcomes

5.2.2 Factors affecting acceptability of waiting for orthopaedic

Author: Geri Arthur, Specialty Registrar Date: 061109 Status: Final

surgery, possibly indicating a degree of triage. The authors found no correlation

5.2.3 Is waiting for orthopaedic surgery harmful?

Author: Geri Arthur, Specialty Registrar Date: 061109 Status: Final

5.2.4 The health economics of waiting for orthopaedic surgery

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