Value for Money Examination  44; Waiting List Initiative   Summary

The Department of Health and Children introduced the Waiting List Initiative (WLI) in 1993 to deal with a persistent waiting list problem in the acute hospitals. This problem involved significant numbers of public patients waiting long periods for elective (non-emergency) hospital treatment. In setting up the Initiative, the Department set targets for the maximum length of time patients should have to wait for treatment in  specialties with the longest waiting lists. The targets were that adults would not have to wait longer than 12 months and children would not have to wait longer than 6 months.

WLI funding which was provided in addition to normal hospital funding was intended to

  • incentivise hospitals and health boards to perform extra elective procedures
  • be targeted specifically at patients waiting longer than target times in the selected specialties
  • be ring-fenced i.e. kept separate from other funding of elective procedures.

Although initially intended to be a short-term initiative, the WLI has been funded each year since 1993 at a total cost of ?246 million. Over two-thirds of this funding (?172m) was spent in the five-year period focused on by this examination, 1998 to 2002. The examination considered

  • how the WLI funding was used
  • what the impact of the WLI has been on the target group of long waiting patients
  • how the waiting time and waiting lists are monitored and managed.

Use of the Funds

The funding provided to individual hospitals under the WLI was used in a wide variety of ways. This included increased use of hospitals? own capacity to treat patients or using other hospitals? facilities to perform extra procedures.

Many hospitals used part of the available WLI funds to pay for extra waiting list administration and bed management staff. In hospitals visited in the course of this examination, initiatives in these areas appear to have resulted in more active management of waiting lists and waiting times, and better hospital bed utilisation.

WLI funding has been used in many hospitals to fund temporary consultant posts on an ongoing basis. Many of these posts are now being made permanent. This has resulted in a situation where, by 2002, the application of up to half of WLI funds to staffing has reduced the level of flexibility available to the Department to target the WLI funds to long waiting patients in other hospitals. One factor not directly taken into account in allocating the available WLI funding to hospitals was the number of long waiting patients in each hospital. In fact, those health boards and hospitals that have performed well in reducing their numbers of long waiting patients, have tended to attract increasing shares of funding.

Impact on Patient Treatment

Between the start of 1998 and the end of 2002, the reported number of patients waiting longer than the target maximum waiting times for elective treatment decreased by 39% ? from just over 14,100 to 8,700.

The reduction in the target group in the period 1998 to 2002 did not affect all target specialties equally.

  • The target groups for the ear, nose and throat, vascular, orthopaedic and, in particular, cardiac surgery specialties declined significantly in this period.
  • The number waiting in the ophthalmology and urology specialties varied but were about the same at the start and end of this period. 
  • The plastic surgery and general surgery target groups increased by a quarter during this period.

The extent to which WLI funding succeeded in achieving extra elective activity cannot be reliably established. Although the extra funding under the Initiative was intended to be ring-fenced from   core funding, in practice, the activity it generated cannot, in most cases, be distinguished separately from core funded elective activity. Consequently, while the WLI aimed to result in additional elective activity, it is not possible to ascertain if, or to what extent, this was achieved, or if this activity benefited long waiting patients as intended.

Prioritisation of the Target Group

Although it was planned that WLI funding would result in the provision of treatment for long waiting patients, the Department has not specified that they should be given priority in receiving treatment paid for under the Initiative. While the Department does not wish to interfere with clinical independence, in order to ensure that the funding is applied for the purposes intended, there should be, at a minimum, formal shared criteria and standards adopted for the prioritisation of patients for elective treatment, as recommended by a 1998 Review Group of the WLI.

Between 1998 and the middle of 2001, the number of patients in the target group moved broadly in line with the number of other patients waiting for elective treatment, which suggests that there was little prioritisation of target group patients over that period. It was only from mid-2001 that the numbers in the target group began to decline relative to those of other patients. The relative prioritisation of target group patients has continued, in part, as a consequence of the introduction in mid-2002 of the National Treatment Purchase Fund which also targeted long waiting patients.

Current Status of the Target Group

The problem of long waiting is highly concentrated. At the end of 2002, over 70% of long waiting patients were waiting for treatment in hospitals in the Eastern region. While some progress was made in reducing the scale of the problem in the region during the period 1998-2000, progress was significantly slower than in most other regions. Analysis of data collected by the ERHA from hospitals in the region indicates that, at the end of 2002, the average waiting time of over 15 months for elective inpatient treatment of adults was significantly greater than the target maximum waiting time of 12 months. Similarly, the combined average waiting time for both inpatient and day case treatment for children was 8.9 months compared to the target maximum waiting time of 6 months.

  • Even within the Eastern region, the scale of the problem in individual hospitals varies greatly.
  • St James?s Hospital had almost eliminated waiting longer than the target maximum waiting times for elective treatment at the end of 2002.
  • Four Eastern region hospitals (Beaumont, Mater, St Vincent?s and Tallaght) together accounted for half of the national target group at the end of 2002.
  • More than 50% of all patients reported as waiting for elective treatment at the end of 2002 in Tallaght Hospital, Temple Street Children?s Hospital and Our Lady?s Hospital for Sick Children in Crumlin were waiting longer than the target maximum times.

Resolving the waiting problem in hospitals such as these will involve a co-ordinated response between the initiatives that now focus on long waiting patients, the WLI and the National Treatment Purchase Fund.

 Measuring and Managing Waiting Time

Improvements are required in the performance measurement and management systems in relation to waiting lists and waiting times.

The Department reports numbers of patients waiting, while measures of average waiting time and maximum waiting time would be more relevant.

  • Greater accuracy and consistency between hospitals in reporting waiting lists and waiting times is required.
  • The Department should begin to measure and monitor the time a patient waits for an outpatient appointment.
  • Existing waiting time targets set by the Department are largely aspirational. In managing waiting time under an initiative like the WLI, milestones and deadlines should be set and periodically reviewed if they are to function as clear and achieveable performance targets.
  • Waiting time for public patients in public hospitals should be benchmarked against waiting time for private patients in those hospitals.
  • The Department?s public reporting of data about waiting for elective treatment could be significantly improved to assist GPs in making choices about referrals for consultations.