Jeremy Hurst, Employment and Social Affairs Directorate, OECD,

and Luigi Siciliani, University of York

European Health ForumGastein, 6-9 October 2004

Workshop 3a: Improving health system performance: new evidence from international research

CAN EXCESSIVE WAITING TIMES FOR ELECTIVE SURGERY BE ELIMINATED?

2

Excessive waiting times for elective surgery

A puzzling phenomenon– About half of OECD countries report having

problems – about half do not (including many with universal, public, health coverage)

– Policies to tackle excessive waiting times (>3 to 6 months) often end in disappointment

– It is the biggest public complaint about the health system in a number of countries but surveys of people actually waiting suggest they are not very worried by waits of up to 3-6 months (except for cardiovascular?)

– Can excessive waiting be eliminated?

3

Scope of OECD project on waiting times

Involved 12 countries with waiting time problems– Australia, Canada, Denmark, Finland, Ireland, Italy, the Netherlands, New

Zealand, Norway, Spain, Sweden, the United Kingdom Also looked at 8 countries without waiting time

problems– Austria, Belgium, France, Germany, Japan, Luxembourg, Switzerland, and

the United States

Focussed on 10 elective procedures, such as hip replacement and cataract surgery

Collected data on surgery rates, waiting times, capacity etc.

Collected information on policies

4

Main questions addressed

What are the causes of variations in waiting times?

What policies are most effective in tackling excessive waiting times (>3-6 months)?

5

The waiting time phenomenon

GP as-sessment

Wait. list(stock)

Surgeonassessment

Publicprocedureperformed

additionsinflow

treatmentsoutflow

Privateprocedureperformed

leakage

Private electivetreatment

Emergency surgicaltreatment

referrals

ReturntoGP

6

Main findings: data on waiting times

Large variations in waiting times for 10 procedures among countries reporting waiting time problems

The UK usually has the highest waiting times Only scraps of evidence for a few countries

not reporting waiting time problems They confirm waiting is very short in these

countries

7

Main findings: data on surgery rates

Rapid increase in elective surgery rates over time (e.g. +64% in England in the 1990s)

Large variations in surgery rates between countries (e.g. more than threefold for 6 procedures, 10 fold for hysterectomy)

Countries reporting waiting time problems generally have lower rates of surgery than countries not reporting waiting time problems

8

Hip replacement rates and waiting times

9

Econometric results 1) 8 waiting time countries

– Lower waiting times with:• More physicians and beds• Higher public and total health expenditure (new)• A higher proportion of day cases (some models) (new)• A higher proportion of elderly (some models) (new)

2) 12 countries with waiting and 8 without– Lower probability of waiting with:

• More specialists and beds• Higher public and total health expenditure (new)• A higher proportion of elderly (new)• Fee-for-service remuneration of specialists (new)• Weak constraints on hospital activity (some models) (new)

Review of policies for tackling excessive waiting (1)

Supply side policies– Increase expenditure and/or capacity

• High benefit, high cost, takes time

– Increase productivity (e.g. by activity related payments; more day surgery)

• High benefit, medium cost (?), takes time

11

Different supply policies, Denmark and England Rates of coronary revascularistion

procedures,, 1990-2000

0

20

40

60

80

100

120

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000

Pro

ced

ure

s / 1

0000

0 p

op

ula

tio

n

PTCA - DenmarkPTCA - EnglandCoronary bypass - DenmarkCoronary bypass - England PTCA -

Denmark

PTCA - England

CABG - Denmark

CABG - England

12

Different supply policies, Median waiting times for coronary revascularisation

procedures, Denmark and England, 1991-2001

0

20

40

60

80

100

120

140

160

180

200

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001

Med

ian

wai

tin

g t

ime

(day

s)

PTCA - DenmarkPTCA - EnglandCoronary bypass - DenmarkCoronary bypass - England CABG - England

PTCA - England

PTCA - Denmark

CABG - Denmark

13

Denmark: Development in waiting time and number of operations for the 18 specific operations

(inpatients)

18

19

20

21

22

23

24

25

26

27

28

Jan FebMarAprMayJun JulAugSepOctNovDecJanFebMarAprMayJun JulAugSepOctNovDecJan FebMarAprMayJun JulAugSepOctNovDec

2000 2001 2002

52,000

54,000

56,000

58,000

60,000

62,000

64,000

66,000

Mean waiting time Activity

Waiting time in weeks

Number of operations

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Review of policies for tackling excessive waiting (2)

Demand side policies– Clinical prioritization

• should increase efficiency and equity

– Manage demand (raise clinical thresholds) as in New Zealand (nobody on waiting list . 6 months)

• Some benefit (does not increase surgery rate and can be seen as increasing ‘waiting to join the waiting list’), low cost, quite quick to implement?

15

Review of policies for tackling excessive waiting (3)

Policies aimed directly at waiting times and mixed policies– Maximum waiting time targets

• Like squeezing a balloon; can clash with clinical priorities, but cheap to implement?

– Mixed policies• Best buy?

160

50

100

150

200

250

Jun-96Dec-96Jun-97Dec-97Jun-98Dec-98Jun-99Dec-99Jun-00Dec-00

Wai

tin

g t

ime

(day

s)

Mean waiting

Mean waiting time for patientson the list (Insalud, Spain)

0

50000

100000

150000

200000

250000

300000

350000

400000

450000

500000

Jun-

96

Dec-

96

Jun-

97

Dec-

97

Jun-

98

Dec-

98

Jun-

99

Dec-

99

Jun-

00

Dec-

00

Nu

mb

er Total activity

Public activity (normal)

Public activity (extra hours)

Private activity

Surgical treatments

provided (Insalud, Spain)

Mixed policies, Spain

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Towards solving the puzzles

Why international variations in waiting times?– Surgical capacity differs– Surgical productivity probably differs– Incentives to form queues differ

Why do policies to tackle excessive waiting times often end in disappointment?– Demand is increasing rapidly through time– There may be backlogs in demand– lower waiting acts like a price to encourage higher demand

Why is the public so alarmed by waiting when patients are less worried?– an inescapable aspect of public opinion or poor

communication?

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Conclusions

Yes: excessive waiting for elective surgery can be eliminated.

Tentatively: mixed policies = best buy– Capacity– Productivity/efficiency– Management of demand

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More information:

www.oecd.org/health

www.oecd.org/healthmin2004

www.oecd.org/health/healthdata