Middle-class patients to wait longer for care under health inequalities project

The “agile waiting list” has been developed by University Hospitals Coventry and Warwickshire Trust, and can use “social value judgements” alongside a range of clinical factors when prioritising patients.

For example, a patient from a deprived area could sometimes be pushed ahead of another patient from an affluent area, if deemed clinically appropriate.

The trust recently showcased the work as part of webinar produced by NHS England’s national elective team, and said it is working with around 70 other trusts to “help them to adopt the software”.

The software works by weighting clinical factors that determine a patient’s outcome with non-clinical factors, such as time on the waiting list and “how many times [the patient has already] attended accident and emergency with the same problem”, alongside the social value judgements.

Medical director Kiran Patel told HSJ: “You can put a different weighting on different factors. So, for example, we have slightly weighted postcodes.

“Likewise, if you have patients who smoke, have hypertensive or are overweight, you can use those factors to weight the position on the waiting list [potentially pushing these patients forward on the list]. Then that algorithm schedules an agile waiting list every day.

“It means we don’t just schedule in accordance with an 18-week wait because we know that widens inequality. Instead, we use clinical factors and drivers of health outcome.”

He said NHSE’s current elective strategy, which is based around the referral to treatment pathway and treating the longest waiters first, was “fuelling” health inequalities, and the software could help with “levelling up”.

The project is being closely watched by other senior leaders, with significant support for its aims.

It has not yet been subject to a robust peer-reviewed study, but the trust said it was evaluating and publishing results as it progresses.

A senior figure at a separate trust, who asked not to be named, warned: “The social value angle will be fraught with differences of opinion, so it could be challenged if not well researched. Most people would accept a wait for someone ‘more needy’, but we may all have different opinions about how that need is defined.”

Dr Patel said long waiting times would – at present until they are bought under control – “trump” other factors in the algorithm. He said: “We put waiting times into the algorithm, and if you are waiting 104 weeks or over, that would effectively trump everything else at the moment.

“But [when waiting times get more manageable, closer to 18 weeks] it may not need to be like that. You may choose for some patients to wait 19 weeks and others 14 weeks.”

Crucially, UHCW does not have any 104-week waiters, so the trust was in a “more comfortable position to identify how we address health inequalities” than other trusts with longer lists.

‘Levelling up’ waiting times

He used orthopaedic patients as an example of how health inequalities were being “levelled up”.

Prior to the new system, an orthopaedic patient from a more affluent background was waiting on average of four weeks less than someone waiting for a similar procedure from a more deprived area.

He said: “What we have done is reduce the waiting time for everybody, but we narrowed the gap, so there is now no differential.

We have not made the affluent patient wait longer than they were, simply, their reduction in waiting time has been slower. So, it’s a kind of a levelling up agenda.”

Waiting lists and RTT ‘fuel inequality’

Professor Patel has also warned about the unintended consequences of NHSE’s elective strategy, which centres on dealing with the longest waiters first, which he said “fuel inequality”.

He told an internal NHSE webinar, seen by HSJ, last month: “Our fear is that if we restore NHS services simply based upon waiting times alone, so, 104, 78, 52 weeks, we will widen health inequality.

“And I put it to you if we want equity, we have to give people a differential access to elective care, so actually, we need an inequity of access to restore and equity of health outcomes.”

He said research had shown more affluent patients were generally better at advocating for themselves and therefore gained swifter access to elective services. Patients from more deprived areas were also more likely to have other health conditions which could impact their outcomes.

So, placing disproportionate emphasis on waiting time and not factoring social issues when scheduling patients will only further broaden the health inequality gap.

Read more about this issue in this week’s Recovery Watch.