Controversy has developed in New Zealand over plans to replace the country's lengthy waiting lists with an appointment system in which only patients who meet defined criteria will be booked for non-urgent surgery.
The move follows reforms in the early 1990s, when the government commissioned the independent National Advisory Committee on Heath and Disability (known as the NHC) to define the core health services which should be publicly funded. The committee defined eligibility for services using clinical guidelines and explicit priority assessment criteria.
1In 1993 an NHC-commissioned group wrote a proposal to 'outline the general principles of waiting list and waiting time management, relevant to the current New Zealand situation'.
2It recommended 'that the present system of hospital waiting lists be abandoned and replaced by a system of 'booked admissions' for nonurgent surgery and medical and diagnostic procedures'.
The group added: 'Patients should be assessed by defined criteria, according to their need and likely benefit from the procedure. Patients who satisfy the criteria should be offered a date for surgery within a defined period of time.'
However, those 'who do not meet the criteria at the time of their specialist assessment should not be registered with the hospital's booking system (or placed on a 'waiting list'), but should be referred back to their GP for ongoing review'.
The group argued that the assessment criteria would aid decisions about priorities and funding. 'For the first time, we w ill be able to determine w ith some precision how far current resources are going, who is gaining access to specified publicly funded services, who is missing out, and what degree of benefit is being foregone as a result.'
2These recommendations were accepted by New Zealand's health minister, and the NHC worked closely with GPs and surgical specialists to develop and pilot national scoring systems for cataract surgery, coronary artery bypass graft surgery and percutaneous transluminal coronary angioplasty, hip and knee replacement, prostatectomy for benign hyperplasia and renal dialysis.
Development of the criteria started with a review of the literature and existing guidelines. Initial criteria were drafted in consultation with clinicians, who advised on current practice. The criteria were then reviewed by an expert panel and a wider advisory group. Unresolved issues were debated through a formal hearing process.
The criteria were then piloted in surgical units throughout New Zealand, alongside current practice. Ongoing revision was part of the process.
3The aims of the priority assessment criteria are to:
ensure that the process used to define priority is fair and consistent across New Zealand;
permit the assessment and comparison of need, casemix and severity;
assist the purchasers in developing new booking strategies;
permit comparison of waiting times across purchasers;
ensure that social values are integrated into the decision-making process in an appropriate and transparent manner;
provide the framework for the NHC to define the maximum waiting times acceptable for patients with defined levels of priority, as well as the levels of each service.
Given the pilot's apparent success, the health minister initially required purchasers to implement booking systems in all crown health enterprises (CHEs) - New Zealand's equivalent of trusts - by July 1998, now postponed to July 1999.
On 1 July 1996 the government provided£52m for a waiting times fund to clear over three years the backlog of patients with the greatest need for elective surgery. The fund was increased by£42m in the 1997 budget.
One function of the fund is to aid the nationwide change.
The booking system is not to be a six-month waiting list.
Instead it should reflect the total volume of elective services the purchaser can buy with available resources during the funding year. This is achieved, using the assessment criteria, by raising or lowering the thresholds for entry.
To secure access to the waiting times fund, CHEs must demonstrate that clinical priority assessment criteria are being developed with clinicians. They must also identify a threshold for access that is 'sustainable', and establish booking systems that can tell people that meet the defined thresholds when they will receive their surgery.
1Since developing scoring systems has been handed over to purchasers, the NHC has shifted its attention to developing clinical guidelines. The move from national to local development of assessment criteria has had drawbacks.
Work has been duplicated because the purchasers have developed criteria for the same procedures.
Different assessment criteria for the same procedures are being used to determine the thresholds for entry to the booking system.
The assessment criteria have not benefited from national peer review by specialists and other health professionals.
Clinicians have not consistently been involved as the primary developers of the assessment criteria.
A consequence has been scepticism among health professionals. The level thresholds will be set at is a cause of unease among some doctors. Clinicians' support could be lost if the government takes decisions that do not allow the thresholds to reflect clinically acceptable levels (see box).
In an attempt to save time, one purchaser developed generic criteria for all elective surgery. This is an attractive option because it could provide a way to compare scores and levels of funding across specialties. But it is unlikely to be possible to develop generic criteria with the sensitivity to provide accurate scores for patients across surgical procedures and specialties, because of the wide range of factors that would have to be taken into account.
4Consultants are understandably anxious about removing approximately 30 per cent of patients from the waiting lists on the basis of generic criteria, when they lack confidence that these will provide accurate scores.
A further problem associated with the scoring systems is inter-observer reliability. It is not yet known what effect the booking system will have on outpatient referrals, emergency admissions, GPs' workload and patients' health.
Some of these problems had been anticipated by the group that proposed assessment criteria. But it argued that this was better than 'idiosyncratic advocacy on behalf of patients, and either naive or assisted knowledge of patients as to the clinical and social circumstances that may assist their priority on the waiting list of a particular surgeon'.
The group concluded: 'It is better that at least the priority system be explicit , and known to all.'
Lessons for the NHS The New Zealand assessment criteria have attracted attention in the UK. The approach is attractive, but its use would probably be quite restricted. There is a greater potential for reliable and acceptable criteria in specialties that can incorporate validated tests with high inter-observer reliability, such as cardiac surgery. The issue is that medicine is an art as well as a science. The subjective element of decision making, which pervades most of the medical and surgical specialties, cannot be reduced to a few questions.
There would only be merit in the NHS exploring the use of criteria in specialties that have reliable, objective methods of ascertaining clinical need for treatment. Criteria would need to be developed nationally, with input from leading specialists and a consideration of whether it is always appropriate for resources to be skewed towards patients who have the greatest level of illness.
It is essential that criteria are piloted and validated before being used to make decisions about patients' access to treatment. While traditional prioritising methods have not undergone the same scrutiny, any alternative must be shown to be better and fairer to give clinicians the confidence to change practice.
Clinical scepticism Why New Zealand doctors did not support the booking system:
lack of clinical involvement in designing the assessment criteria;
lack of inter-observer reliability;
the speed with which the scoring systems were developed, with minimal time for piloting and validation;
the risk that a rigid threshold score would be used to determine which patients received treatment;
concern that the threshold would be unacceptably high.
Key Points New Zealand is attempting to replace waiting lists with a booking system for elective surgery such as hip replacements, cataract removal and heart bypass operations, and medical procedures.
The proposed system would only accept for treatment those patients assessed as likely to gain the greatest benefit.
Purchasers were originally instructed to implement the system by this month. This has now been postponed until July 1999.
The proposals are being opposed by clinicians on the basis that, in some cases, they would rule out 30 per cent of patients from treatment.
1 National Advisory Committee on Health and Disability. Fifth Annual Report . New Zealand, 1996.
2 Fraser G, Alley P, Morris R. Waiting Lists and Waiting Times: their nature and management. A report to the National Advisory Committee on Core Health and Disability Support Services. New Zealand, 1993.
3 Edgar W. Publicly Funded Health and Disability Services: health care priority setting in New Zealand . Paper for international seminar on healthcare priority setting. Birmingham, 18-19 May 1995.
4 Kipping R, Dennett E, Windsor J, Parry B. Priority access criteria for elective cholecystectomy: a comparison of three scoring methods. New Zealand Medical J 1998 (in print).