Understanding how the outpatient system interacts with the rest of the NHS is important - but assessing waiting-list performance is far from straightforward, writes John Appleby

The waiting list for the waiting list - those waiting to attend an outpatient clinic for a specialist opinion - hit its peak in the quarter ending September 1999. At that time over half a million people had been waiting over three months; nearly 150,000 had waited over six months. For the past four or five years, increases in these numbers have seemed inexorable.

But a report from the National Patient Access Team last November suggests that long waits for outpatients can be tackled.

1The team's intensive work with a handful of those trusts which performed poorly in terms of outpatient waiting times indicated that improvements can be made. Compared with a control group of trusts, the 'learning set' group managed to cut long waits by 20 per cent within a few months.

Meanwhile, the control group experienced an increase in the total number of outpatients waiting to come into hospital. By the end of the team's work, three learning set trusts had improved their outpatient league table position, moving from the bottom 11 to the top 25 per cent. Even the most poorly performing of the learning set trusts managed to pull out of the bottom 11 and into the bottom 20.

But the 'waiting list for the waiting list' is, in reality, more complicated. For example, the outpatient waiting times - first collected in 1994 - only cover appointments for the first outpatient visit.

Subsequent visits are not included (70 per cent of all outpatient attendances). Moreover, only outpatients referred by GPs are included in the waiting times.

Referrals from within hospitals are excluded.

But there are more fundamental issues with outpatient waiting times.

2For example, access to the healthcare system does not, of course, start at the time a GP writes a referral letter. There are at least two earlier stages. The first covers the time a (potential) patient decides to visit their GP. This period will vary enormously around the country and within communities depending on a range of socioeconomic and cultural factors.

The second stage is the time it takes a GP (perhaps after a number of visits by their patient) to decide to refer on for specialist opinion. Again, this will vary.

Guidelines on GP referral variations will be issued by the National Institute for Clinical Excellence over time, and these should start to iron out some of the known differences in GP behaviour and practice.

Mapping the outpatient 'system' is essential in understanding the relationships between this part of the NHS and other aspects of the service. For instance, although it is sometimes presumed that squeezing the inpatient waiting-list balloon will simply result in an expansion in, for example, outpatient numbers waiting, national figures only show a weak link between the two.

More surprisingly, again from national figures, there seems very little relationship between numbers of patients seen in outpatients following a GP referral and the numbers still waiting to be seen.


1 Department of Health. Tackling Outpatient Waiting Times: a new approach. National Patient Access Team, 2000.

2 Harrison A. The War on Waiting. In: Health Care UK. Winter 2000. King's Fund.