Weights for waits: lessons from Salisbury

This paper describes a waiting list patients' points scheme under development in Salisbury, UK, for the fair management of elective inpatient and day case waiting lists. The paper illustrates how points can be assigned to patients on a waiting list to indicate their relative unmet need, and illustrates the impact on case mix and resource use of the implementations of the points system versus 'first come, first served'. The paper explores a range of philosophical and technical questions raised by the points system.

The Salisbury Priority Scoring System enables surgeons to assign relative priority to patients at the time they are placed on a waiting list for elective health care. Points are assigned to patients to reflect the rate of progress of their disease, pain or distress, disability or dependence on others, loss of usual occupation and time already waited. In recognition of the need for resource planning alongside the prioritization of elective inpatients and day case waiting lists, a range of iso-resource groups has been developed for all procedures on these lists. These categorize procedures in terms of their resource use (i.e. bed days and theatre time required).

In a modelling exercise, application of the Salisbury Points Scheme to a 'first come, first served' orthopaedic waiting list produced considerable changes in the order of patients to be treated. Only seven patients appeared in the first 20 patients to be treated under both regimes. The Salisbury Scheme required fewer resources to treat its first 20 patients than 'first come, first served' and met more Salisbury-defined 'need', but eliminated fewer days of waiting from the list.

Development of a points scheme and iso-resource groupings opens up opportunities for more sophisticated purchasing, based on treating patients in order of unmet need rather than according to arbitrary maximum waiting time guarantees, as has been the dominant policy on waiting lists pursued in the UK, Australia, and Sweden, to date. However, such schemes raise three issues: first, the necessity of defining need as a composite of clinical and social factors; second the necessity to determine the acceptability of explicit prioritization to both health care professionals and patients; third, the thorny issue of whether such prioritization schemes will lead to 'gaming' by well-meaning general practitioners and specialists, aiming to secure the priority of their own patients and clinical specialty. Rigorous piloting of schemes, such as that developed at Salisbury, will be required to identify their dynamic effect over time on case mix, waiting time and resource use.