Patient Choice and Waiting Times
Taming of the Queue
Pre-Conference Workshop
March 28 2012
Diane Lorenzetti
Dr Tom Noseworthy
Choice in Health Care
General Practitioner
Hospital
Specialist
Treatment
Benefits of choice
Empowers patients
Increases access
Encourages market competition
Efficiencies
Quality of care
Waiting times
History of Patient Choice
Pre 1980s: Patient choice of specialist or hospital is an implicit right in
Australia, Belgium, England, France, Germany, and the Netherlands. In
many other countries patients have the right to choose their general
practitioner
1980s: Patient choice legislated in Denmark, England, New Zealand,
Norway and Sweden
Early 1990s: Patient choice schemes introduced in response to long waiting
times in Denmark, England, Norway and Sweden
2000s: European Union Commission supports patients’ right to receive care
in any member state
2006: Choose & Book online patient booking system introduced in the UK to
facilitate access to choice of specialist, appointment date and time
Canadian Experience
Choice of general practitioner within province of residence
Isolated initiatives to facilitate faster access to
specialists/hospitals for patient groups (eg: Ontario Cardiac Care
Network) or services (eg: radiology in Nova Scotia)
No concerted effort to implement broader patient choice
schemes
Studies of effectiveness primarily limited to patient stated
preference surveys (eg: hip and knee patients in Saskatchewan)
Does patient choice reduce waiting times for
scheduled services?
Factors which impact on patient choice
Other
Initiatives
Patient-level
CHOICE
System-level
Provider-level
Patient-level factors affecting willingness to exercise choice
Relationships
Pain
Reputations
Recommendations
Decision support
Quality of life
Chronic/multiple health issues
Choice
CHOICE
Travel
Waiting times
Aftercare
Appointment dates
Socioeconomics
Arthroplasty Patients in Saskatchewan
In a 2006 survey of 1200 arthroplasty patients in
Saskatchewan, 40% of those waiting for surgery and
35% of those who had had surgery would consider
switching surgeons for shorter wait times
In a similar survey of 303 patients who had
undergone surgery, if given a choice of switching
surgeons for shorter waiting times:
68% would not switch
15% would switch
17% uncertain
Provider/system-level responses to patient choice
WT increase at a greater
rate for providers with low
waits than reduces for
providers with high waits
Where patient demand
outstrips capacity there is
little incentive to reduce
waiting times
Choice
CHOICE
Fixed budgets can be a
disincentive for providers
to increase activity (reduce
waiting times) or accept
very ill patients
Reduced waiting times
may encourage providers
to attract more patients
Patient choice in practice
Norway Patient Bridge Pilot Project (2000)
Patients on waiting lists could transfer to private hospitals in
Sweden, Denmark and Germany
Expenses related to travel were subsidized
Project resulted in reduction in waiting times for patients who
travelled abroad and those who remained at home
Patients guaranteed aftercare at home hospital more willing
to travel
50% of public hospitals chose NOT to recruit patients for the
project
Norway Patients’ Rights Act (2001-)
Patients’ right to receive elective care at any hospital,
irrespective of geography
In 2004, this right was extended to private hospitals under
contract to a Regional Health Authority
A 2004 study determined that, on average, patients who
chose to travel for care had their procedures 11 weeks
sooner than those who did not choose to travel
UK Patient Choice Pilots (2002-2003)
Patients in London and Manchester waiting more than 6 months for an
operation (including: ophthalmology, ear, nose & throat, general surgery,
and orthopedics) Patients throughout England waiting more than 6
months for cardiac surgery
Administrators purchased services from designated hospitals with
capacity to take on additional patients
Patient care advisors assisted patients in obtaining information, choosing,
and booking appointments
Linkages between hospitals ensured adequate aftercare
Transportation to alternate hospitals provided free of charge. One
relative could travel and remain with a patient during their stay
NHS Choose & Book (2006-)
An electronic booking system for outpatient appointments
Since 2006, patients in the UK referred for an elective
procedure by their GP have been able to choose secondary
care providers, appointment dates and times
Money follows the patient (case-based hospital payment)
Private hospitals were able to compete for NHS patients
Choose & Book was introduced alongside 18 week referral to
treatment targets for scheduled services and increases in
health spending
Effectiveness of Choose & Book
Many patients reported not having been aware of or offered
a choice by their GP (51% in a 2010 King’s Fund Report)
69% of patients who were offered choice chose local
providers
GPs were influential in directing patients’ choice at referral
GPs found the electronic booking system time consuming
Impact of choice varied and was both dependent on
proximity of similar providers and the services required
Factors Influencing NHS Patients’ Hospital Choice (2009)
Cleanliness
2.6
Quality of care
2.5
Hospital reputation
2.1
Length of waiting list
2.1
Travel distance
2
Personal experience
2
Appointment Time
1.8
Consultant of choice
1.7
Family/Friends Experiences
1.5
Travel costs
1
0
0.5
1
1.5
2
Not Important (0) to Very Important (3)
2.5
3
Patient Choice and Waiting Times
Uptake of patient choice varies
Little data linking choice to waiting time reductions (outside
of pilot studies)
Challenging to tease out the effects of choice from other
initiatives (eg: waiting time targets)
Equity & Patient Choice
Culture
Physical
mobility
Flexible
employment
Family
responsibilities
Comprehension
Travel costs
Travel distance
Policy Implications
Patient choice may be a means of reducing waiting times for
scheduled services……….HOWEVER
Choice should be considered as but one component of a
comprehensive strategy
Choice appears to work best when introduced alongside
supportive policies
Patient and provider buy-in is key
Patient uptake depends on a variety of factors, only one of
which is waiting times
Choice should be implemented so as not to negatively impact
patient equity
Questions/Comments
Diane Lorenzetti
Department of Community Health Sciences
University of Calgary
dllorenz@ucalgary.ca