Patient harm and system inefficiency arising from the waiting list

Our work1 came from the first-hand experience of practicing surgery in England since the COVID pandemic. Patients were waiting longer, and the consequences of this were anecdotal: patients’ lives put ‘on hold’, cases becoming more complex in theatre, patients suffering preventable ill-health. The challenge was how we might measure some of that, fortunately the COVID pandemic had also accelerated the central collection of patient-level waiting list data by NHS England. This creates a record of all the surgery waited for in England, and the start and end of that wait, which could be checked against other records held at NHS England.

The paper describes the results in detail, but we found that significant numbers of patients admitting to hospital as an emergency, and that these admissions would have been prevented by prior surgery. In some pathways the number of days spent treating patients as an emergency outweighed the number of days treating patients with their elective surgery. In practice, the vast majority of these admissions, largely through Emergency Departments, are treated medically. Very few of these patients were given surgery on admission, which meant once the acute emergency had passed these patients were back on the waiting list. Some patients had multiple emergency medical admissions while waiting for surgery, potentially complicating the eventual surgery.

I’ve always been interested in the unintended consequences of our actions and choices, and the truism, “every system is perfectly designed to give the results that is gets.” What I’ve described above could be seen as ‘allocative inefficiency’. By not allocating enough resource or priority to one part of the system, we make the system inefficient overall. The healthcare system is massively complicated, and in such systems its very easy not to see consequences that are occurring elsewhere. What is occurring here is pressure from elective pathways being played out in emergency care, or delays in surgical care being experienced as an increased demand for medical care. This was known intuitively and anecdotally, I hope this paper goes some way to measuring it at scale.

Central to this is the clinical risk experienced by patients on the waiting-list. The harms experienced by some patients include sepsis, internal haemorrhage and other life-threatening conditions. Good management of these risks, can therefore be life-saving. This can be how we prioritise cases, within pathways, or between pathways. How theatre time is allocated, between specialities, or how local systems might cooperate to facilitate treatment between hospitals. It’s possible that in the most high-risk cases, the elective pathway may not be the best management option.

The observations in this paper then acknowledge the power of services delivered with a timeliness that is linked to the clinical situation and therefore the impact on the whole system and the patient. It acknowledges the power of surgery and interventions to resolve ill-health, incidentally in a way that may be twice as cost-effective as innovative medicines2. Furthermore, these observations present some of the limitations, harms and counter-productive impacts of the current approach to prioritisation, within a system under pressure.