Government & Medicine

First come, first served takes a wallop

The WCWL says fairness needs to be top priority for waiting lists -- not everyone agrees

By Susan Usher

Waiting lists are an unfortunate side effect of a universal healthcare system and every province in the country is trying to find a way to deal with the problem. According to figures from a Fraser Institute study in late 2003, waiting times jumped by 7.3% in the last year. Though we'd all love for them to be shorter, at least one Canadian health policy group thinks the first priority should be making waiting times fair.

"If people have to wait at all, the wait should be proportionate to the degree of urgency," says Dr Tom Noseworthy, chair of the Western Canadian Waiting List (WCWL) Project Steering Committee. The WCWL was born out of recommendations of the 1996 National Forum on Health and is funded by the Health Transition Fund. It involves federal and Western provincial governments, regional health authorities and provider and research organizations in the four western provinces. The overall goal of the project is to improve management of access to scheduled services. Dr Noseworthy has seen the agenda evolve over time. "Our first priority was to make it fair, which we thought of as getting people in the line-up ordered based on the urgency of a person's problem, rather than firstcome first served."

Setting priorities isn't currently a management approach for waiting lists in Canada, except for heart disease and some forms of cancer. The clinical areas the WCWL is looking at are not urgent, so the timing for intervention is not as clear-cut as it is for procedures like cardiac surgery. "With cataracts or hip and knee replacement, urgency is more a matter of the impact on the person living with the condition," says Dr Noseworthy.

The WCWL determines urgency by assessing the pathophysiological severity of the problem, the socio-behavioural impact on the person, and the benefit potential of the intervention. "As we started work, we were attacked for not doing enough to shorten the waiting time, so we added timeliness to our agenda," says Dr Noseworthy.

Getting waiting lists right doesn't happen overnight, however. First, scoring systems based on the concept of urgency had to be developed in the five clinical areas WCWL deals with. "We're just about at the point where the score will determine your position on the waiting list in a select group of jurisdictions including Regina, Saskatoon, Edmonton and Calgary," says Dr Noseworthy. People are currently being scored using this system, but the scores have not yet been used to determine their place in line. Only once the system is in full use will the WCWL be able to assess whether it does in fact lead to high scoring people being served faster than low-scoring people. As they implement the scoring system this year, the WCWL will also be formulating benchmark waiting times. "By December 2004, the hip and knee scoring system will have a set of maximum acceptable waiting times that match the urgency scores," says Dr Noseworthy.

Despite all the methodical planning, Dr Noseworthy anticipates physician resistance to this new way of managing waiting lists, especially in Saskatchewan where an aggressive top-down approach to implementation is being used. "Saskatchewan is moving very quickly toward a registry for all scheduled surgery in the province and they want every patient scored," he states. Until now, physicians have been centrally -- even exclusively -- involved with the determination of the order of their lists. This doctor-centric approach will need to move toward a patient-centric one, in that the characteristics of the patient will determine the list order, not the approach of the doctor. Dr Noseworthy suggests implementation could begin more slowly by getting each physician to use the score to order their own lists, then perhaps expand to the hospital and then the region. "[As] The system gets more complex we will need to compromise more when we start prioritizing across physician practices," he says.

Patient focus groups have shown very high levels of support for the change in waiting list management. Dr Noseworthy thinks many doctors will reserve judgement until they can be shown that it actually improves patient outcomes. Of course, it's hard to study a system until it's in use. No sense waiting any longer.