Jeremy Hurst, Employment and Social Affairs Directorate, OECD, and Luigi Siciliani, University of York European Health Forum Gastein, 6-9 October 2004 Workshop 3a: Improving health system performance: new evidence from international research CAN EXCESSIVE WAITING TIMES FOR ELECTIVE SURGERY BE ELIMINATED?

2 Excessive waiting times for elective surgery A puzzling phenomenon –About half of OECD countries report having problems – about half do not (including many with universal, public, health coverage) –Policies to tackle excessive waiting times (>3 to 6 months) often end in disappointment –It is the biggest public complaint about the health system in a number of countries but surveys of people actually waiting suggest they are not very worried by waits of up to 3-6 months (except for cardiovascular?) –Can excessive waiting be eliminated?

3 Scope of OECD project on waiting times Involved 12 countries with waiting time problems –Australia, Canada, Denmark, Finland, Ireland, Italy, the Netherlands, New Zealand, Norway, Spain, Sweden, the United Kingdom Also looked at 8 countries without waiting time problems –Austria, Belgium, France, Germany, Japan, Luxembourg, Switzerland, and the United States Focussed on 10 elective procedures, such as hip replacement and cataract surgery Collected data on surgery rates, waiting times, capacity etc. Collected information on policies

4 Main questions addressed What are the causes of variations in waiting times? What policies are most effective in tackling excessive waiting times (>3- 6 months)?

5 The waiting time phenomenon

6 Main findings: data on waiting times Large variations in waiting times for 10 procedures among countries reporting waiting time problems The UK usually has the highest waiting times Only scraps of evidence for a few countries not reporting waiting time problems They confirm waiting is very short in these countries

7 Main findings: data on surgery rates Rapid increase in elective surgery rates over time (e.g. +64% in England in the 1990s) Large variations in surgery rates between countries (e.g. more than threefold for 6 procedures, 10 fold for hysterectomy) Countries reporting waiting time problems generally have lower rates of surgery than countries not reporting waiting time problems

8 Hip replacement rates and waiting times

9 Econometric results 1) 8 waiting time countries –Lower waiting times with: More physicians and beds Higher public and total health expenditure (new) A higher proportion of day cases (some models) (new) A higher proportion of elderly (some models) (new) 2) 12 countries with waiting and 8 without –Lower probability of waiting with: More specialists and beds Higher public and total health expenditure (new) A higher proportion of elderly (new) Fee-for-service remuneration of specialists (new) Weak constraints on hospital activity (some models) (new)

Review of policies for tackling excessive waiting (1) Supply side policies –Increase expenditure and/or capacity High benefit, high cost, takes time –Increase productivity (e.g. by activity related payments; more day surgery) High benefit, medium cost (?), takes time

11 Different supply policies, Denmark and England Rates of coronary revascularistion procedures,,

12 Different supply policies, Median waiting times for coronary revascularisation procedures, Denmark and England,

13 Denmark: Development in waiting time and number of operations for the 18 specific operations (inpatients)

14 Review of policies for tackling excessive waiting (2) Demand side policies –Clinical prioritization should increase efficiency and equity –Manage demand (raise clinical thresholds) as in New Zealand (nobody on waiting list. 6 months) Some benefit (does not increase surgery rate and can be seen as increasing ‘waiting to join the waiting list’), low cost, quite quick to implement?

15 Review of policies for tackling excessive waiting (3) Policies aimed directly at waiting times and mixed policies –Maximum waiting time targets Like squeezing a balloon; can clash with clinical priorities, but cheap to implement? –Mixed policies Best buy?

Jun-96Dec-96Jun-97Dec-97Jun-98Dec-98Jun-99Dec-99Jun-00Dec-00 Waiting time (days) Mean waiting Mean waiting time for patients on the list (Insalud, Spain) Jun- 96 Dec- 96 Jun- 97 Dec- 97 Jun- 98 Dec- 98 Jun- 99 Dec- 99 Jun- 00 Dec- 00 Number Total activity Public activity (normal) Public activity (extra hours) Private activity Surgical treatments provided (Insalud, Spain) Mixed policies, Spain

17 Towards solving the puzzles Why international variations in waiting times? – Surgical capacity differs –Surgical productivity probably differs –Incentives to form queues differ Why do policies to tackle excessive waiting times often end in disappointment? –Demand is increasing rapidly through time –There may be backlogs in demand – lower waiting acts like a price to encourage higher demand Why is the public so alarmed by waiting when patients are less worried? – an inescapable aspect of public opinion or poor communication?

18 Conclusions Yes: excessive waiting for elective surgery can be eliminated. Tentatively: mixed policies = best buy –Capacity –Productivity/efficiency –Management of demand

19 More information: