The Operating Theatre Journal - Journal - Page 2
Why managing NHS waiting lists is about
safety, not just numbers
Safely managing waiting lists has become an intricate balance for healthcare professionals as they strive to meet targets,
and to also identify and act for all of those who are most-in-need, writes Dr Mark Ratnarajah, practising paediatrician and
UK managing director for C2-Ai.
NHS waiting lists have remained highly visible in the public eye,
especially since the pandemic. With more than seven million people
now waiting for elective procedures, media reports have focused on
growing numbers month after month.
Addressing the elective recovery challenge has understandably become
a national priority, with targets set to reduce long waiters, and
commitments made to bring numbers down.
But in a time when healthcare resource is stretched, numbers form only
part of the challenge facing NHS professionals.
Finding those in greatest need: the people sometimes
hidden in the numbers
An urgency to manage waiting list safely has become imperative for
NHS organisations and integrated care systems.
Dr Mark Ratnarajah
More and more are adopting innovative approaches, as they examine
how they can bring the waiting list down as expediently as possible,
whilst also considering patient safety, and managing the list in a way
that minimises avoidable harm and suffering.
Acting on clinical decision support, working as a system
Strategies have developed far beyond waiting list validation techniques,
such as a numerical cleaning of the list, where duplicates are removed,
or where patients are contacted to see if they still want their operation.
Instead, there has been a shift to understanding changing clinical risks
for individuals at scale, in order to identify and expedite support to
vulnerable high-risk patients on waiting lists, who might otherwise be
missed.
Those patients might not necessarily be cancer patients, or people
who have been waiting for 74 or even 104 weeks – who might be
relatively straightforward to 昀椀nd. Some of the most vulnerable might
be waiting for a seemingly routine procedure, but still be at a high risk
of decompensating, without appropriate intervention. They might be
at risk of developing additional complexity, or even face an increased
risk of mortality as they wait, due to the impact of comorbidities or
progression of their underlying condition.
There is no average patient
Healthcare systems are introducing new methodologies and technology
supported approaches, to help them manage lists based on a simple
idea: that there is no average patient.
No two patients on a waiting list are the same. Much more than a
number, each person waiting has a unique and potentially complex mix
of clinical risks, as well as biological, social and psychological needs
that might need to be considered.
These factors can be more dif昀椀cult to measure than time spent on a
list, but can be important in determining an individual’s ability to wait
well, or highlight their risk of coming to harm if nothing is done to
prioritise their needs.
Measuring the dynamic individual need of the patient, and doing so at
scale, has consequently become a new requirement in the mission to
safely stratify elective lists.
Healthcare providers and systems are, in response, using technology
and combining data to gain an increasingly sophisticated understanding
of where a culmination of events will take an individual patient in the
future.
They are acquiring a means to plot a trajectory and to anticipate the
needs of the patient in the near future, in order to mitigate serious
consequences or harm for that individual, as well as avoiding additional
cost and requirements placed on the health system.
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Trusts and entire ICSs are now deploying clinical decision support to
help clinical and operational teams make decisions. But in a constrained
system where there is limited resource, including human capital, beds,
ICU access, theatre capacity, how can this intelligence be best used?
Prioritisation of patients – moving them up the waiting list – might
be possible to an extent. But balanced against capacity limitations,
system-wide thinking is starting to deliver the biggest impact.
Con昀椀guring system wide services to help to de-risk patients, has been
one successful approach. This has in part taken the form of targeted
and tailored prehabilitation, based on individual patient needs. In other
words – understanding what measures can be applied in the community
to support a patient as they prepare for surgery, to improve the success
of their operation, and to enhance and speed up their recovery. And
thinking beyond a single operation – measures to help them manage
their chronic condition and support their ongoing wellbeing into the
future, to prevent further demand on the system.
Regions can use intelligence to better match demand and supply. This
might mean creating surgical hubs in the right locations to manage low
complexity, high volume activity. Or it might mean matching supply and
demand across a region to individual patient risks – for example moving
patients to sites with appropriate additional capacity, and not moving
high-risk patients to sites without an emergency department or ICU.
It could also mean more judiciously using private capacity – matching
patients to the capabilities of those sites.
Genuine patient engagement
Intelligence being generated can also provide patients with more
informed, and potentially safer choice.
Simply asking a patient if they still want a procedure without an
evidence base can place a lot of pressure on an individual. Some might
decline their operation because they don’t want to become a burden,
or because of a sense of duty. Others might feel apprehension about
going into hospital.
But a discussion with those most at risk, can allow informed decisions
based on a trajectory of what is likely to happen if an operation does
or does not happen, and potentially about the type of procedure they
have, such as a lower risk anaesthetic where appropriate.
There is now an opportunity to measure the in昀氀ection point at which
things go wrong, and to present the best options for patients to
mitigate that problem, to monitor and engage patients all the way to
the point at which they have their surgery, and to help ICSs deliver on
their fundamental mandate of delivering integrated health and care for
individuals across their population.
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