International Experience of Prioritisation of Elective Surgery

Given the unprecedented financial pressures on the National Health Service in Wales, difficult decisions have to be made about how to allocate and use resources. The objectives of this research were to review international experience of approaches to prioritising elective surgery and draw out key issues and useful approaches that may be relevant for implementation in Wales.

All developed health systems use strategies to assess and prioritise health care interventions, in recognition of the need to manage the demands for healthcare. In the context of elective surgery, three types of strategy have been used:

  • Waiting time targets: where all of those who are considered eligible for treatment are subject (in theory) to the same maximum waiting time.
  • Scoring systems: where clinicians use pre-defined criteria to ‘score’ patients’ in terms of need and anticipated clinical benefit. These scores determine whether a patient receives treatment.
  • Guidelines: where guidelines, informed by evidence based best practice, are used to determine the likely effectiveness (and cost effectiveness) of specific treatments.

All these approaches can have implementation issues and challenges. Waiting time targets can distort clinical priorities and resource allocations and may not create equitable service delivery across different socio-economic groups (driven by information asymmetry, choices of location). Scoring systems can be subject to abuse and provider manipulation as well as non-adoption by some surgeons leading to unequal treatment. Guideline programmes can drive evidence based best practice but there is limited evidence of effectiveness on prioritisation of elective surgery. Prior attempts to affect clinical decisions through guidance suggest that to be successful they require intelligent implementation, training programmes, appropriate use of incentives and dedicated tools for monitoring outcomes using routine electronic health data.

If a guideline approach is the best option for prioritising elective surgery in Wales it will require: engagement with the ‘influencers’ in providing and delivering healthcare in Wales, both within Government and in the healthcare community; patient and public engagement to communicate any changes and their justification; and improvement in data identification, collection and utilisation to enable monitoring, transparency and accountability.