Guidelines for waiting lists

• Abstract
• Characteristics of this policy
• Purpose and process analysis
• Expected outcome
• References

Abstract

The conflict between patient needs and health care services availability still remains the main challenge in health care policy (especially in case of very high-cost medical procedures). The main objectives of introducing the new guidelines to the waiting list system are: improving transparency in wait list management and making access to health services more equitable and fair. The other reason concerns the problem of optimum public health care resources use.

Neue Entwicklungen

Waiting lists as a tool to manage supply and demand

The waiting lists issue, like in many other countries, is an intense question in Poland. The increasing "gap" between patient needs and the availability of public system resources (in terms of financial resources to cover costs of medical procedures,  technical diagnostic and terapeutical posiibilities, engagement of medical professionals) is a problem that calls for some reasonalbe solutions. Waiting lists, as it has been described in a previous report, are the unavoidable solution to manage demand and supply but there are some other problematic questions involved in this matter, for instance the problem of which rules should be applied to the management of such lists (priorities, rules of decision making process, criteria for choosing patients from the list, potential conflicts of "medical" and "social" interests).

New guidelines for wait list management - increasing equity and transparency

The Polish MoH elaborated a new set ot guidelines, based on new regulations. The guiding principles and objectives of the introduced guidelines are:

1. assurance of equitable and fair access to limited, expensive health care services; and 
2. the creation of a system of social (public) control over the waiting lists.

For the realization of  the above mentioned objectives it is absolutely necessary to establish and introduce the new formal guidelines within the legal system of the country. The MoH, acting in this sphere, bases the new guidelines on the following legal acts:

• the Law from 27th of August 2004 on health care services financed from public funds (OJ/210/2135 with further amendments); 
• the MoH Regulation from 26th of September 2005 on medical criteria used by health care providers to place patients on waiting lists (OJ/200/1661); and 
• the MoH Regulation from 29th of July 2005 on the information health care providers have to collect, on the method of information registration and on the process of information submission to the responsible Minister as well as the National Health Fund as the responsible organ for service financing from public funds, and on the types of data carriers used for the collection of information.

All stakeholders - health care providers, the MoH, the NHF and the beneficiaries of the health care system themselves (patients) - have to obey to the rules included into the set of regulations in case of limited health care services.

High level of corruption and EU regulations also call for clear and transparent rules for wait list management

The issue of proper management of waiting lists, the application of clear rules and the transparency of decisions touches also on a contemporarily very "popular" subject - corruption in health care, especially at the time of incoming elections to the Polish Parliament. It should also be remembered that the European Council defined priorities for patient treatment in case of services shortages: the biggest needs are always decisive for the patient's placement on the list. This rule, established by the EC in 1998, suggests also that health risk evaluation and the evaluation of quality of life should be taken into account in wait list management. The next requirement concerns the time of waiting: According to the EC this period of time should in any case be shorter than the time span after which the health status of a patient could decrease. The above described rules are an unquestionable foundation for the new Polish guidelines. The MoH project for the elaboration process of the guidelines recalls also Evidence Based Medicine as a method for the preparation of the guidelines.

Innovationsgrad	traditionell		innovativ
Kontroversität	unumstritten		kontrovers
Strukturelle Wirkung	marginal		fundamental
Medienpräsenz	sehr gering		sehr hoch
Übertragbarkeit	sehr systemabhängig		systemneutral
current    previous

The idea of introducing formal and legally defined conditions for the patient placement on waiting lists is a traditional one but the procedures proposed by the MoH (unified formal conditions introduced legally in one common piece of legislation) are new. Concerning the degree of controversy the issue at the first glance seems to be consensual but looking more deeply there are some exclusions (possible changes in patient's attitude that depend on a particular situation). In general, all the interested actors (NHF, MoH, providers) agree that such regulation is needed - potential controversies may occur in a concrete situation, ie. when priorities have to be set. Public visibility is low due to the fact that the only source for information are the websites of MoH;  patients not neccessarily have access to the discussion, also due to the fact that Polish patient organizations are rather week. On the other hand, patients get information from the media and often such information is not objective but aims at public attention and "publicity".

Purpose and process analysis

Current Process Stages

	Idee	Pilotprojekt	Strategiepapier	Gesetzgebung	Umsetzung	Evaluation	Veränderung/Richtungswechsel
Implemented in this survey?

Initiators of idea/main actors

• Regierung: The MoH, on the one hand, is the organ responsible for the definition of the legal conditions (criteria for the waiting lists) but, on the other hand, in case of some specialized and costly procedures, the MoH is also a payer (services payed directly from the central budget).

• Leistungserbringer: Health care providers are in a difficult situation: in an atmosphere of anti-corruption efforts in the sector they are forced to support the idea (clear rules) despite the time costs they will face for the fulfillment of the formal conditions (data collection and management).

• Kostenträger: The NHF has a strong interest in elimination of under-the-table payments and in a clear relationship with providers (concerning the process of all health care services recording). It supports the idea of service limitation.

• Patienten, Verbraucher: Patients are interested in the widest possible access to health care services but it does not necesserily mean that the mechanism of guidelines is understood by them as a tool for accessibility improvement (they sometimes approve under-the-table payments).

• Medien: The media treat problems concerning waiting lists as one more type of controversial news that brings them publicity.

Stakeholder positions

The new guidelines confirm the previously used differentiation between two main types of patients:

1. "urgent patient" cases and 
2. "stable patient" cases.

The first one is defined as a patient in urgent need of health care services due to the dynamics of the disease process and to the possibility of a sudden and fast health status deterioration and decrease of the chances for health recovery. The second is defined by the use of a negative definition (exclusion of the first case): all cases that are not qualified as sudden and urgent cases should be recognized as a stable case.

Joint development of wait list management criteria to increase acceptance and transparency

The main change concerns the clear statement of the MoH that the guidelines should be elaborated as a piece of legislation - and not just under the unique competence of MoH. In this respect the MoH initiated the preparation of such legislation. In the policy paper published by the MoH the New Zealand example has been recalled as a good practice example (the internet link to the issue has been included into the policy paper). The MoH appeals now to the medical professionals society for further cooperation in this respect.

Inclusion of medical, social and economic criteria in wait list management

The paper also mentions that apart from the medical perspective some social and economic criteria should be included into the set of guidelines (and recalls examples of New Zealand and Kanada in this context).

Such a change of attitude towards waiting list criteria may cause some problems concerning the management process. Moreover, the independent decision of a doctor, which was so far based on his knowledge, experience and strictly on medical conditions, may suffer and doctors may not approve such "interference" to their professional competences. Taking into account the last Polish research on health inequalities, poverty and social exclusion in relation to access to health care services such a change of attitude seems to be however coherent to the results of different research on this issue. In fact, it may cause not only problems on the professionals side - patients may also be doubtful about the feasibility to implement such new social criteria. Among such criteria there are of course some that are very easy to employ (eg. income per capita in a family) but some may not be so obvious and slightly "flexible". Patients are interested in the widest possible access to health care services but in some cases they would like to have also another choice - eg. additional insurance that would give them a chance to avoid the waiting list or even under-the-table payments.

The NHF is willing to eliminate "under-the-table" payments but first of all the NHF will choose the solutions that aims at the limitation of health care services. Health care providers as professionals support the idea of clear and precise rules for patient placement on the list. They would probably prefer the use of strictly medical criteria in this respect and would not easily accept the social or economic criteria (even as an additional type of criteria). Doctors would probably not support the idea of a complicated system of data registration if they would be obliged to mange it themselves. The services providers have so far been obliged to provide the NHF unit on voivodship level with the proper information about the number of patients placed on the waiting list and about the average time of waiting (it should be reported annually). But this obligation may be further developed and expanded (additional information, more frequent reports). Up till now the maintenance of the lists was a duty of service providers rendering their services in the following areas: outpatient department treatment, hospital treatment, rehabilitation, stomatology (also the ortodontal outfit and dentures), psychiatric treatment, and long-term care. It should also be mentioned that the idea has been strongly supported by the national consultants and some professional gremiums (The Medical Chambers).

Actors and positions

Regierung
MoH	sehr unterstützend		stark dagegen
Leistungserbringer
Hospital	sehr unterstützend		stark dagegen
Medical Chambers	sehr unterstützend		stark dagegen
Kostenträger
NHF	sehr unterstützend		stark dagegen
MoH	sehr unterstützend		stark dagegen
Patienten, Verbraucher
Patients	sehr unterstützend		stark dagegen
Medien
TV	sehr unterstützend		stark dagegen
current    previous

Influences in policy making and legislation

The work on the new regulation on the criteria for patient placement on waiting lists has just been started in 2007. The MoH invited different interest groups to the discussion and at the moment some parts of the guidelines (for particular specialized fields of medicine) have been prepared in the form of the project (available on the MoH website). The last changes have been added on 20.08.2007 (in the field of psychiatry, radiotherapy in oncology and in the field of medical rehabilitation). The future legislative process depends on the work progress and probably will take some more time. There are projects of guidelines for 16 separate disciplines (specializations) of medicine elaborated at the present moment (the last three of them finished on 20th of August 2007). In the near future the ICD codes will be added to the prepared guidelines (and all of the projected "parts" of guidelines that are already prepared are "visible" on the MoH websites).

Actors and influence

Regierung
MoH	sehr groß		kein
Leistungserbringer
Hospital	sehr groß		kein
Medical Chambers	sehr groß		kein
Kostenträger
NHF	sehr groß		kein
MoH	sehr groß		kein
Patienten, Verbraucher
Patients	sehr groß		kein
Medien
TV	sehr groß		kein
current    previous

Positions and Influences at a glance

Adoption and implementation

In the adoption and implementation process health care providers and the National Health Fund units at the voivodship level  will be involved because they are the main players concerning the waiting lists management and responsible for implementing the formal criteria concerning the proper functioning of the system for information collection and dissemination.

Monitoring and evaluation

The Ministry of Health monitored the problem of waiting lists and waiting times with the help of the computer program "Package of Health Care Provider" which was implemented by the National Health Fund. The program provided tools that allowed for waiting list services management by providing information on the following issues (given only as examples): review of the waiting lists, review of status of patients on the waiting lists, review of the statistics, shift within the list, cancellation from the list etc. After almost two years since the previous report on waiting lists issue, the question of formalized and legal guidelines seems to be resolved in about one more year time (the criteria have to be elaborated separately for each  field of medicine and then discussed and adopted in a form of unified piece of MoH regulation).

Expected outcome

The waiting list problem would never find a solution that satisfies all patients' needs. The shortage of resources in a public health care system constitutes a major problem and a constant obstacle to absolute equality in access to some very expensive services. What makes it worse, even the introduction of additional (private) insurance into the system would not resolve this issue: private insurance companies tend to limit the scope of services and mostly exclude the most expensive services from the basket and the poorer groups of society would not be able to buy additional insurance. Furthermore, technical medical "devices" are undergoing a process of  constant development that influences the costs.

In such a situation the only one thing that is possible is to make the rules for patient placement on waiting lists as transparent and just as possible. The other thing is that such rules should be widely approved by society: patients, professionals and decisions makers. This calls for discussion and consultation, both on the professionals' and patients' side. The present situation, ie. the possibility to check waiting lists via the internet does not realize the equal access rule - in Poland the use of computers is still not so common especially among elderly people or in the country. Therefore, the new regulation should include not only guidelines for placement on waiting lists, but in experts' opinion also some technical conditions concerning access to information (dissemination rules), providing real access and professional help in this respect (eg. in the primary care unit).

Impact of this policy

Qualität	kaum Einfluss		starker Einfluss
Gerechtigkeit	System weniger gerecht		System gerechter
Kosteneffizienz	sehr gering		sehr hoch
current    previous

The impact of the new waiting list guidelines on quality of health care services may be described as neutral - it does not influence health care services and prices of services. But the new guidelines strongly influence the level of equity: due to transparent procedures and clear criteria the whole system would be more fair. The impact on cost-efficiency is also high: the cost -effect relation has been introduced to the priorities of waiting lists guidelines (see above).

References

Sources of Information

Ministry of Health. The MoH project on the guidelines for waiting lists problem. www.mz.gov.pl/wwwmzpl/index?mr=&ms=&ml=pl&mi=448mx=0&ma=6171   

Ministry of Health: MoH Regulation from 26th of September 2005 on the set of criteria in choosing patients from waiting list (regulation establishing health care providers procedures). 2005.

Law from 27th of August 2004 on health care services financed from public funds. OJ no 210, clause 21350, article 137 p.10.

Reform formerly reported in

Criteria to choose patients from waiting lists Process Stages: Umsetzung, Gesetzgebung

Author/s and/or contributors to this survey

Mokrzycka, Anna

Author works as a Lecturer in the:

Health Policy and Management Department
Institute of Public Health
Medical College, Jagiellonian University
31-531 Kraków
Grzegórzecka street 20

Tel: (12) 424-13-74, (12) 424-13-6
Fax: (12) 421-74-47
E-mail: amokrzycka@poczta.onet.pl

Empfohlene Zitierweise für diesen Online-Artikel:

Mokrzycka, Anna. "Guidelines for waiting lists". Health Policy Monitor, October 2007. Available at http://www.hpm.org/survey/pl/a10/4