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Програма PHARE
Small Projects 2004
Europe Direct
Портал Европа
Препоръка No. R (99) 21 относно критериите за управление на списъците на чакащите и записването на часове в сферата на здравеопазването
Приложение към Препоръка No. R (99) 21
Приложение към Препоръка No. R (99) 21

General considerations

1. The health care systems in European countries are experiencing both increasing expenditures and rising demands for their services. In most countries there is a gap between what health services are able to do and what they can afford to do. One consequence of this is that some patients face delays, or waiting times, before getting specialist care and there can be waiting lists for some services. European countries have different health care systems that exist in varied political and cultural environments. The channels through which patients have access to specialist care also differ between member states and there are contrasting degrees of public and private provision and funding. The emerging issue in some countries is a risk of fast-tracking when employers send their employees directly to special services, not accessible to other patients (or register them earlier on waiting lists). The organisation and provision of health care is an important factor to consider when examining waiting times and waiting list issues. This recommendation does not deal with the issue of waiting lists for organ transplantation

2. Waiting times and waiting lists give focus to particular parts of the health care system, mainly elective surgical care, but they can not be seen in isolation. Policies to address waiting times will need to reflect the relative priorities for achieving improvements in the whole health system, including self care, social care, primary care, preventive care, secondary care, rehabilitation and long-term care.
Policies to address waiting times will need to bear this in mind, as other services otherwise may suffer, including:
- preventive care;
- care for the elderly;
- psychiatric care;
- primary health care;
- rehabilitative services, etc.
Appropriate management of waiting times and waiting lists (where they exist) may also prevent patients from going abroad to receive care.

3. Waiting lists and waiting times are quality issues and work to reduce delays in access to care should be part of the quality improvement system or program, both at institutional, regional and national levels.

4. Waiting lists and waiting times are not necessarily representative only of the need for health care, but may reflect various aspects of the health care environment and organisation. The existence of such a system usually translates society’s wish to ensure a fundamental principle: that access to health care should be available to all according to their needs, and regardless of their ability to pay.
In a system of liberal medicine, based on supply and demand, the use of waiting lists as an instrument for prioritisation does not usually exist, and preference tends to be given to other instruments aimed at reducing demand, such as co-payments.
The waiting lists may reflect an increased demand and higher expectations. They could also be manipulated by the managers and by hospital staff, especially in smaller units.

5. A goal of waiting times policies should be to ensure that access to treatment is based on transparent criteria, agreed at national level, that address the risk of deterioration both in clinical (pathological) and quality of life (functional) terms. These criteria determine thresholds for providing treatments or for determining priorities once patients are on a waiting list.

6. There is no single explanation for the existence of waiting times and it is important that their causes are investigated before any action is taken to reduce them or to allocate additional funding. Before such action is proposed, long waiting times should be analysed and any bottlenecks within the provision of care addressed through appropriate action by clinicians and hospital staff.

Criteria for assessing and treating patients

7. Within secondary care, priority should be accorded to patients needing emergency admission but policies should also be in place to improve access for patients requiring elective diagnosis and treatment. Distributions of waiting lists and waiting times are important benchmarks of equity in health services. The central principle of access to care irrespective of the client’s ability to pay should be taken into account. Access to elective care should be based on agreed criteria, and if patients are placed on waiting lists then this should be on the basis of standardised measures that can be used within all specialities and, ideally, for all procedures. These criteria and measures should be agreed at national level through an open and consultative process

Registration of patients on to a waiting list
8. All patients referred for diagnosis or for whom a decision to refer or to treat has been made should be registered by the relevant clinic or hospital and the date of the referral or decision recorded.
Consideration should be given to developing a standardised minimum data set for registration within member states that is consistent across all providers and specialities, with data ideally at the level of individual diagnoses and procedures. This should be in accordance with national and international policies applying to the collection and processing of health data

9. Once a decision to treat patients has been made, all patients should have a chance of being treated. To give a patient a place on a waiting list means a commitment to give care to that patient.

10. Patients should not be placed on a waiting list as a precautionary measure, that is, on the grounds that they will probably need treatment at some time in the future, and waiting lists should not be used as a means of gaining time.

11. The patient must have given her or his consent to be scheduled for treatment before being put on a waiting list.

Criteria for admitting patients from waiting lists
Priority must be given to patients with the greatest need for services, but waiting times should not be so long that the patients' health is at risk of deterioration. Doctors' decision-making on the individual patient's priority should be supported by nationally agreed guidelines on the criteria to be used in choosing patients for admission in order to maintain the principal goals of equity, fairness and efficiency in health care services.

13. Patients' needs and relative urgency for admission in terms of acceptable waiting times and order on waiting lists should be determined transparently, respecting the patient's preferences and developing and employing criteria that address the risk of deterioration to a patient's clinical status and their quality of life.

14. These criteria need to take account of the fact that need and urgency should never be determined on the basis of race, sex, religion or socio-economic status. Age should not be used to determine priority and should only be taken into account as an aspect of a patient's general medical condition and as a risk factor for particular treatments.

Monitoring waiting lists and waiting times
15. The different levels of organisation in health care do not have the same requirements with regard to necessary information systems to monitor waiting lists and waiting times. These systems should collect data needed to follow up and evaluate policies, and provide information about the past and current waiting list situation to all parties involved in health care decisions, that is:
- the public;
- patients;
- staff.

16 Systems developed to collect data on waiting lists and waiting times need to include arrangements for regular review and validation of waiting lists in order to ensure that they remain an accurate account of patients waiting for treatment.

Informing patients
17 Information about the patient's booking and waiting time situation shall be given directly to the patient, and if the patient has been referred by a doctor, also to this doctor:
- as soon as possible after the hospital has received a self- referral or referral from the doctor;
- at regular intervals, if a booking date has not been established;
- on each request.

18. Ideally, patients should be informed of their admission date at the time when a decision is made to admit them. This may not be possible in all cases, but all patients should be given a realistic estimation of waiting times and of the arrangements made for notifying them of their admission date.

19. Patients are entitled to have adequate information on waiting lists and waiting times in specific settings. They should have access to individualised information about their own ranking on a waiting list through a named contact within the relevant institution. Patients should be able to obtain guidance and assistance from statutory bodies or consumer organisations when interpreting such information and, where the system allows this, enables choices to be made about alternative options for treatment.

20. There should also be a requirement on patients to contact the clinic or hospital if they have decided that they no longer need the treatment, have moved or are unavailable for admission due to family or work commitments.

Informing staff
21. To assist in the organisation of services, the information systems used at institutional level to monitor waiting times should be based on the process of provision of patient care and include data on the following:
a. Waiting lists (booked and non-booked patients):
- number of patients waiting for preliminary contact (outpatient appointment, waiting for diagnosis) in different specialities and, where possible, clinical priority group and prospective diagnosis;
- number of patients waiting for treatment in different specialities and where possible by clinical priority group and intended treatment or procedure;
b. Measures of productivity in relation to the number of patients on waiting lists, for example the numbers of admissions from waiting lists and the use of beds and operating theatres;
c. Patient non-attendance;
d. Quality measures, especially when efforts are made to reduce waiting times, such as readmission rates, unplanned admission rates and mortality rates;
e. Waiting times:
- actual waiting times for the patients waiting on a given date, for example the last day of every month or quarter;
- actual waiting times for the flow of patients who have been treated in a given time period, such as a year;
- expected waiting times for referral or treatment based on data for patients actually treated, such as the distribution of actual waiting times or an average waiting time.
In addition the whole waiting time from initial referral through to treatment should be kept under review.

Informing the public
22. Information about the waiting time situation should be open to the public, including referring doctors without prejudice to the data protection requirements. This could include standardised information at national and regional levels, but should include information on waiting times at:
- hospital level;
- department (speciality) level;
- if possible, diagnostic level.

23. Organisations representing patients and consumers should be involved in the interpretation and dissemination of waiting lists and information on waiting times as well as in monitoring of any problems with access to services.

Management of waiting lists and waiting times
24. Policy recommendations should be developed for the management of waiting lists and waiting times on different organisational levels in the health care system. In the policy document the following issues should be tackled:
- goals for the accessibility of care and access to waiting lists;
- responsibility for the application of waiting time policies;
- acceptable waiting time limits, depending on the speciality, the patient's state of health and diagnosis;
- definition of emergencies and urgent treatment, and the process to be followed;
- selection of patients for admission;
- the booking process;
- guidelines for priority-setting;
- communication with patients and referring doctors including a system for feedback from clients and patients;
- structure of the waiting lists, including necessary data;
- review and validation;
- publication and reporting of waiting lists and waiting times;
- how to handle patients who have been on a waiting list for a long time;
- recommendations on how to solve waiting list problems, that is, if objectives can not be reached, what action should be taken;
- arrangements for the evaluation of the policies applied.

Organisational development
25. Policies for waiting lists and waiting times should identify the responsibility within institutions for managing access to services as well as action to be followed to identify and then address any problems in the process that lead to delays in treatment of patients. A senior member of staff should hold clear responsibility for the management of waiting lists. The involvement of clinicians in the management of access to elective care is important. Work to improve waiting times must examine the organisation and functioning of health care systems and can not be confined to data collection alone.

26. The nature of waiting times and their management should be a part of the undergraduate and postgraduate health care education programmes in European countries. This should be accompanied by information about the principles of prioritising patients who need care.

Further research into waiting times and waiting lists in Europe
27. Research on a pan-European basis should be conducted to enable countries to share knowledge and experience about reducing waiting lists and waiting times in health care. There should be joint research projects into waiting times in European countries, the results of which could be used in different countries. This type of research could include:
- minimum data requirements used within member states for waiting times and waiting list purposes and suggested common data requirements;
- the impact of waiting times on health outcomes;
- equity of access on an age, sex, ethic or socio-economic basis;
- the impact of waiting on vulnerable groups such as the mentally ill or developmentally handicapped;
- a comparison of actual waiting times in health care within member states;
- systems for setting criteria for treating patients;
- booking and admission systems in hospitals;
- communication between hospitals, patients and referring doctors about waiting times;
- delays in informing the referring doctor or specialist of symptoms;
- access to specialist care and its impact on waiting times and waiting lists;
- the relations between waiting times and funding mechanisms for health care;
- cost-benefit analysis of the impact on the economy and society of time spent waiting for elective care;
- definition of waiting times used in member states.
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