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Booking systems for elective services A literature scan to ---

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Booking systems for elective services A literature scan to ---

    Booking Systems for Elective Services in New Zealand:

    Literature scan to identify any ethical issues

    of national significance

    A report to the National Ethics Advisory Committee

     25 February 2005

    Sarah Derrett

    Centre for Health Planning and Management

    Darwin Building

    University of Keele

    Staffordshire

    ST5 5BG

    United Kingdom

Preface

    This report to the National Ethics Advisory Committee (NEAC) is based on a scan of literature reporting research and developments related to New Zealand‟s booking

    1system. The purpose is to assist NEAC identify any ethical issues of national significance addressed, or raised, about booking systems for elective services. The focus is on publications reporting research and/or discussing the NZ booking system and accompanying policy. The scanned research projects were variously funded by:

    2the New Zealand Health Research Council, small grants, or the Ministry of Health.

    The developmental, Continuous Quality Improvement (CQI) work referred to in the report, has been undertaken by members of the Elective Services Group within the

    3Ministry of Health. Because booking system developments are ongoing,

    conversations with civil servants about current research and policy developments in

    4NZ also inform this report.

An „elective‟ (non-urgent) condition has been defined as one „not requiring

    immediate treatment, such as a hip replacement or cataract operation‟ (Elective Services Group 2004). The term „urgent‟ (acute) generally refers to conditions that, if left untreated, may result in death or considerable disability (e.g. certain cancers

     1 Sarah Derrett (SD) is a lecturer in health services research and MBA (Health Executive) programme director at the Centre for Health Planning and Management, University of Keele. She is on the steering group of the NHS Service Delivery and Organisation-funded research project examining the current use and development of GP referral guidelines and practices for elective surgery in the NHS (REFER Research Team 2004). Together with former colleagues (Associate Professor Charlotte Paul, Dr Robin Gauld, Associate Professor Peter Herbison , Dr Jenny Morris and Ms Sue McAllister) from the Department of Preventive and Social Medicine, University of Otago, she has undertaken research evaluating the perceptions, experiences and health status of i) patients on former waiting lists for surgery and ii) patients assessed and prioritised for surgery according to the introduced booking system for elective surgery.

     2 Research undertaken by the NZ CPAC Evaluation Consortium.

     3 The Elective Services Group within the Ministry of Health runs a programme alongside the booking system which “aims to implement a strategy to achieve improved equity of access to treatment, certainty and timeliness…[and] assist in the provision of clear information for patients and their carers regarding their eligibility for publicly funded elective services and to improve the management of waiting times for elective services” (p.3) (Williams and Gandar 2004).

     4 SD is most grateful to Dr Ray Naden, Ms Alison Barber and Mrs Helen Williams (from the Ministry of Health Elective Services Group) for agreeing to speak with her about current developments in New Zealand, and/or providing her with reports, unpublished communication and/or conference presentations at short notice. SD is also very grateful for the helpful comments on earlier versions of this report received from: Dr Andrew Moore (Chairperson of NEAC), Associate Professor Charlotte Paul (NEAC Committee member and formerly fellow-researcher of patients‟ health status and

    experiences of waiting lists and booking systems ) and Dr Ray Naden. Of course, responsibility for any errors or omissions is SD‟s.

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    and cardiac conditions). However, the boundary between elective conditions and urgent conditions is sometimes blurred in relation to elective services‟ prioritisation. For example, non-urgent conditions may be progressive and ultimately result in an acute health problem. Sometimes the priority tools (Clinical Priority Assessment Criteria CPAC) prioritise access to treatment across the range of conditions treated within a clinical specialty, including both urgent and elective conditions. Because of difficulties separating elective and urgent conditions, this report sometimes refers to

    5 prioritisation for both elective and urgent conditions.

    The report contains four sections. Section 1 provides a background to the booking system for elective services its origins, aims, patients‟ pathways through the

    system and a patient-centred framework for considering any ethical issues arising from the system. Section 2 presents the results of the literature scan. Section 3 is a summary and Section 4 contains concluding comments.

     5 To SD‟s knowledge, no research has been published reporting on prioritisation for conditions

    requiring exclusively medical treatments within New Zealand‟s booking system. Therefore the report often refers to elective surgery rather than elective services. However, any ethical issues raised by the booking system for conditions requiring surgical treatment may well be similar for conditions requiring medical treatment.

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Contents

Preface ................................................................................................................. i

    1. Background ............................................................................................. 1

    1.1 Origins of the booking system ...................................................... 1

    1.2 Aims of the CPAC prioritisation tools and the booking system ..... 4

    1.3 The booking system pathway to elective services ......................... 4

    1.4 Framework for considering any ethical issues arising from the

     literature scan ............................................................................... 8 2. Literature scan to identify any ethical issues of national significance arising

     from the booking system ........................................................................ 11

    2.1 Referral pathways and processes ................................................ 11

    2.2 Hospital outpatient clinics and Assessment Criteria for first

    Specialist Assessment (ACA) ..................................................... 16

     2.3 CPAC tools and prioritisation ..................................................... 18

    2.3.1 Reliability ....................................................................... 19

    2.3.2 Validity .......................................................................... 20

    2.3.3 Implicit and explicit CPAC tools .................................... 22

    2.3.4 The CPAC scoring process ............................................. 24

    2.3.5 CPAC and patient outcomes ........................................... 27

    2.3.6 CPAC tool use and „gaming‟ .......................................... 35

    2.4 The Treatment Threshold and use of resources ........................... 38

    2.5 Certainty, re-referral and reassessment ....................................... 43

     2.5.1 Certainty about status...................................................... 43

     2.5.2 Re-referral and reassessment ........................................... 45 3. Literature scan summary ........................................................................ 48 4. Concluding comments ........................................................................... 54

    List of Abbreviations ......................................................................................... 58 Reference .......................................................................................................... 59

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1. Background

    The NZ booking system origin, aims and functioning are briefly described because they: 1) raise issues of ethical significance through identification of weaknesses associated with the antecedent waiting list system, and 2) influence the nature of research and developmental projects evaluating and appraising the booking system.

1.1 Origins of the booking system

    NZ is unique in developing explicit prioritisation tools and systems for managing the

    6prioritisation and rationing of access to state-funded elective services. Before the

    introduction of the booking system, access to surgery was rationed according to waiting time (delay). Patients, placed on waiting lists, were generally not given dates for surgery, but were usually given indications of the possible duration of wait (Fraser, Alley et al. 1993). There was a degree of prioritisation within the waiting list. Patients were allocated an implicitly determined priority ranking by surgeons: A (urgent), B (semi-urgent) or C (routine). Patients with a priority of „A‟ were to wait a

    7shorter period of time than patients with a priority of „C‟. Patients also arrived at

    hospitals acutely (as emergencies) and surgery would usually then be provided within 24 hours (Cranfield and Comber 1989).

    Lengthy waiting lists for surgery were identified as a prompt for the NZ health service reforms enacted in the Health and Disability Services Act 1993. A Green and White Paper recommended the formation of an advisory committee to advise the Minister of Health on the allocation of health care resources (Upton 1991). In 1992 the Core Services Committee (CSC) was established. The CSC undertook public

     6 Other countries have developed, or are developing, systems for prioritising access to treatment but these initiatives do not rely on score thresholds to ration access to services (see 1.3 for discussion of the score threshold). NZ is unusual in making its determinations about which patients will or will not access services on the basis of explicit scoring of those patients‟ relative priority. Other countries with

    elective service prioritisation systems also make decisions about which patients will, or will not, gain access to services but make these rationing decisions implicitly (usually according to clinical judgement) (Derrett, Devlin et al. 2002). In such systems, the prioritisation process is used solely to determine the waiting list „queue order‟ or the „timeliness of access‟ to treatment.

     7 Anecdotally, a study undertaken with 149 patients on waiting lists for surgery at Dunedin Hospital revealed that many patients had been informed of their priority ranking after the outpatient assessment (Derrett 1997).

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    consultation exercises and commissioned a report by Fraser et al that summarised some of the problems associated with waiting lists. (Fraser, Alley et al. 1993).

    Identified problems with the former NZ-style waiting lists include:

    ; efforts to reduce the list size being accompanied by paradoxical waiting list

    increases; inaccuracies in the numbers of patients waiting (Porter 1985;

    Fraser 1991; Lee, Don et al. 1991; Riley, Grupcheva et al. 2001);

    ; inappropriate deterrent effects where some patients do not present for

    surgical assessment because of list size and the perceived duration of wait

    (Bloom and Fendrick 1987);

    ; the potential for conflicts of interest where surgeons with long public sector

    waiting lists may benefit because patients may believe they need to pay for

    private treatment to receive timely access (see Yates);

    ; variation between surgeons in implicit decision-making about the indications

    for surgery and placement of patients on the waiting list (Fraser 1991;

    8 Hadorn and Holmes 1997b);

    ; poor relationships between implicit priority ranking (A, B, C) and health

    status (Derrett, Paul et al. 1999);

    ; adverse consequences to patients of lengthy waiting times (Mulgan and

    Logan 1990; Rigge 1994; Martin, Elliott et al. 1995; Derrett, Paul et al. 1999),

    and

    ; little certainty for patients about the duration of wait and poor pathways of

    access to timely reassessment should patients‟ conditions deteriorate (Derrett,

    Paul et al. 1999).

Fraser et al. recommended:

    …the present system of hospital waiting lists be abandoned and replaced by a

    system of ‘booked admissions’ for non-urgent surgery and medical and diagnostic

    procedures. Patients should be assessed by defined criteria, according to their need

     8 To the reviewer‟s knowledge, the criteria by which clinicians made their decisions about i) access to the waiting list and ii) A,B,C ranked priority within the waiting list have not been explicitly stated or publicly available. Perhaps the historical absence of publicly available decision-making criteria indicates the inevitable complexity of the clinical decision-making. The development work undertaken by the CPAC Consensus Working Groups suggests firstly that some agreement about the key decision-making criteria could be arrived at; and secondly, that universal agreement about the decision-making criteria is problematic. Recently, research undertaken in New Zealand has further indicated the range and quantity of underlying constructs influencing implicit clinical decision-making (MacCormick, A., Macmillan et al. 2004).

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    and likely benefit (worthwhile health outcome) from the procedure. Patients who

    satisfy the criteria should be offered a date for surgery within a defined period of

    time. Patients who do not meet the criteria at the time of their specialist assessment

    should not be registered with the hospital’s booking system (or placed on a ‘waiting

    list’), but should be referred back to their general practitioner for ongoing review

    (Fraser, Alley et al. 1993)(p.8).

    The CSC then facilitated the formation of Consensus Working Groups to develop Clinical Priority Assessment Criteria (CPAC) tools for prioritising patients referred for access to high volume high cost elective procedures (National Advisory Committee on Core Health and Disability Support Services 1993; Hadorn and Holmes 1997a; National Health Committee 2002).

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1.2 Aims of CPAC prioritisation tools and the booking system

The CPAC tool development and booking system aimed to:

    ; Develop a fair and consistent means of defining priority

    ; Permit assessment and comparison of need, case-mix and severity ; Ensure the inclusion of social values in decision-making

    ; Allow appropriate and transparent decision-making

    ; Make possible national studies on health outcomes for patients who do and

     do not receive surgery

    ; Ensure that patients with the greatest need and potential to benefit received

     treatment first

    ; Provide certainty to patients about the timing of treatment

    ; And provide nationally consistent access to surgery

    (National Advisory Committee on Core Health and Disability Support Services 1995; Shipley 1996; Feek 2000; Ministry of Health 2000).

    The next section briefly describes the booking system as it was, and now is, intended to function.

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1.3 The booking system pathway to elective services

    In NZ the „booking system‟ refers to the entire process governing access to elective surgery from the time when patients first seek advice about their condition from

    9 The primary health care professionals (usually GPs) (Gauld and Derrett 2000).„booking system‟ begins with the use of referral guidelines by GPs to determine the appropriateness of referral. The letters of referral are then prioritised at outpatient clinics according to Assessment Criteria for First Specialist Assessment (ACA). ACA guide the speed of access to outpatient appointments with surgical consultants. The next step in the booking system process occurs at the outpatient clinic after the surgical consultant has determined or confirmed the patient‟s diagnosis and fitness for surgery. Patients are then „scored‟ using CPAC to determine whether or not they gain access to surgery, and if so, the speed of access to surgery. It is not until this CPAC scoring has occurred that patients are either „booked‟ or „not booked‟ for surgery.

    The final „booked‟ status is dependent on the Treatment Threshold (TT). The TT is the CPAC score at or above which patients are eligible to receive surgery in a state-funded NZ hospital. This is ultimately governed by allocation of funding to services from the funder arm of the District Health Boards (DHBs) to the provider arm. Initially the score threshold determining access to surgery was known as the Financially Sustainable Threshold (FST), and colloquially known as the Financial Threshold. The FST was calculated by 1) estimating the number of anticipated discharges for the coming year (by considering total case-weights purchased by the DHB funders and the numbers of procedures undertaken in the previous year), 2) cumulatively summing the CPAC score profiles for a sample of previous patients and graphing this information, and 3) entering the purchased number of cases and locating the CPAC score on the X-axis of the graph to determine the FST.

     9 In England, the term „booking‟ refers to particular components of the pathway to elective surgery –

    rather than the overall pathway. The NHS „booking system project‟ has focussed on the booking of outpatient appointment slots for patients to be assessed by the surgical consultant (Devlin, Harrison et al. 2002; Ham, Kipping et al. 2002; Kipping, Robert et al. 2002; REFER Research Team 2004), alongside initiatives for greater patient choice. Generally in England, „booking‟ does not relate to the

    use of referral guidelines, ACA or CPAC-type priority scoring tools. Although such tools are being developed and used throughout Primary Care Trusts (PCTs) and Hospital Trusts to guide or even determine access to outpatient appointments and/or surgery; these are the result of local initiatives rather than national policy (Selvachandran, Hodder et al. 2002; Demand Management Team and Orthopaedic Services Collaborative 2003).

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    More recently, and in an effort to simplify the calculation of the threshold, other terms have been used to describe the CPAC score thresholds determining access to surgery. The Actual Treatment Threshold (aTT) is used to inform one of the Elective Services Performance Indicators (ESPI 3). The aTT is the CPAC score at, or above, which 90% of patients were treated in that local service over the past 12 months, and is argued to be the best indicator of the next years predicted or forecast Treatment Threshold (TT). The aTT is set at the priority score at, or above, which 90% of patients received that elective treatment in the past year to allow for the fact that the threshold will not necessarily be precise over the next 12 months because of unanticipated capacity management issues affecting the provision of elective surgery and also to allow for the “…small number of patients with exceptional circumstances [that] will need to be given higher priority than the CPAC would indicate, or offered surgery even when their relative priority does not reach the normal threshold” (Naden 2003). A further

    threshold term has also been identified. This is the Commitment Threshold (CT). The CT is the score at which DHBs agree to provide certainty to patients that they will receive elective treatment within the next six months (from the time of their outpatient FSA). The Commitment Threshold is meant to be based closely on the previous year‟s aTT although there are reports of some DHBs setting their CTs at much higher levels than their aTT (Naden 2003).

    When the booking system was first introduced a Clinical Threshold also accompanied the CPAC tools. This was the CPAC score at which clinicians believed surgery should ideally be provided. In part because of ongoing difficulties removing patients from residual waiting lists, the explicit identification of Clinical Thresholds for each CPAC tool was abandoned and a system of Active Review (AR) was introduced with the aim of addressing the needs of patients clinically in need of surgery but with CPAC scores beneath the TT.

    When first introduced in 1996, the booking system required patients with CPAC scores beneath the TT be returned to the care of the primary health care referrer until such time as their condition deteriorated necessitating a re-referral to an outpatient assessment and re-entry to the referral guidelines/ACA/CPAC assessment pathway. More recently, the Active Review (AR) system has introduced the possibility of hospital-led follow-up for patients with CPAC priority scores falling just beneath the

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