Medical student perspective: reducing patient waiting times in the UK National Health Service.

Dear editor

We read with great interest the article by Zaghloul and El Enein and agree with the conclusions made in particular regarding overbooking of outpatient services due to a mismatching of resources and the need for efficient outpatient scheduling.1 We believe these points to be relevant to the current status of the National Health Service (NHS), which is facing an ever growing demand for its services, leading to increasing waiting times as a result.2 Across NHS England, 838,600 patients were waiting for a key diagnostic test at the end of November 2015, a 5.6% increase from November 2014.3 Waiting times have been associated with lower patient satisfaction and reduced clinical outcomes.4,5 It is therefore crucial that management teams take an active approach to reducing waiting times. Figure 1 illustrates a process map through which we have developed strategies for minimization of waiting times by facilitating patient flow.

Figure 1

Process map of patient pathway through NHS trust.

Note: Process bottlenecks are highlighted in gray boxes.

Abbreviations: NHS, National Health Service; GP, general practitioner.

Strategy

Minimizing unnecessary appointments

The current referral process involves too many steps causing delays in access to consultations with hospital specialists. As highlighted by Zaghloul and El Enein, follow-up appointments contribute significantly to overall outpatient appointments.1 There are 37 million yearly follow-up appointments in the NHS, many of which are deemed clinically unnecessary. Furthermore, there are currently 6 million missed appointments each year where patients have failed to notify the hospital in advance. Ultimately, this wastes valuable resources such as time, labor, and money, which would be better suited to treating others in true need of medical attention.6

These issues can be improved by eliminating steps, which do not create patient value within the referral process, in accordance with lean transformation model.7 Referrals should be direct between hospital departments rather than the traditional path of returning referrals to general practitioners. Furthermore, NHS England found that only 50% of general practitioners use e-referral effectively, despite the system’s ability to reduce the number of DNA appointments by up to 60% when its use is optimized throughout a trust.8 A qualitative analysis should be performed to understand the current barriers to the use of e-referrals among practitioners.9

Optimizing appointment scheduling

Currently, the scheduling of outpatient and investigation appointments is not aligned to the predictable, fluctuating demands of patient care. The national audit office identified that between Friday and Saturday demand for elective and emergency services falls dramatically, with the former dropping more significantly.8 Multiple carve-out queues add inefficiency throughout this process, especially at times of high demand, increasing waiting times for patients.6

Hence, when forecasted emergency admissions are low, strain on the system is relieved; thus, we propose shifting the demand for elective services to these periods.8 Alternatively, transferring capacity within the system may allow meeting overflow demand. This will include adding appointment slots as needed or making infrastructural changes such as outsourcing demand to other departments.10

Reducing delays in transfer of care

Delays in transfer of care create a bottleneck at the end of the patient process pathway, resulting in backlog throughout the entire trust. Data from NHS England have shown that these delays have been increasing consistently, despite one-third of delays having been shown to be avoidable.11 Two clear problems facilitate these delays; absence of a clear protocol in the discharge process and a lack of available, trained staff competent in discharging patients.

Discharging a patient must become a core goal in treatment, and hence the discharge process must be planned as soon as a patient is admitted. Implementing a guideline-based discharge system, specific to various patient pathways, would significantly decrease length of stay.12,13 Diversifying the workforce by multiskilling nurses can speed up the discharge process when doctors are scarce, allowing discharges to proceed more efficiently.14,15 An educational program must be established, with focus on protocol-driven discharge, ensuring a regulated diffusion of responsibility from doctors to nurses.16

Conclusion

There are many factors contributing to the growing waiting times within the NHS. We have identified three key areas that contribute to waiting and have outlined general strategies for their improvement. We agree with Zaghloul and El Enein that each health care system must focus on scheduling of patients as a key method of optimizing resources,1 although we have highlighted further areas to supplement reduction of waiting times. Ultimately, we believe that it is important to focus on all areas simultaneously in order to improve patient flow, as focusing on just one would shift strain on the system to a different area.