#84 Please just tell me when the appointment will be!
18 June 2019
Your patient told you they’d been putting off making an appointment to see you, but now they’re finally at your GP clinic. At first the symptoms weren’t that bad, but they haven’t gone away and it’s starting to affect their quality of life. Perhaps it’s that increasing pain in their hip, intermittent rash or a ringing in the ear that is now keeping them awake at night and affecting their functioning. So you decide your patient needs to see a non GP specialist for assessment; perhaps even an operation.
They don’t have health insurance and can’t afford the out-of-pocket cost of a private specialist, so you decide to send off a referral to the local public hospital’s specialist clinic.
After a few weeks, your patient rings the hospital clinic to find out a date for their specialist appointment but they’re given no idea how long it might be until one is available. You also try to enquire, but no-one can provide an answer. You may even be told they are on the waitlist for the waitlist. Your patient is now on what some call the public health system’s ‘secret waiting list’… and they may be there for years.
This is a scenario that confronts all too many of my patients. Without the funds to see a specialist in the private system, they join an opaque, seemingly endless queue for treatment at a public specialist clinic. Depending on their ailment and where they live, it can be months or even years until their first appointment. (There was outrage recently when it was revealed some people in South Australia had waited more than 16 years to see a specialist.) With an ageing population with more complex medical needs, it’s a problem that is only likely to get worse if we don’t act.
While elective surgery waiting times (the time between a specialist deciding a patient needs an operation and the patient having surgery) are reasonably transparent, data on how a hospital performs for the time to first appointment is notoriously poor. There is no national standard for compiling or releasing it; a situation complicated by the fact that the states use different triage practises. In Queensland, for instance, patients are classified as ‘urgent, non-urgent and routine’, while in Victoria they are simply ‘urgent’ and ‘routine’.
Victoria, it should be said, is arguably one of the better states for releasing data on wait times, and among the best performers in timely treatment. The state recommends that routine patients should receive an appointment within a year and data from the Victorian Agency for Health Information shows 90 per cent of patients are seen within this time.
However, even here there is a frustrating lack of clarity and transparency in providing assistance for the patient in front of me. Often I am not even sure which hospital my patients are eligible to attend. Some hospitals have geographical catchments, but finding this out is almost impossible. Additionally, if I knew my patient faced a nine-month wait, we could have a second discussion about a private referral. They may decide that the expense is better than months of pain and uncertainty. If this is not an option, my management plan while the patient is waiting may well be different.
Patients and their GP can feel abandoned and helpless. This is a situation that can and should be improved.
There are three simple measures that can make a profound difference:
1. Transparency and accountability
Hospitals need to make it abundantly clear which patients they are prepared to accept and how they perform. They should:
- make it clearer on their websites what conditions they treat, which areas they will accept patients from and the required tests and investigations that should be done by the GP before referral.
- publish the expected current waiting time for a first appointment for both urgent and non-urgent referrals for each of their services.
2. What we measure
The UK health system has a target that encompasses the entire process, from referral by a GP to the start of specialist treatment. This ‘Referral to Treatment’ is the clinical measure that matters and is the one that is harder to ‘game’ (having a waitlist for the waitlist).
3. What we think is acceptable
In the UK, the Referral to Treatment maximum waiting time is 18 weeks (for cancer it’s even less). It is a high standard and British hospitals took time to come to grips with it, but there is every reason we should aim to match this system.
As much as possible, GPs should eliminate unnecessary referrals to specialist clinics in the first place. HealthPathways, a practical, free, online tool, can assist with this. HealthPathways, written by clinical GP editors employed at Primary Health Networks, provides up-to-date clinical and local service information for hundreds of conditions and diseases. It helps doctors provide optimal care for their patients and helps the GP navigate the referral to a specialist clinic when needed.
Another strategy is to make specialist advice available to GPs via email or telephone. Often a quick consultation at this level can resolve the GP’s uncertainty, meaning there is no need to refer at all. Overseas experience shows these systems can decrease referrals to specialist clinics by 30 per cent in the first few months of use. I had a recent, informal experience of this when I talked over a case with a friend who is a gynaecologist and was able to resolve my patient’s issue without them seeing a specialist.
Once a patient has seen a specialist we need to ensure they are discharged back to their treating GP with clear clinical handover to ensure continuity of care. This means that GPs who look after the whole of their patient’s health needs can keep on doing this, knowing that specialist care or advice is there when needed.
Opaque waiting lists are not a problem unique to Australia. In any system that aspires to universal health coverage, access to specialist outpatient services is a noted choke point. But experiences in the UK and elsewhere show we can do better. For the sake of my patients, I hope to see those improvements here; sooner rather than later.
Dr Ines Rio
Chair, AMAV Section of GP and North Western Melbourne PHN
This article appears in the June 2019 edition of Vicdoc.