Friday, 16 June 2017

#ClinicSpeak: the waiting game

Understanding why healthcare systems have delays is important. #ClinicSpeak #MSBlog #BrainHealth

In response to my post yesterday, on delays in the MS path and comments from you, today's post is an attempt to explain the reason for the waiting game (even in the USA) and its potential consequences. I have also included a survey to explore what are acceptable delays for you as individuals with MS.

The following perspective on why healthcare systems build-in waiting times into their services is self-explanatory. If you want to optimise the use of resources and maximise profits you need waiting lists. Waiting lists means you maximise the use of your staff and healthcare infrastructure. Healthcare is big business and has to generate income and return on investment. The NHS is no exception, but due to under-investment the NHS tends to push this policy to the extreme and as a result there are major consequences for people with MS and other diseases. The NHS tries to address the latter issues by using triage systems for prioritising urgent problems, for example the 2-week target for cancer.

Healthcare provider's who have no waiting times have to invest in extra, or spare, capacity to meet fluctuating demand. Excess capacity costs money and these providers simply charge more for their services. This is why the Mayo Clinic and the Cleveland Clinic, who were mentioned in comments yesterday, charge more than other providers. The extra charges pay for spare, or idle, capacity that these and other institutions have. So in reality waiting lists are dictated by finances.

Ryu & Lee. The Waiting Game — Why Providers May Fail to Reduce Wait Times. N Engl J Med 2017; 376:2309-2311.


.... When patients wait weeks or months for physician’s appointments, bad things happen. Some adverse consequences are emotional: patients become anxious and even angry. Some are clinical, such as medical issues that worsen, especially if patients don’t show up when their appointments finally roll around.

..... But other consequences of long waits are financial, and they help explain why most health care providers have dragged their feet in cutting waiting times for all types of visits, but particularly for specialty care. Redesigning care to reduce waits requires investing in systems, may reduce revenue, and will irritate physicians who like to control their schedules.

...... Understanding the financial dynamics of the “Waiting Game” can clarify the strategic context in which waiting times are most likely to fall. It also sheds light on the implications of fee-for-service versus value-based payment methods for the way practices and systems approach the access conundrum.

...... Waiting has emotional effects on patients. Uncertainty causes anguish, particularly in patients concerned that disease may be progressing and intervention opportunities may be lost. Other variables such as teamwork, communication, and empathy are more powerful drivers of patients’ likelihood of recommending clinicians to others, but no one likes to wait. Data reveal a dose–response effect: the longer the wait, the lower patients’ satisfaction with care. When patients have to wait weeks for a specialist appointment, their satisfaction falls off a cliff.

...... Given this trend, it’s ironic that physicians often cite long waiting times as evidence of their excellence. Physicians and practice administrators rationalize delays by noting that they’re already working flat out and demand for their services is simply too great. Most deny that they like having long waiting lists, but when their lists shorten they worry that competitors are taking their business. In a fee-for-service environment, physicians dread having open slots in their schedules, bringing in no revenue while expenses mount.

...... The longer patients wait for their appointments, the greater the chance that they won’t show up (see graph Relationship between Waiting Times for Appointments and No-Show Rates.). No-shows are as problematic from a fiscal perspective as unfilled schedule slots. To reduce their impact, practices often “double-book” patients, which makes volume surge when all patients show up. The result may be chaos, with angry patients waiting an hour or more and dispirited clinicians and staff trying to both appease and care for them.

...... In short, it requires recognizing that the Waiting Game provides rewards for letting patients wait, or at least makes investments in reducing waits less attractive than other uses of providers’ resources. But as providers compete on their ability to improve value for patients, the Waiting Game should be subsumed under the more strategic challenges of attracting patients and meeting their needs as efficiently as possible.


  1. Severity of symptoms, type of symptoms and how the patient is coping are important factors I feel should be considered.
    For example brain stem syndromes and weakness or paralysis to limbs in MS can be particularly traumatic. It would be important these traumatic symptoms are managed and a diagnosis is given sooner rather than later in order to start DMT.

    1. Yes, attacks that require admission speed up the investigation and treatment of MS. Part of the delay is the NHS outpatient system.

    2. Attacks that require admission what are the requirements for this?

      I ask this as I had severe brain stem syndrome leading on to paralysis of limbs. Yet I was not admitted to hospital.

    3. AnonymousFriday, June 16, 2017 1:17:00 pm
      Attacks that require admission what are the requirements for this

      Anonymous, sometimes you have to admit yourself to emergency then use a strategy of smiles intermixed with tantrums to stay admitted and investigated.

  2. I would agree with your comment about Mayo Clinic, it is a super expensive option. However, this doesn't explain why fund-deprived health systems have much shorter waiting times than the NHS.

    It took 2 years for my GP in the UK to suspect serious neurological problems and refer me to a hospital. Then it took 6 months to start a DMT and I achieved that only after tons of pressure to anyone who was related to it.

    On the contrary, I've been told it'd take one month to have diagnosis and start a DMT to the public health system of my funds-deprived home country. Yes, it may not be the optimal health system, but we should not measure people's lives on monetary terms. Or at least don't measure them in the same way as in the UK, where money seems to be more important than health.

  3. How do you intend to use the survey results?

    1. I have no idea yet; an anonymous commentator asked me to set this survey up.

      We are doing something similar as part of a Delphi process for our audit tool as part of the Brain Health initiative. It would be nice to see if pwMS agree with HCPs in terms of acceptable delays.

  4. Couple of points: comparing the Mayo Clinic against the NHS is a little bit apples and oranges. Mayo is excellent at diagnostics where the NHS side of the calc is diagnostic plus time to start treatment.

    Given that the time to diagnosis is the problem, and the fact that we now have several treatment options; why can't we focus all research efforts on diagnosis of MS? Wouldn't that be the most value to the most people?


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