Final

 

Report of Working Party

 

Established by the Society of Cardiothoracic Surgeons of Great Britain and Ireland  at the request of the Department of Health

 

to consider a common waiting list policy for coronary artery bypass surgery

 

 

April 2001

 

 

Terms of Reference

To consider the advantages and disadvantages of a common waiting list for first time elective coronary artery bypass grafts patients (CABGs).

¨      excluding urgent patients - all units currently have a common waiting list for urgent “in-house” patients

¨      excluding patients undergoing valve replacement and other complex procedures.

 

Membership of Working Party

 

Mr JRL Hamilton (Chairman), Consultant Cardiac Surgeon, Freeman Hospital, Newcastle.

Mr G Cooper, Consultant Cardiothoracic Surgeon, Northern General Hospital, Sheffield

Mr P Magee,  Consultant Cardiothoracic Surgeon, London Chest Hospital.

Mr S Nashef,  Consultant Cardiac Surgeon, Papworth Hospital, Cambridge.

Mr J Roxburgh, Consultant Cardiac Surgeon, St Thomas’ Hospital, London.

 

 

Executive Summary

¨      The current inequity of access of  patients for coronary artery bypass surgery (CABG) is incompatible with core principles of the NHS.

¨      A common waiting list within units has been proposed.  More radically, regional and national common waiting lists have been suggested.

¨      Common waiting lists are contrary to the principles of informed consent, good communication, and ideal surgical practice.

¨      Options include:

¨      more informed feedback to cardiologists on waiting time for individual surgeons.

¨      a common referral list.

¨      There is an urgent need to develop scoring systems to allow objective assessment of individual clinical need.

¨      A common waiting list is a short-term solution for the chronic problem of inadequate resources – as provision increases with implementation of the National Service Framework, the problem of long and unequal waiting lists will disappear.

Introduction

Core principles of the NHS are:

¨      equity of access to treatment for all patients

¨      clinical care is based on an individual and personal relationship between the patient and their doctor.

¨      provision of care is based on clinical need.
Clinical need: patients referred for CABG are allocated to one of three categories:

i)    unstable angina - remain in hospital.

ii)   urgent waiting list.

iii)   elective

This decision is based on many factors including coronary artery anatomy and severity of angina but is largely subjective.  Much of the variation in waiting time for patients undergoing CABG is accounted for by this decision making process.

 

NB If the provisions of the National Service Framework and the NHS Plan are implemented satisfactorily, the current problem of long, unequal waiting lists will disappear. 

 

Current problem

There is significant variation in the time patients wait for elective CABG.

¨      this paper does not consider patients in need of urgent CABG (ie during the same hospital admission) as all units have already developed a common waiting list to deal with this problem – however even here there is variation among cardiologists in criteria for referral.  Accepted criteria are severe (>90%) left main stem (LMS) disease , moderate (>70%) LMS with occluded right coronary artery and “unstable” angina – however, cardiologists vary in their interpretation of unstable angina and in their criteria for urgent surgery.

 

Mathematically, the waiting list for an individual surgeon is due to an imbalance between the number of patients referred  and the number of his/her available operating sessions.

 

The number of patients referred for CABG depends on several factors – the level of coronary heart disease in the population, the threshold for referral by the GP and the criteria used by the cardiologist for investigation and referral for surgery . There are elements of subjectivity in all these decisions.

 

A very important factor is the variation in the apportionment of surgeon’s time to adult cardiac surgery.  Some surgeons devote all their operating sessions to adult cardiac surgery but obviously not all of these will be for coronary artery bypass grafting.  Other surgeons have subspecialty interests eg thoracic, academic, transplantation, paediatric, or management and so there is significant variation in the number of sessions devoted to adult cardiac surgery.

 

In addition, there may be an imbalance between the provision of catheter lab facilities and surgical facilities.  In the recent past an increase in catheter lab throughput (eg by day case angiography) has not always been accompanied by extra surgical/intensive care provision.

 

Another problem at present, in planning operating lists, is the regular disruption by cancellations due to the national shortage of intensive care nurses - as a specialty we are not in a position to influence this issue.

 

The media perpetuates the myth that surgeons deliberately maintain a long waiting list and waiting time in order to promote their private practice.  This is nonsensical as the waiting list for a department depends on the balance between the number of procedures purchased by commissioners and the facilities provided by the NHS Trust to carry out those procedures. Assuming the surgeon is fulfilling his/her contract and undertaking surgery during the allocated sessions  (if not, this is a separate management issue), the surgeon has no influence over the overall waiting time. However, the time an individual  patient waits for surgery depends first on their clinical priority and it is the surgeon’s responsibility  to prioritise patients referred to them on the basis of clinical need.  At present, the assessment of clinical need is largely subjective, particularly when based on the patient’s description of the severity of their angina.  Thus, there is an urgent need to develop an objective scoring system to define clinical need.  Attempts have been made in New Zealand to use a scoring system to define access to surgery but this has not proved popular.

 

Options

The current 12 month waiting time limit for CABGs forces Trusts to re-allocate patients from surgeons who have long waiting lists – this is obviously not ideal.  Under the status quo, the same provision will apply when the target waiting times are reduced as planned in the National Service Framework.

 

There are three possible options to develop a system which will give equity of access – improved feedback to cardiologists about surgical waiting lists, a common waiting list with the current referral pattern, or a common referral list.

 

1)         Improved feedback to Cardiologists about surgical waiting lists. 

If referrals could be spread more evenly, differential waiting lists would not develop.  This could be improved by providing feedback to cardiologists on the waiting time for each individual surgeon in the hope of influencing referral patterns.  A formal information system has been developed at Papworth: WARP (Workload Adjusted Referral Practice) to address this problem.

 

1.1)      Advantages

¨      would even out some of the current inequalities in waiting time

¨      patients would still be seen , accepted for surgery, and operated on by a specific surgeon

           

1.2)      Disadvantages

¨      may not be sensitive enough to maintain complete equity of access

¨      would not have any significant effect for at least 12 months due to the current backlog.

 

2)         Common waiting list with current referral patterns

            Patients would continue to be referred to an individual surgeon who would see the patient and accept them for surgery.  Patients would then be placed on a common waiting list within the unit. At time of admission, patients would be allocated to a surgeon at random – some attempt could be made to match patients with the original surgeon. It could conceivably be extended to regional or even national level.

           

2.1)      Within a unit

2.1.1)   Advantages:

¨      this would fulfil the aim of equity of access

¨      would be easier to manage.

 

2.1.2)   Disadvantages:

¨      impersonal care (the idea of a common waiting list is particularly ironic coming at a time when care is moving from a consultant-led to a consultant-provided system – this should enhance the personal relationship between consultant and patient rather than diminish it).

¨      consent: the General Medical Council has recently issued guidelines for obtaining informed consent for surgery.  These state that “consent is a process” which begins well in advance of the operation – patients should be allowed time for reflection.  Ideally consent should be taken in outpatients by the surgeon who is going to undertake the procedure. Doctors can no longer treat patients in a patriarchal manner. Patients now rightly expect to participate in the decision-making process about their treatment. Even in the relatively homogeneous coronary surgery patient group, informed consent for an operation is essentially a contract between patient and surgeon.  This contract includes information about the operation, its likely benefits, its timing (optimal and practical), the way it is to be performed (conduit choice, on or off pump, minimally invasive or open, method of myocardial protection etc) and, most importantly, an assessment of the risk of the operation for that particular patient in the particular surgeon’s hands. Without this background, truly informed consent cannot take place. It can be clearly seen that common waiting lists of any type are not compatible with the above principles.