It was announced this week that the Outpatients Department at Cork University Hospital (CUH) are changing their appointment system for patients attending the Department. The new system comprises of a timed appointment system only. Not much different to the previous system I hear you say.
Previously patients were given an appointment time, however upon presenting at the Department they were seen at a first come first served basis (regardless of their appointment time) – resulting in strong incentives to come before your time and queue to be seen.
So what does this tell us about the Irish health care system?
Queues and waiting lists are all forms of rationing – an activity which is an integral part of a public health care system such as Irelands’ where demand exceeds supply and resources are scarce.
Using gate-keeping systems, whereby appointments for consultants in outpatient departments are made on behalf of the patient in Emergency Departments or by GPs, aims to reduce inappropriate uses of specialists for generalist advice. Patients are directed towards specialists in outpatients as deemed necessary.
The experienced in CUH to date where people physically waited to be seen on a given day is comparable to the rationing mechanism referred to as queuing. Here allocation of health care services is based on the patients’ willingness to allocate time to queuing for services. This demonstrates the relationship between willingness to allocate time and the social value placed on the service. For example those who place a high value on their time (someone in full time employment; full time care giver etc.) will want to spend the least time queuing.
Such a system is inefficient and inappropriate for the delivery of health care services. It offers a means of maximising efficiency of the health care providers’ time rather than a means to ration services and distribute them fairly and efficiently.
The revised appointment based system implemented in CUH is similar to waiting lists which in principle avoids prioritising higher value demands. Here the underlying assumption is that all cases receive the same weight on the list. Thus it aims to be a fairer means of rationing scarce resources among cases of equal social value.
Despite the fairness of a waiting list system, one could assume that lengthy waiting lists are evidence of inadequate resource allocation within the health service. Thus suggesting more resources are required.
However, is this always the most appropriate solution? If one focuses attention instead on those who are controlling the rationing of resources it could be argued that such decision makers may face perverse incentives. The allocation of additional resources based on the length of waiting lists could be viewed as rewarding inefficient service provision. Such a basis for allocation would create little incentives for service providers to increase productivity and efficiency in outpatient departments.
So what do we learn about the Irish health care system from what appears to be a minor change in service delivery at CUH’s Outpatients Department?
Well Ireland’s health care system is predominantly a public health care system characterised by “under funding” and scarce resources, where demand outstrips supply. This provides an adequate basis for rationing health services. Achieving optimal rationing however is a difficult task but moving from a queue based to waiting list/appointment based system is a step in the right direction. In allocating scarce resources amongst services, decision makers must strive for efficiency and value for money, while providing life saving health services in an equitably and effective way.