Real-time priority scoring system must be used for prioritisation on waiting lists

Editor—We would like to contribute to the debate in the BMJ about the role of prioritisation scoring systems^1–3 and respond to the BMA’s recent discussion paper on this subject (which briefly mentions our work for a project initiated by the Welsh Office).⁴

Weale dismisses the possibility of providing an infinite variety of treatments to an infinite number of patients from finite resources.⁵ To channel the limited resources effectively, we have argued that the introduction of a clinical management tool incorporating a system of prioritisation based on the patient’s degree of need is necessary.³ Workers at various centres throughout the world have investigated this problem without a clear consensus emerging.¹,²,⁴ Prioritisation variables in common use are social handicap, morbidity, and disease.

Our elective algorithm incorporates these principles and introduces time in a proportionate and cumulative manner, adding the patient’s derived priority score to an accumulating waiting list score each week. The higher the need is scored the faster the progression through the list. Current guarantees in the patient’s charter have been incorporated into the algorithm. An alternative algorithm incorporating the rate of progress of the condition, the ability of treatment to influence outcome, and the patient’s level of pain and distress is used in patients with life threatening problems.

A computerised prioritisation system that changes with time allows more advanced analyses of the list, aiding effective management and resource allocation. The creation of a booking system is facilitated by prediction of admission dates. Potential breaches of the patient’s charter can be predicted and patients diverted to other centres, or demand met with targeted resources.

The priority score for elective cases (termed the patient’s initial quotient) is entered at the bottom of the waiting list. As it grows with time it is redefined as the patient’s eligibility quotient, until the patient reaches the top of the list, at which point it is redefined as the patient’s exit quotient. The summed total of patients’ eligibility quotients, the average eligibility quotient, the mean exit quotient, and various other derivatives are amenable to analysis.

In our opinion the traditional method of analysing waiting lists, with its emphasis on maximum wait and patient numbers, is inadequate. Alternative concepts are needed when prioritising and managing waiting lists and resources. We believe that understanding waiting list dynamics will be possible only when a real-time priority scoring system is used.