[ 28 ]
International Journal of
Health Care Quality
Assurance
9/7 [
1996
] 28–38
© MCB University Press
[
ISSN 0952-6862
]
Improving the quality of out-patient services in NHS
hospitals: some policy considerations
Mike Hart
Department of Public Policy and Managerial Studies, Leicester Business School,
De Montfort University, Leicester, UK
One of the key objectives in
the Patient’s Charter was to
reduce the amount of time
typically spent waiting for
treatment in NHS out-patient
clinics, a documented source
of discontent. Presents the
results of a quality improve-
ment programme instituted at
Leicester General Hospital.
Discusses some of the tech-
niques and problems encoun-
tered in the measurement
exercise. While the results of
the monitoring exercise
indicated that waiting times
were being radically reduced,
doubt is expressed as to
whether this one simplistic
indicator is sufficient to
measure the overall quality of
out-patient clinics. There is a
danger that measurement
systems have concentrated
on that which is measurable
rather than that which is
significant. In particular, the
voice of the patient is not
incorporated into the league
table approach to out-patient
quality. Discusses several
approaches to the measure-
ment of overall quality and
the problems and dangers
inherent in adopting a league
table approach to quality
measurement.
Introduction
In recent years, successive British govern-
ments have applied themselves to the task of
improving the quality and efficiency of the
public services in the UK. One particular
strand of policy has been to privatize or at
least to “market test” a range of services, on
the assumption that a private sector philoso-
phy is better able to deliver the quality of
services that the public demands. Another
strand of policy, running in parallel with the
former, is to publicize various standards in
the forms of charters (e.g. Citizen’s Charter,
Patient’s Charter) and then monitor and
publish the performance of public sector
bodies in meeting the obligations imposed on
them.
This paper will take one such charter, i.e.
the Patient’s Charter, and will examine the
way in which one important aspect of it – the
waiting time that people spend in out-patient
clinics – has been operationalized. After
examining some case-study material which
explores how improvements may have been
effected, the paper then considers whether
the broader objective of the policy (greater
efficiency and effectiveness of the hospital
service) has actually been achieved.
The concern over hospital waiting
times
In NHS hospitals, there are approximately 40
million out-patient attendances a year at a
cost of some £1.2 billion (1988-89 figures)
according to the National Audit Office
(NAO)[1]. About one-fifth of such attendances
may be new referrals as a result of referral by
a GP. The remainder are due to second or
subsequent visits or, more typically, follow-up
consultations following a period as an in-
patient. The fact remains that, for many peo-
ple, the experience of treatment in an out-
patient department is their main experience
of the hospital service. When questioned,
many patients testify to the excellence of
treatment that they have received and are
understanding of any shortcomings in the
service that they may have experienced.
Nonetheless, the one consistent feature of
dissatisfaction which has been expressed
with the out-patient service is the length of
waiting time in the out-patient clinic.
Concern over long waiting times in clinics
appears to have been a consistent source of
dissatisfaction. Evans and Wakeford[2] report
that the main criticism of out-patient services
was the lengthy waiting time, compounded by
an absence of explanation. Nor had the situa-
tion improved by the 1980s. Jones et al.[3], as a
result of their literature search, indicate that
although satisfaction levels were very high,
most discontent was expressed over the
length of waiting time and the provision of
amenities while waiting.
In the 133 clinics surveyed in the NAO sam-
ple, it was found that the average waiting
time was 30 minutes or less in only 47 per
cent of clinics. A comparable finding is
reported by Cartwright and Windsor[4]
although their data were collected in spring
1989 (see Table I).
It is interesting to observe the tolerance
expressed by the vast majority of patients for
waits of up to half-an-hour, after which time
their tolerance understandably diminishes.
The “30-minute threshold” was incorporated
into the Patient’s Charter[5] as a National
Charter standard i.e.:
Table I
Waiting times in clinics (percentages): national
sample (1989)
Proportion
who found
Time spent Cumulative wait
Time (minutes) waiting percentage unreasonable
Less than 10 11 11 2
10 < 20 18 29 2
20 < 30 16 45 2
30 < 45 14 59 10
45 < 60 13 72 34
60 < 90 13 85 44
90 < 120 99461
120 or more 6 100 77
All out-patients 639 23
Source: [4, Table 26, p. 59]