Horizontal and vertical management can reduce waiting times
The negative effects of waiting lists as a rationing mechanism can still be mitigated by improving internal resource use within the health service. Waiting lists can be managed in two ways: horizontally and vertically, and these approaches are closely linked.
With a horizontal approach, beneficial care is prioritised over low-value care, and diagnostic procedures or treatments without a documented effect are eliminated. More is not always better, and considerable efficiency gains can be achieved by reducing overdiagnosis and overtreatment. But how do we determine what is well documented and beneficial? The renowned American healthcare researcher John E. Wennberg (12) categorised health care into three groups: effective care, such as treatments with well-documented efficacy and broad professional consensus; preference-sensitive care, where multiple treatment options exist and patient preferences should carry significant weight; and supply-sensitive care, where the intervention has a low cost–benefit value and consumption is driven by availability.
More is not always better, and considerable efficiency gains can be achieved by reducing overdiagnosis and overtreatment. But how do we determine what is well documented and beneficial?
Wennberg estimated that in the United States, 15 % of healthcare resources are spent on effective care, 25 % on preference-sensitive care and 60 % on supply-sensitive care with uncertain benefit or debatable efficacy (6). Although the United States spends roughly twice as much per capita on health care as Norway and the American figures are not exactly transferable, this framework can nonetheless help inform solutions to the waiting list problem (7). Broadly speaking, the problem is underuse of beneficial effective care and overuse of low-value preference- and supply-sensitive care. Controlling the volume of care and the supply per patient has a greater impact on waiting lists than controlling the price of services. Thus, it is the volume that must be managed. Wennberg notes that deprioritising low-value care is best achieved within clinical networks, but if this is not feasible, it must be centrally managed.
Jeffrey Braithwaite, another international expert in the field, suggests viewing health care in a 60–30–10 perspective (13). According to him, around 60 % of care is supported by sufficient evidence, including cost–benefit considerations; 30 % lacks such evidence and therefore represents a misallocation of societal resources; and 10 % of care is directly harmful to patients.
Broadly speaking, the problem is underuse of beneficial effective care and overuse of low-value preference- and supply-sensitive care
What does this mean for waiting times at Norwegian hospitals? For effective care, waiting times should be minimal in order to avoid loss of life or health. For preference- and supply-sensitive care, waiting times can have a positive, rationing effect. Patients are given time to try conservative treatments and lifestyle changes before undergoing any surgical interventions, for example in cases of hip or knee osteoarthritis. Studies show that systematic exercise can reduce pain and improve function, leading some patients to forgo surgery (14). However, Wennberg demonstrates that supply-sensitive care drives unnecessary utilisation, thereby contributing to unnecessarily long waiting lists. One such example is preference- and supply-sensitive outpatient follow-up.
A vertical approach involves scaling down the specialisation level of diagnostic and therapeutic services (15). The Norwegian health service is primarily based on the principle of lowest effective care level, supported by a well-developed primary care service. However, the specialist health service does not follow this approach (15), and more patients are being assessed and treated at a higher care level by specialists with less broad expertise. This results in parallel appointments with multiple clinicians within the specialist health service.
An intermediate level in the healthcare pyramid, staffed by specialists with broad expertise and the mandate and capacity to address multiple problems in a single consultation, would reduce the number of referrals, which could potentially shorten waiting times.
Wennberg also shows that referring multi-morbid, chronically ill patients to highly specialised, high-intensity care leads to overuse at the expense of both quality and cost-efficiency. He further demonstrates the self-reinforcing negative effect that occurs when unnecessary supply-sensitive interventions trigger additional consultations with different specialists, which leads to a demand for more specialist staff to manage the waiting lists that the healthcare providers themselves have unnecessarily created (12, 16, 17). Increasing resource use in low-value services risks legitimising them, diverting resources from beneficial care and prolonging waiting times.