Waiting times usually arise as the result of an imbalance between the demand for and the supply of health services. Although some waiting times can improve the efficiency of resources by reducing idle capacity, these efficiency gains are exhausted rapidly and when waiting times become long (e.g. above two or three months) patient dissatisfaction will increase. Addressing long waiting times for at least some health services was already a challenge for most OECD countries before the COVID-19 crisis, and the challenge will be exacerbated during and after the crisis as treatments and elective surgery are postponed. As a result policy makers will have to trigger changes to improve the appropriateness, responsiveness and efficiency in health service delivery. Such changes also provide an opportunity to make health systems more people centred by measuring waiting times along the patient pathway.
Waiting times for elective surgery, which are usually the longest, stalled in many countries over the past decade or increased at least slightly in others even before the COVID-19 crisis (e.g. Canada, Estonia, Ireland, Portugal). Denmark, England and Finland succeeded in reducing waiting times for many elective health services and maintained these reductions over sustained periods at least before the COVID‑19 pandemic, although in some of these countries waiting times started to increase again as the demand for elective surgery grew faster than the supply.
The right policy mix to address long waiting times is likely to depend on the health system in each country. However, successful approaches typically combine the specification of an appropriate maximum waiting time together with supply-side and demand-side interventions and a regular monitoring of progress. Maximum waiting times can then be used as a target for the provider and/or a guarantee for the patient (as in England and Finland), with penalties for providers not meeting these targets. Waiting time guarantees can also be linked with patient choice policies (as in Denmark and Portugal), whereby patients are offered a greater choice of providers (including private hospitals) when they approach or reach the maximum waiting times without any additional cost for them. On the supply side, only permanent and sustained increases in supply can lead to permanent reductions in waiting times. The Netherlands is an example of a country that increased activity at a rapid pace in the 2000s through a range of supply initiatives that did reduce waiting times over that decade, though waiting times started to rise again in recent years even before the COVID-19 outbreak.
However, supply-side policies on their own are unlikely to deliver the expected reductions in waiting times. The main risk is that the additional supply is offset by an increase in demand, through an increase in referrals, tests and procedures, some of which may be inappropriate. Countries need to ensure that supply‑side policies are linked to maximum waiting time enforcement to avoid disappointment. A demand‑side approach is also necessary to rationalise either GP referrals to specialists, or the propensity of specialists to add patients to a waiting list. Maximum waiting times can act as an indirect policy lever to ensure that when supply increases providers do not offset these by increasing demand (though supply‑induced demand or inappropriate referrals).
Policy makers can also introduce several complementary and more direct approaches on the demand side to reduce waiting times for elective treatment (as in New Zealand), though acknowledging any explicit reduction in demand can be politically challenging (as it can be interpreted as rationing access to care). Clinical prioritisation tools that distinguish between patients with different health benefits and severity can improve the referral process and the composition of the patients on the list. Prioritisation policies can also help to re-allocate waiting times by letting patients with more severe conditions wait less than those with less severe conditions (as in Norway). Strengthening the primary care referral systems from primary to second care, and improving the coordination between primary and secondary care, is a key policy to ensure the resources are used efficiently and to reduce waiting times.
The traditional focus has been on measuring and addressing waiting times in elective care, an area where measures of waiting times have improved by taking a broader look at the entire referral-to-treatment waiting time rather than focussing only on the last part of the patient journey after specialists have added patients to waiting lists. A growing number of OECD countries also measure waiting times in other areas, including in primary care, for hospital emergency department visits, mental health services or cancer care. Waiting times in primary care are less often considered a policy concern than in elective care, and only a few countries (such as Finland, Norway, and Spain) have implemented maximum waiting times to get an appointment with a general practitioner (family doctor) or other primary care providers. Policies in primary care often focus on increasing the supply of general practitioners, nurses and appointment slots. However, more and more countries (such as Australia, Luxembourg and Estonia) are exploiting the potential of new technologies (e.g. teleconsultations) to improve timely access to primary care, and the implementation of teleconsultations and other digital health tools have accelerated during the COVID-19 crisis.
More than half of OECD countries have developed waiting time strategies for cancer care covering both diagnosis and treatment, sometimes as part of national cancer control plans. Countries, such as Denmark, Ireland, Latvia, Poland, Slovenia and Spain, have also introduced fast track pathways for cancer patients, sometimes facilitated by additional dedicated funding and capacity and efforts to improve coordination.
Policies to reduce waiting times policies for mental health services appear to be focused on better meeting demand through increased service volume or scope, rather than managing demand, possibly due to historical underfunding of mental health. In some cases, waiting time targets are part of a drive to increase overall access to mental health services, linked to a broader recognition that a significant treatment gap exists in this clinical area.