The waiting list taboo

Keane-waiting-list

You cannot reduce waiting lists if you do not address the taboo of appropriateness of the question.

Waiting times for specialist visits and diagnostic examinations are one of the most critical issues of the National Health System (i.e. in Italy) and cause a strong discontent among the citizens. Despite this, the problem is still being tackled by trying to intervene only on the supply side.

The resources of the Health System are limited and constant over time and, given the shortage of doctors, destined to decrease in the short term. We can certainly hope that these can be increased to meet the growing demand for health services but, considering the budget, this perspective is scarcely realistic.

Setting maximum waiting times according to clinical priority is a correct theoretical principle, but it risks becoming one more parameter that health authorities are unable to respect. It is discussion area on which, however, it is easy to find the consensus of all stakeholders, including doctors.

If the focus is shifted to the appropriateness and effectiveness of the demand, the discussion will completely change to focus on the competence of doctors and their professional autonomy, a real taboo.

Of course, there is no shortage of assumptions and reasons to discuss about this. The report of the Parliamentary Committee on Medical Errors revealed that 71% of doctors admit to prescribing laboratory tests for defensive purposes, a figure that rises to 76.5% for instrumental examinations.

Hospital specialists complain about the poor appropriateness of the visits they are asked for and the lack of an effective filter capable of correctly direct the patients who need a rapid takeover by them.

The problem, however, is not only the appropriateness but also the effectiveness of the demand. Often the patient, after waiting for a more or less long period of time, is visited by the specialist who prescribes instrumental examinations necessary to verify the diagnostic hypothesis or evaluate the effects of the disease. This means another reservation with relative waiting, then an additional reservation for the visit with the specialist to complete the diagnostic and therapeutic path.

To address the problem, primary care should be enhanced by increasing their gate keeping capacity. We need an alliance between specialists and general practitioners who, together, define diagnostic protocols to be adopted in the evaluation and prescription of instrumental examinations and visits. An exchange of skills and experience is needed to enable family doctors to be more effective.

Appropriate IT tools are also needed. The electronic medical record must be not just a container of information and a means of carrying out prescriptions, but a real support system for the doctor guiding him through the diagnostic and therapeutic process.

Tele-consultation and tele-collaboration systems are also needed to put family doctors in contact with specialists with the aim of avoiding visits for diseases that can be managed directly from primary care or to send patients to the specialist to show him the results of the necessary instrumental examinations.

In short, it would be necessary to tackle the problem from the head rather than the tail, recognising that there is a great problem on the demand side and looking for, all together, the best solutions. Without taboos and ideological positions.

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