Reducing waiting times is important in any condition, but arguably more so in time-critical cancer diagnosis and treatment. To reduce waiting lists collectively and effectively, we must stay connected to a broader vision of improving the quality, equity and effectiveness of care.
Katie is a patient with lived experience, and Spela is Q’s Insight and Evaluation Manager.
One of the Q Lab test teams, Aneurin Bevan University Health Board in Wales, set off to tackle long waits for head and neck cancer. In some cases, the team successfully reduced appointment waiting times to two days.
While this reduced waiting time had some clear benefits for patients, the test team were mindful about how drastically reducing waiting times may affect equitable access to care. For example, some people are more easily reachable. While someone without a phone, who relies on the postal system, is unlikely to receive messages in time.
Equally, some people have more flexibility around appointment times. Those with caring responsibilities, in precarious work arrangements or with limited transport options may find attending appointments at short notice challenging.
Katie’s experience
“I live with a long-term condition and I’m parenting a young child. I have to attend regular appointments, which requires my carer to come along. Some of my appointments take three or four hours. I don’t know that I can get the train fare or the childcare, and take several hours out of my day, to attend an appointment at short notice.
Even if I know it’s life or death, I sometimes have to sit and think about what’s doable.
“Health care providers must understand that people have many responsibilities and challenges to navigate. For example, if they don’t collect their kids from school, nobody collects their kids from school. If they take a day off work, perhaps they don’t get paid. The changes in shorter waiting times can be brilliant and positive from a health care perspective, but it could take additional effort to become brilliant and positive for all patients as well.”
How can we ensure equity while drastically reducing waiting times?
Read on for Katie’s perspective on challenges to equity as a patient, and to discover what the Lab teams learned about supporting equitable access to appointments.
Don’t make assumptions about barriers and needs.
Barriers to attending appointments are local and personal. Any solutions need to be grounded in understanding what people’s needs and challenges are. We often assume that geographical distance is why people miss appointments, but we don’t often consider that appointments could clash with, for example, people’s caring commitments or school runs.
The teams initially made some assumptions about the best thing for their patients. But it quickly became clear that what was best for some people, would be the worst for a significant number of others. It’s important to understand what makes a service, and/or access to it, inequitable. But the only people who can identify inequities are the individual, their carer or their family.
How can you make something as accessible as possible without making assumptions about the people that you’re trying to provide the care for?
Keep needs and preferences up to date.
Everyone involved in the patient pathway needs to be collectively responsible for keeping communication preferences and details up to date. Does a patient prefer a text, a voice message, or a call? What mode of communication is most likely to reach them?
The Aneurin Bevan team reflected on the equity in their project, and now approach patients to check details and preferences, simply asking “What is the best way to get hold of you?”
People’s needs and preferences change. For example, perhaps someone used to be able to take their child to appointments, but can no longer do this.
Get to know the patient, and encourage them to express their communication wants and needs regularly. This will help you get information to them and make sure they attend appointments, particularly when time is of the essence.
Communicate the importance of appointments.
Patients with long-term health conditions or multiple diagnoses are often required to attend a lot of appointments. Without sufficient support, some may need to make difficult decisions about which appointments they attend. If they have limited understanding around the importance and urgency of each appointment, this may affect their attendance.
For example, if a GP says to a patient, “I’m really concerned about this, I’m going to send you in urgently”, ‘urgent’ can mean different things to different people. But if somebody says, “I’m really concerned that this may be cancer. So I’m sending you on a pathway which means you will be seen as quickly as possible to explore that” – that’s different.
The Aneurin Bevan team recognised that making sure patients understood the severity of their referral helped them prioritise their appointment, especially when the timing was urgent, and important.
With clear information, as a patient, you have a different perspective about what you’re waiting for. Communicating the importance of appointments supports patients to attend and get the care they need.
Improve convenience and choice for how people attend appointments.
Offering greater choice of appointment types and times can increase attendance.
People might be required to attend multiple face-to-face appointments within a short time frame (as is the case for cancer pathway). On average, it takes seven appointments from a referral to a patient being told they have cancer. That’s seven appointments within (ideally) 28 days. This means that someone living an hour away from the hospital is required to spend 14 hours travelling in a car, or longer on public transport, increasing the risk of non-attendance. For people in precarious employment, with caring commitments or financial difficulties, understandably this is very challenging.
The Aneurin Bevan team improved how they group different appointments so that patients can attend multiple separate appointments in one day. The Stockport team added in more choice for how patients attend appointments, including in-person, video and telephone consultations (where remote options were possible).
So, consider how multiple appointments could be done as part of a single-day visit, rather than requiring patients to travel on separate days. Or perhaps add in the option for virtual, or telephone appointments. What other flexibility could you offer to patients, so that they can attend appointments?
Improvement and innovation can risk exacerbating inequalities. Involving patients can highlight blind spots, and help incorporate the views of different lived experiences. It also increases the chance that solutions and service improvements benefit everyone, not just some.
The information here was drawn from data collected during workshop discussions and conversations with Q Lab test teams and Katie’s reflections as a patient.