This backgrounder provides some detailed information on the booking system and the Clinical Priority Access Criteria (CPAC), which are at the heart of a successful booking system.

Steering Committee: Made up of representatives from various areas of the health sector. Currently being formed and will be announced once complete

Hospitals are at different stages in the development of booking systems and procedures. The intention over the next few months is to achieve consistency in progress.

Hospitals that are progressing well with implementation include: Auckland Healthcare, South Auckland Healthcare (Northern area), Health Waikato (Midland area), Hutt and Healthcare Hawkes Bay (Central area), Canterbury Healthcare (Southern).

The development of a fairer system to access the public hospital system based on "health benefit" started in 1992. The Core Health Services Committee originally investigated some individual procedural scoring systems with particular reference to hip and knee replacement, coronary artery by-pass surgery, cataracts and a number of other procedures.

With the introduction of the RHAs there was a policy directive to implement a prioritisation system for patient access to medical, surgical and diagnostic services. The introduction of booking systems to replace waiting lists was also prescribed by Government.

Each RHA developed its own strategy to implement these Government strategies, ranging from various scoring systems for procedures and specialties, to generic scoring systems which identified "health benefit" across specialities, to the Midland approach which categorised patients according to urgency of need. The latter system was a complete process of referral guidelines, patient management systems, clinical priority access criteria for both assessment and treatment for all specialist services, information monitoring, reporting and audit.

It was recognised during this development phase that if booking systems were to be implemented, then there was a need to deal with the backlog of patients waiting for first assessments and treatments. Thus the Waiting Times Fund was created, with an impetus to further develop the tools of prioritisation of patient access. The concept of financially sustainable thresholds was born. This theoretically allowed an understanding of how much could be purchased in the hospital services area with the health dollars available.

The RHAs were also charged by Government to work together to standardise scoring systems. This essentially did not occur until the formation of the THA/HFA.

The National Waiting Times Project has the task of bringing together the work already achieved into a national system which allows fair and equitable access to medical, surgical and diagnostic services across the country, and at the same time introducing a booking system for patients based on health benefit.

There is much work to be done. The project has started and we are taking a very careful and responsible approach so that New Zealanders will have a clear understanding of what is available to them in the publicly funded health service. Thus access will be fair and equitable across the country.

At the heart of a successful booking system is an effective method of assessing patient need. CPACs place the need of the individual patient in the context of the whole population or community

Most doctors are used to assessing the health needs of their individual patients. Through professional training and clinical experience, doctors have developed an implicit yet systematic approach to this assessment and use it before starting a treatment they believe to be effective for the particular individual concerned.

However, such a systematic approach can be applied to assessing the health needs of a broader group of patients or a population—whether by a single doctor or a group or the funder. Most often this occurs in assessment of the needs of a patient for intensive care management as measured against the availability of ICU resources. Another example involves patients requiring access to end stage renal failure (dialysis) therapies as measured against their ability to benefit from the therapy and also against the resources available.

Distinguishing between individual needs and the wider needs of the community is important in the planning and provision of health services—nationally as well as locally. CPAC are a mechanism chosen to enable the wider needs of the community to be prioritised and managed appropriately.

The CPAC develop project’s purpose is "to forge, in a systematic and evidence-based manner, in conjunction with doctors, a national set of CPAC (covering all medical, surgical, diagnostic and related ‘aspects-of-care’ services) to enable consistent prioritisation of the unmet need of patients throughout New Zealand:

• based on ‘capacity to benefit;
• using a synthesis of existing regional and international qualitative and quantitative approaches’;
• regularly reviewed, evaluated and replanned according to the evidence.

In addressing issues related to the development and formulation of national CPAC, it is important to understand the following:

• the population’s ability to benefit from health care equals the aggregate of individual’s ability to benefit;
• the ability to benefit does not mean that every outcome will be favourable, but rather that need implies potential benefit, which on average is effective;
• the benefit is not just a change in clinical status but can include reassurance, supportive care, and the relief of carers; and, last,
• health care includes not just treatment but also prevention, diagnosis, continuing care, rehabilitation and palliative care.

For individual doctors, specialist services, hospitals and other healthcare organisations, the development of health needs assessment through CPAC has many benefits. These are far wider than implementation of a booking system. They will provide the opportunity for:

• describing the patterns of disease/injury in the local population and the differences from locality, regional or national patterns;
• learning more about the needs and priorities of their own patients and those of the local population;
• highlighting the areas of unmet need and providing a clear set of objectives to work towards meeting these needs;
• deciding rationally how to use resources to improve their local population’s health in the most effective and efficient way;
• influencing policy, inter-agency collaboration, or research and development of health care priorities;
• providing a method of monitoring and promoting equity in the provision and use of publicly funded health services and addressing inequalities in health

These benefits will only truly emerge as CPAC are operated consistently across the country and across specialties. The process of developing CPAC and benefiting from them will take time.

The initial focus of this project will be to created a generic CPAC form based on need or capacity to benefit. Currently, the funder, public hospitals and individual doctors utilise a number of different methods on which ‘booking systems’ priority access criteria have been based (refer item by Dr Paul Malpass). The National Waiting Times Project (NWTP) will develop an ‘overlay tool’ to create a nationally consistent mechanism for prioritisation of patient need for services.

In undertaking this work, a small group of doctors, experienced in population needs analysis and systematic decision-‘thinking’ analysis, will develop the initial tools and formats. It is important to realise that the tool will involve a points scoring system using generic criteria.

These criteria will work towards defining an individual patient’s ‘capacity to benefit’ from a service. It will include three major components—namely, degree of suffering/pain; degree of potential disability without the service; achievable life-expectancy. This framework will deal with some shortcomings in some systems developed by the RHAs that have emerged from pilot activities. Namely some points-scoring systems do not adequately consider patients with certain cancers—a system which takes due regard of achievable improvements in suffering, ability and life-expectancy should answer these concerns.

These factors are already taken into concern by doctors when formulating certain interventions. The new system is making their decision processes explicit and will allow for equity across the spectrum of medical care.

Following on from the initial work on a ‘generic and overlay tools’, a Professional Advisory Group (PAG), experienced in using existing priority systems, will be established. The generic formats and systems will be tested using the PAG and then reviewed through meetings with specialty services clinicians.

It is likely, at this point that a ‘lookback’ process will need to be developed which will revisit patients who are currently booked and reprioritisation will take place using the generic tool template. This will ensure that patient’s who meet a defined level of priority will be able to be appropriately booked for services within the recommended time.

At about the same time in the process, it will be necessary to work on a systematic way to ensure that all patients who meet the acceptance criteria receive the services specified. Currently, patients who are ‘low on the waiting list’ are frequently dropped off if someone who has greater need enters into the system. The new system will work towards eliminating this by assigning a level of priority which increases as the time to service lessens. That is, a patient given a time of 6 months who is now only two months away from the defined time will have their priority automatically increased in the system to the 2 month level. At this stage, it is expected that they will receive a defined date for the service.

Appropriate audit and evaluation tools will also be constructed to ensure that the services delivered are meeting the performance standards expected by the funder. These mechanisms will, for the first time in New Zealand, provide a surety and clarity around access to an agreed and consistent standard of care for all booked patients, for services which are publicly funded.

The process will also necessitate having a group of providers and organisations ‘piloting’ the tools and formats developed under the NWTP/CPAC banner. Such pilots will then be evaluated, the tools revised as required and the system will then be fully implemented. Appropriate tools to audit, evaluate and monitor performance will enable the tools to be constantly updated and refined to enable greater finesse over time and security in services provision to meet patients needs and to provide ‘benefit’ in terms of health as a consequence.

Because of ongoing work with CPACs and the need to assess quite significant numbers of patients, it is impossible to predict with any accuracy the numbers of patients who will be booked over the next year or who will remain in their care of their GP.

To overcome this problem and to keep the public informed on progress with this project a system of regular reporting is being developed and details will be made available soon. This information is likely to be made public by the Minister in a regular report.

It will provide information on the number of patients booked for treatment and for assessment. It will identify the numbers of patients not booked and who will receive care from their GP.

It will also provide information on the numbers of people on the residual waiting list and what happens to them as they are taken off (booked, referred to GPs, other outcomes).

The key to a successful booking system is the development of CPACs. CPACs are complex and require development by experts and extensive consultation with clinicians. As a rough measure of the complexity, there are 30 specialties across 23 CHEs (some with multiple hospitals). CPACs have to apply in all situations.

There is only so much development that can take place in theory, they have to be developed in the real situation to ensure they meet the requirements of patients.

There are some shortcomings in the CPAC design at this stage in their development which will be overcome with further work. If CPACs are giving inconsistent or inappropriate results they can be over-riden by clinicians so that patients are not adversely affected.

We are arriving at the need to prioritise the delivery of care at about the same time as other countries and ahead of many. In that respect we are at the forefront of these developments and many other countries are trying to go through a similar process to us whilst allowing for national and cultural differences.

This waiting list will be kept for a relatively short period of time. People will be gradually taken off the waiting list and booked for treatment or continued under the management of their GP. Retaining the waiting list allows a more gradual development of CPACs and therefore a fairer and more equitable booking system.

Despite continuing growth of spending on health care and the treatment of more and more patients each year, demand continues to rise all around the world. This is because the availability of technology and modern practice means that people expect more from their health services. Their expectations have outstripped the ability of governments and health insurers to pay.

In most countries elective hospital services are rationed either on the ability to pay or by queuing (waiting list).

The development of CPACs will ensure the fairest allocation of services with those in most need getting the service. The booking system ensures patients receive the service in a clear timeframe enabling them to plan their life and commitments.