BOA recommendations on pooled waiting lists

Continuity of care forms an important part of medical care and is highly valued by patients and surgeons alike. The therapeutic relationship of one patient with their consultant throughout their course of treatment should remain the norm to which we aspire.

All surgeons have a duty to manage their practice to avoid developing an excessive waiting list. However, under the circumstances of inequity of supply and demand that can often be found in the NHS, consultants within the same Trust may develop very different waiting lists for the same procedure, imposing highly variable waiting times for the same procedure within the same hospital.

Strategies for managing uneven waiting lists might include the reorganization of a consultant’s job plan, either temporarily or more permanently, if this can be done without disadvantaging others.

Alternatively, pooling of waiting lists, in which patients who are waiting for a number of pre-agreed procedures, may be switched from the care of one consultant to another after their initial outpatient appointment, may also be used to mitigate such inequity. Pooling carries the following possible benefits:

• Helps to ensure equality of waiting times for patients who are waiting for some types of routine surgery
• Enables orthopaedic departments to balance the work load between consultants with similar clinical interests
• A properly organized pooling framework still allows those patients who want a specific choice of surgeon to remain under their chosen consultant’s care

Nevertheless, pooling, if done without attention to detail, may also be associated with a number of risks:

• Depersonalisation of the relationship between patient and their consultant, with the potential for particular added stress if the patient does not meet their new surgeon until the day of surgery
• Possible lack of clarity regarding the responsibility for the patient’s care
• Confusion or disagreement regarding the indication for surgery, possibly leading to duplication of assessment and investigation, thereby causing unwarranted delay in treatment 

In order to avoid such risks, the following principles should be applied when waiting lists are pooled:

• There must be agreement within the department concerned of which procedures are suitable for pooling and of which surgeons have the skills to perform them. Not all procedures are suitable for pooling.
• The surgeon listing a patient for surgery should indicate if that specific patient is suitable for pooling
• The patients must be made aware at an early stage that their surgery might not be performed by the surgeon who has listed them
• Patients may express a choice to remain under the care of their original listing surgeon.
• Patients undergoing inpatient surgery, such as primary hip or knee replacement, should attend a pre-assessment clinic where they will have the opportunity to meet the consultant who will be responsible for their care. Thereby the transfer of care from one consultant to another should occur at the pre-assessment visit and not after
• Patients undergoing in-patient surgery should not meet their treating consultant for the first time only on the day of admission
• Patients undergoing routine day-surgery, subject to local protocols and agreements, will not normally need to be seen again before admission, but will, as routine, need to be seen by the operating surgeon on admission
• Responsibility for the care of the patient transfers to the consultant who accepts the patient either in pre-assessment clinic or on admission in the case of day-surgery

To assist consultants please see the Department of Health’s guidance on the choice of named consultant-led teams, and how this correlates with pooled waiting lists.