Referral Criteria Adjusted to Reduce Waiting Lists, but Patients Ultimately Suffer

Whilst the NHS may have been set up in 1948 with the ethos that a good standard of healthcare should be available to everyone, recent investigations by the National Audit Office indicate that the NHS seems to be going against its basic principles. Waiting lists for treatments provided by nine NHS trusts were put under scrutiny and threw up some uneasy results. The shocking reality is that criteria for treatments are being adjusted to allow patients to be removed from waiting lists to improve the figures that they provide to the Department of Health. The Royal College of Surgeon’s President Professor Norman Williams has described the practice of adjusting referral criteria to shorten waiting lists as “outrageous” and “worrying”. So what has spurred these actions and what impact does this have on patients?

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The 18 week wait

In 2004 the Labour Government put forward the concept of the 18 week wait to reduce how long patients had to wait to receive treatment. The theory was that no patient should wait longer than 18 weeks between referral from their GP to receiving treatment. Those NHS trusts failing to meet these criteria face hefty fines, an incentive when money is already scarce. The drive to reduce waiting times has been blamed as the reason for why treatment criteria have been changed – if fewer patients are on the list it leads that they will have to wait a shorter time for their treatment. However, it hasn’t only had an impact on patients considered as new referrals, as those already on the waiting list have been affected – they have subsequently been removed from the list. For example Kent and Medway PCT have changed their criteria for referral for surgical removal of gallstones – patients must have two acute episodes of pain sever enough to warrant a hospital admission – allowing 250 people to be shaved off the waiting list.

A strategy to save money

The NHS is currently stretched to its limits, with further cuts in spending on healthcare looming. It is therefore understandable that NHS trusts are on the lookout for money saving strategies. Tightening referral criteria for operations to reduce the number of procedures carried out is one such way to save money. Ensuring that only those treatments that are essential are carried out could allow money to be spent more effectively. However, this isn’t a comfort for any patient living with a medical condition they have been refused treatment for.

Removal from the waiting list

While adjusting referral criteria is one way to remove patients from a waiting list, it is not the only way. The recent audit found that although accidental errors by junior staff were a source of error in relation to waiting lists, it did not account for the majority of cases. Some patients were found never to have been added to waiting lists, others were not added till the month they were to receive their treatment. Some of the figures reported to the Department of Health were also shown not to be a true reflection of the actual figures. A significant way of reducing the waiting list was found to be so called “suspended” patients, who are those patients unable to attend the date that they were offered for treatment. On the surface this might seem legitimate, but after digging deeper it was found that these patients had been offered dates at short notice or deliberately given a time when they were known to be unavailable. The National Audit Office is planning to investigate a further 13 NHS trusts who have at least 10 percent of patients marked as suspended on their waiting lists.

Impact on patients

In the audit 6000 patients were found to have been affected by playing with waiting list figures. The emphasis seems to have been changed from patient care to meeting targets. Ultimately patients are put at risk, as those who were initially added to the waiting list must have been deemed as appropriate and in need of surgery in the first place. Removing their chance to receive such treatment on the NHS increases their risk of complications from their unresolved medical conditions, resulting in worse outcomes for patients, both in terms of their health and quality of life. While changes to referral criteria might encourage the usage of private providers for more minor procedures such as removal of cataracts, this option is not available to everyone, only those who can afford private treatment. The concept of free treatment at the point of need, a key idea behind the NHS, is not embraced by this move.


Referral criteria for procedures vary between NHS trusts, so a patient who might be eligible for treatment in one part of the country, does not meet criteria in another. Patients are not being assessed on an individual basis for treatments, but whether they tick certain boxes. Indeed, the Health Secretary Andrew Lansley believes that Primary Care Trusts should not be rationing treatments and should offer them to all patients who have a need.

by Amy Millband