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Eight months for a hospital appointment: Mater Dei under the NAO spotlight

Up to half of the yearly 500,000 outpatient visits are unnecessary

The average patient waits more than eight months for their first outpatient appointment at Mater Dei, a National Audit Office report into hospital waiting lists has found.

The state hospital's 250-day waiting time average is double that in the UK and seven weeks longer than that Irish patients endure, the NAO report reported, as it warned that a new outpatient block being planned would not be a panacea to waiting list issues.

Mater Dei receives roughly half a million outpatient visits every year, at an annual cost of approximately €32 million to taxpayers. That figure boils down to an average of €3.18 per minute for each consultation visit.

Waiting lists have long plagued public healthcare services, and the NAO report released on Wednesday evening indicates that unless systemic problems such as the lack of available consultants in afternoons and weekends are addressed, there is little chance of matters improving in the near future. 

Although patients continue to wait for long periods of time, NAO auditors found that the hospital had made some significant strides in improving outpatient services it was held back by various factors which are in many cases out of its direct control. 

NAO analysts studied five departments at Mater Dei - genetics, medicine gastrointestinal tract (GIT), neurology, urology and vascular  over a one-month period in October 2016 to compile the study.

The report lends credence to the Medical Association of Malta's claims last year that overly-long waiting lists were leading patients to "give up" on Mater Dei appointments.

It highlights a number of shortcomings in the way Mater Dei hospital’s outpatient system functions – and not all of them are the hospital’s fault.

No-shows and queue-jumpers

Anything between 20 and 50 per cent of the annual 500,000 outpatient visits, for instance, were considered unnecessary by senior clinicians and could have been handled by regional healthcare centres.

Had such inappropriate referrals been caught in time, waiting times in specialisations such as genetics and neurology could have been halved, the study found.

In this respect, the report found, “primary health care is not acting as an effective gatekeeper to secondary health care access.”

Patients who walked into hospital without an appointment, as well as those who had appointments but didn’t bother to show up were also adding strain to the system.

A new outpatient block would help, but it was no silver bullet, the NAO warned.A new outpatient block would help, but it was no silver bullet, the NAO warned.

More than one-fifth of patients did not turn up for their appointments. While the number is higher than in UK hospitals analysed by the NAO, it is signicantly lower than the one-in-three no-show rate Mater Dei reported back in 2010.

More than one in every four outpatients were registered as “walk-ins” without a scheduled appointment. However, the NAO found that a number of these did not physically attend the outpatients department and were instead marked as such by consultants who scheduled test appointments for their private patients.

The NAO concluded that there was “ample evidence” that many of these walk-ins were bypassing the hospital’s appointment procedures, branding them “queue-jumpers.”

Consultant discrepancies

While the waiting time for a first appointment averaged out to 250 days, there were significant differences between consultants.

One genetics consultant, for instance, had a waiting list of nearly 600 days, while their department colleagues averaged closer to 200. In the hospital’s vascular department, patients of one consultant must wait roughly 450 days for an appointment, while patients of two other vascular consultants are seen in just over three months.

These variations are not necessarily linked to over- or under-performance: the NAO study found significant imbalance in the distribution of cases between consultants, with some having far more patients to see than others.

Mater Dei problems

Aside from these demand-side issues, the NAO noted several concerns with the way Mater Dei was running its department.

The hospital, it noted, does not have an integrated administrative IT system, and several of its management control mechanisms remain inadequately robust.

Synchronisation between shifts remained poor, and the outpatients department was unable to distribute patient loads across the entire day due to many consultants having private practices to attend to. As a result, a disproportionate bulk of outpatients appointments were set in the mornings and early afternoons.

The NAO report warns hospital administrators that while a planned new outpatient block, scheduled to be completed in 2020, should ease infrastructural strains and enhance service delivery, unless the hospital found ways of extending outpatient services to the afternoons and weekends, “it is unlikely that the new infrastructure will be optimally utilised.”

“As was the case in the past, increasing supply is proving to be an insurmountable issue,” the report writers note.

The report notes that hospital management has gone some way towards improving matters. Administrators are in the process of developing outpatient strategies, and a new system whereby outpatients were sent an SMS reminding them of their upcoming appointment had reduced no-shows by 11 per cent as of the end of August 2017.

Recommendations

If Mater Dei Hospital is to improve its outpatient services, the NAO found, it will have to collaborate with the private sector and look to signing public private partnerships to ease strain on its limited resources and cut waiting times.

The hospital had to be faster at recruiting key staff and improve its IT infrastructure to better exploit electronic referral tickets and create audit trails for patients.

Patients should be able to see real-time waiting times for various consultants, allowing them to make more informed decisions about their healthcare, and the hospital had to get tough with no-show patients, rather than automatically book them a new appointment as currently happens.

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