Long Waiting Times for Elective Hospital Care – Breaking the Vicious Circle by Abandoning Prioritisation

Document Type : Original Article


1 Department of Health Promotion, Norwegian Institute of Public Health, Bergen, Norway

2 Department of Clinical Science, University of Bergen, Bergen, Norway

3 Department of Research and Development, Haukeland University Hospital, Bergen, Norway

4 Department of Clinical Medicine, University of Bergen, Bergen, Norway

5 Clinic of Surgery, Haukeland University Hospital, Bergen, Norway

6 Dynaplan AS, Manger, Norway (https://www.dynaplan.com/en/)


Policies assigning low-priority patients treatment delays for care, in order to make room for patients of higher priority arriving later, are common in secondary healthcare services today. Alternatively, each new patient could be granted the first available appointment. We aimed to investigate whether prioritisation can be part of the reason why waiting times for care are often long, and to describe how departments can improve their waiting situation by changing away from prioritisation.
We used patient flow data from 2015 at the Department of Otorhinolaryngology, Haukeland University Hospital, Norway. In Dynaplan Smia, Dynaplan AS, dynamic simulations were used to compare how waiting time, size and shape of the waiting list, and capacity utilisation developed with and without prioritisation. Simulations were started from the actual waiting list at the beginning of 2015, and from an empty waiting list (simulating a new department with no initial patient backlog).
From an empty waiting list and with capacity equal to demand, waiting times were built 7 times longer when prioritising than when not. Prioritisation also led to poor resource utilisation and short-lived effects of extra capacity. Departments where prioritisation is causing long waits can improve their situation by temporarily bringing capacity above demand and introducing “first come, first served” instead of prioritisation.
A poor appointment allocation policy can build long waiting times, even when capacity is sufficient to meet demand. By bringing waiting times down and going away from prioritisation, the waiting list size and average waiting times at the studied department could be maintained almost 90% below the current level – without requiring permanent change in the capacity/demand ratio.


Supplementary File 1 (Download)

Supplementary File 2 (Download)

Supplementary File 3 (Download)

Supplementary File 4 (Download)

Supplementary File 5 (Download)

Supplementary File 6 (Download)

Supplementary File 7 (Download)


Main Subjects

  1. Fuglset AS, Karstensen A, Håndlykken EK. Ventetider og pasientrettigheter 2015. Trondheim: Helsedirektoratet; 2016.
  2. Karstensen A, Håndlykken EK. Ventetider og pasientrettigheter 2018. Trondheim: Helsedirektoratet; 2019.
  3. Larsen BI. Ventelister, helsetap og sykehuskapasitet. Tidsskr Nor Laegeforen. 2001;121:2255.
  4. Derrett S, Paul C, Morris JM. Waiting for elective surgery: effects on health-related quality of life. Int J Qual Health Care. 1999;11(1):47-57. doi:10.1093/intqhc/11.1.47
  5. D'Souza DP, Martin DK, Purdy L, Bezjak A, Singer PA. Waiting lists for radiation therapy: a case study. BMC Health Serv Res. 2001;1:3.
  6. Ostendorf M, Buskens E, van Stel H, et al. Waiting for total hip arthroplasty: avoidable loss in quality time and preventable deterioration. J Arthroplasty. 2004;19(3):302-309. doi:10.1016/j.arth.2003.09.015
  7. Sampalis J, Boukas S, Liberman M, Reid T, Dupuis G. Impact of waiting time on the quality of life of patients awaiting coronary artery bypass grafting. CMAJ. 2001;165(4):429-433.
  8. Koopmanschap MA, Brouwer WB, Hakkaart-van Roijen L, van Exel NJ. Influence of waiting time on cost-effectiveness. Soc Sci Med. 2005;60(11):2501-2504. doi:10.1016/j.socscimed.2004.11.022
  9. Joskow PL. The effects of competition and regulation on hospital bed supply and the reservation quality of the hospital. Bell J Econ. 1980;11(2):421-447. doi:10.2307/3003372
  10. Iversen T. A theory of hospital waiting lists. J Health Econ. 1993;12(1):55-71.
  11. Brustugun OT, Nome O, Bruland ØS, Ottestad L, Lilleby W. Brystkreftpasienters vurdering av ventetid før strålebehandling. Tidsskr Nor Laegeforen. 2003;123:1685-1686.
  12. Borowitz M, Moran V, Siciliani L. A review of waiting times policies in 13 OECD countries. OECD Health Policy Studies. 2013:49-68. doi:10.1787/9789264179080-6-en
  13. Piene H, Loeb M, Hem K. Sykehuskapasitet og ventetid for behandling-er det noen sammenheng? Tidsskr Nor Laegeforen. 2000;120:2988-2992.
  14. Bratlid D. Personellressurser og pasientbehandling ved et regionsykehus. Tidsskr Nor Laegeforen. 2000;120:3021-3026.
  15. Kreindler SA. Policy strategies to reduce waits for elective care: a synthesis of international evidence. Br Med Bull. 2010;95:7-32. doi:10.1093/bmb/ldq014
  16. Bratlid D. Ventelistesituasjonen ved et regionsykehus. Tidsskr Nor Laegeforen. 2003;123:3241-3244.
  17. Murray M, Berwick DM. Advanced access: reducing waiting and delays in primary care. JAMA. 2003;289(8):1035-1040. doi:10.1001/jama.289.8.1035
  18. Kreindler SA. Watching your wait: evidence-informed strategies for reducing health care wait times. Qual Manag Health Care. 2008;17(2):128-135. doi:10.1097/01.QMH.0000316990.48673.9f
  19. Naiker U, FitzGerald G, Dulhunty JM, Rosemann M. Time to wait: a systematic review of strategies that affect out-patient waiting times. Aust Health Rev. 2018;42(3):286-293. doi:10.1071/ah16275
  20. Valente R, Testi A, Tanfani E, et al. A model to prioritize access to elective surgery on the basis of clinical urgency and waiting time. BMC Health Serv Res. 2009;9:1. doi:10.1186/1472-6963-9-1
  21. Abedini A, Ye H, Li W. Operating Room Planning under Surgery Type and Priority Constraints. Procedia Manuf. 2016;5:15-25. doi:10.1016/j.promfg.2016.08.005
  22. Durán G, Rey PA, Wolff P. Solving the operating room scheduling problem with prioritized lists of patients. Ann Oper Res. 2017;258(2):395-414. doi:10.1007/s10479-016-2172-x
  23. Comas M, Castells X, Hoffmeister L, et al. Discrete-event simulation applied to analysis of waiting lists. Evaluation of a prioritization system for cataract surgery. Value Health. 2008;11(7):1203-1213. doi:10.1111/j.1524-4733.2008.00322.x
  24. Bowers JA. Simulating waiting list management. Health Care Manag Sci. 2011;14(3):292-298. doi:10.1007/s10729-011-9171-x
  25. Abbasgholizadeh Rahimi S, Jamshidi A, Ruiz A, Ait-Kadi D. Multi-criteria Decision Making Approaches to Prioritize Surgical Patients. In: Matta A, Sahin E, Li J, Guinet A, Vandaele N, eds. Health Care Systems Engineering for Scientists and Practitioners. Cham: Springer; 2016:25-34.
  26. Abbasgholizadeh Rahimi S, Jamshidi A, Ruiz A, Ait-kadi D. A new dynamic integrated framework for surgical patients' prioritization considering risks and uncertainties. Decis Support Syst. 2016;88:112-120. doi:10.1016/j.dss.2016.06.003
  27. NOU Guidelines for priority setting in the Norwegian Health Care System (in Norwegian). Oslo: Universitetsforlaget; 1987.
  28. Norges Offentlige Utredninger (NOU). Prioritering på ny: gjennomgang av retningslinjer for prioriteringer innen norsk helsetjeneste. Priority setting revisited. Norwegian.) Oslo: Statens Forvaltningstjeneste; 1997:18.
  29. Norheim O, Allgott B, Aschim B, et al. Åpent og rettferdig–prioriteringer i helsetjenesten. Norges Offentlige Utredninger; 2014:12. The. 2013;2014.
  30. Lovdata. Lov om pasient- og brukerrettigheter (pasient- og brukerrettighetsloven). Lovdata; 2001. https://lovdata.no/dokument/NL/lov/1999-07-02-63/KAPITTEL_2 - KAPITTEL_2.
  31. Lovdata. Forskrift om ventelisteregistrering2001.
  32. Helse- og omsorgsdepartementet. Høring - rapport om alternativer for regulering av pasientforløp og registrering av ventetid. Helse- og omsorgsdepartementet; 2018. https://www.regjeringen.no/no/dokumenter/horing---rapport-om-alternativer-for-regulering-av-pasientforlop-og-registrering-av-ventetid/id2606713/.
  33. Dynaplan Smia [computer program]. Version 1.4.12016.
  34. Tjoflot GK, Waaler HT, Iversen T. [Simulation of waiting time and effectiveness in hospitals]. Tidsskr Nor Laegeforen. 2005;125(11):1472-1475.
  35. Oudhoff JP, Timmermans DR, Rietberg M, Knol DL, van der Wal G. The acceptability of waiting times for elective general surgery and the appropriateness of prioritising patients. BMC Health Serv Res. 2007;7:32. doi:10.1186/1472-6963-7-32
  36. MacCormick AD, Tan CP, Parry BR. Priority assessment of patients for elective general surgery: game on? ANZ J Surg. 2004;74(3):143-145. 
  37. Gangstøe JJ, Heggestad T, Norheim OF. Norwegian Priority Setting in Practice - an Analysis of Waiting Time Patterns Across Medical Disciplines. Int J Health Policy Manag. 2016;5(6):373-378. doi:10.15171/ijhpm.2016.23
  38. Gystad SO, Håndlykken EK. Kvalitet i ventelistedata. Helsedirektoratet; 2014.
  39. Bratlid D. Pasienttilgang og pasientbehandling ved et regionsykehus. Tidsskr Nor Laegeforen. 2002;122:386-391.
  40. Martin S, Smith PC. Rationing by waiting lists: an empirical investigation. J Public Econ. 1999;71(1):141-164. doi:10.1016/S0047-2727(98)00067-X
  41. Stavrunova O, Yerokhin O. An equilibrium model of waiting times for elective surgery in the NSW public hospitals. Econ Rec. 2011;87(278):384-398.
  42. Bennett G, Jessani N. The knowledge translation toolkit: bridging the know-do gap: a resource for researchers. SAGE Publications India; 2011.
  43. Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009;4(1):50. doi:10.1186/1748-5908-4-50
  44. Kreindler SA. Six ways not to improve patient flow: a qualitative study. BMJ Qual Saf. 2017;26(5):388-394. doi:10.1136/bmjqs-2016-005438
Volume 9, Issue 3
March 2020
Pages 96-107
  • Receive Date: 24 January 2019
  • Revise Date: 25 September 2019
  • Accept Date: 28 September 2019
  • First Publish Date: 01 March 2020