Timely access to specialist outpatient care: can applying systems thinking unblock our waiting lists?

Background: The purpose of this qualitative study was to focus on review and repeat review outpatients and the structural role they play in exacerbating waitlists for Specialist Outpatient (SOP) services in Queensland. Waitlists, which record the number of patients waiting for an initial consultation (new appointment), are an indicator of a health system under strain. Waiting too long to access SOP can have a detrimental effect on people's health outcomes. Not tackling the structural drivers of waitlists can result in non-systemic, non-sustainable fixes that perpetuate waitlists and detrimental outcomes. Patients should be discharged from specialist care when the episode of care is completed, provided appropriate care is available. When review patients remain in the SOP system, they impact the number of new appointments available.

Methods: This paper uses a feedback systems approach to make transparent the touchpoints, dynamics and impact of review and repeat review appointments on waitlists. The evidence used to construct the causal loop diagrams (CLD) in this paper was an output of Group Model Building (GMB). Two facilitated half-day participatory workshops were held in April and June 2023. The project brought together researchers, consumers, hospital and health services (HHS) specialty clinical leads, General Practitioners (GPs), Executive sponsors, HHS outpatient service managers and analysts to provide hospital and healthcare expert stakeholders an opportunity to translate their collective mental models into meaningful system diagrams which communicated how the outpatient system was working.

Results: The CLD provided a cross-boundary visual of how the review and repeat review appointment contributes to the waitlist. It shows that the review and repeat review outpatients are a hidden feedback loop contributing to growing waiting lists. In the absence of a discharge planning intervention, they have the potential to become a vicious cycle that grows review appointment demand, consuming the availability of new appointments.

Conclusions: A feedback systems approach can enhance SOP system understanding, ultimately shifting policy response in health away from local "firefighting" fixes towards more sustainable systemic solutions which promote timely outpatient access. The results suggest that the review patient process impacts the waitlists and should be viewed as a leverage point in the management of growing specialist outpatient waitlists.