Waiting lists

Where would we be without waiting lists? It's only the patient who suffers

Why would we want to reduce waiting lists? Surely not. They serve so many in the NHS so well. Doctors like them because patients faced with a long wait will, if they can, go private.

Managers like them because they are a lever to get more money. A long list shows you are under undue pressure (never that you are a poor manager). This gives you power to fight other directorates.

Chief executives like them because they provide a means to put pressure on the health authority. Acute trusts like waiting lists a lot because few community trusts have Patient's Charter monitoring of waiting, so they can be easily out-argued in the competition for funding.

Even HAs can find them useful in arguing for more funds for their area. With a bit of luck there will be another waiting list initiative along to sort out the deficit if you have long enough lists.

So why change? It is, after all, only the patient who suffers, who waits in a haze of worry for weeks for their few minutes with the consultant. It is only the patient who waits, maybe in pain, for what others consider a non-urgent operation. We say there is nothing we can do: waiting lists have been part of the NHS since it began.

Has no one in the NHS noticed that we used to wait for interminable weeks for a new car, a carpet and other goods? Something has changed in industry. Now we have more choices, delivered more quickly and at lower prices than ever before. Industry has been learning from a man named Eli Goldratt. But keep us from using his ideas, please. They might work - and where would we be without our waiting lists?

Trust chief executive

(Name and address supplied)

Reply-paid letters gave our service users a choice and us a break

In 1996, our child and adolescent mental health team had become overwhelmed by the growing number of cases on our waiting list.

Although each new case would be discussed in detail, and accorded a priority rating, it had become impossible to make just comparisons of relative need and urgency.

We discussed contacting all those waiting more than six months, which we were ethically bound to do, but there was great anxiety that this would stimulate hope or despair.

The resolution was a letter inviting them to contact us and stamped envelopes to increase the likelihood of a response. This was superseded by one which made it explicit that failure to reply would result in our closing the case or referral.

We received replies from half the clients contacted, 36 in all, half of whom were quite willing to continue on the waiting list, much to our surprise.

An almost identical number chose to be removed from the list or told us that the situation had worsened. Only one chose to re-contact the referrer, and two had moved. Where the situation had deteriorated we were able to reprioritise and offer appointments.

The cases of those who did not reply and some of those who did could be closed. The former entailed first confirming with the referrer, lest there be problems with literacy or language. Cases of those who had left the district could be closed. Team meetings became less burdensome - an unanticipated benefit.

Towards the end of the financial year, some underspend was available to employ a short-term counsellor to offer a brief but largely effective service to those who had elected to stay on the list.

This work was done only in one team in a larger, beleaguered service. The service is now proposing to separate more formally the activities of assessment and treatment.

Over the past two years we have also looked at referral quality. I imagine the high variability we found is common. This unreliability of information makes prioritisation, risk and needs assessment more difficult.

John Henderson

Principal child psychotherapist

Newham Community Health Services trust

Making a statement

Having worked at a large teaching hospital for some years, my best tip for clearing waiting lists is to ensure that all patients who have waited nine months positively identify that they still wish to come in. In pre-contracting days this cleared nearly half an 8,000-strong waiting list, and ensured consultants did not inflate their private practice by quoting long waiting times to hapless patients.

We also discovered that operating theatre time in one specialty was only 52 per cent, while its waiting list ran over 12 months. A suitable number of operations per list was suggested, which increased utilisation to 80 per cent, still leaving 20 per cent of time for emergency and private patient operations.

Carol Hall

Heywood

Lancs

Patients struck off by GPs without explanation

If you had a falling out with a friend, wouldn't you want to know why?

Steve Ainsworth in 'Omission to explain' (page 27, 30 July) is absolutely right in stating that the vast majority of patients know full well why they have been removed from a GP's list.

No one expects a doctor to tolerate harassment, abuse or physical assault by patients, and removal of such people is the GP's ultimate sanction.

However, a sizeable minority of patients are totally bemused when a GP arbitrarily removes them without explanation.

I recall one elderly gentleman who had been with his GP for over 20 years, enjoying what he thought was a cordial relationship with the doctor and his practice staff.

He was at a loss in reconciling the GP's action with his own impressions of a long doctor-patient partnership based on mutual respect. He felt it would be difficult at over 70 to start afresh with a new GP. He speculated that perhaps he was 'too old' or that his medication was too costly, and that was the reason for his removal. He clearly did not understand what he had done that the doctor found so unacceptable.

Steve Ainsworth feels that we patients should think of our relationship with GPs as being more akin to solicitors or hairdressers.

I would suggest that this demeans the role of a family GP, which at its best is that of a friend and confidant who looks after our best interests health-wise. If you fell out with a friend, wouldn't you want to know why?

June Haswell

Chief officer

Kingston community health council

Visiting the doctor is not like going to the pub

I've just seen a tearful elderly client who went to see their doctor seeking a referral.

The GP said he would send the referral and 'come and see me again' - instead, two days later, the patient got a letter striking them off. Funnily enough, there was no explanation.

It's crude and insulting to patients (and to GPs) to compare the patient- doctor relationship with going to a pub or the hairdresser.

That this could be contemplated, let alone written, by a former primary care manager illustrates the difficulty of getting the issue taken seriously. Health authorities don't want to know, and seem determined to blame 'difficult patients'.

If you don't believe me ask a mental health trust.

These difficult patients are the same ones blamed for being ill and causing longer waiting lists. Goodness, what a lot of trouble they cause.

If only GPs could be left alone to get along as independent contractors and not be troubled by patients.

But then they wouldn't have any NHS money.

Niall Fitzgerald

Chief officer

Hammersmith and Fulham community health council

A distressingly high number of people with mental health problems are struck off by GPs

Despite Steve Ainsworth's statistic of 'only one person per GP per year', there is a distressingly high incidence of people with mental health problems being removed from GPs' lists.

It is entirely plausible that those with mental health problems may behave inappropriately towards their doctor. If they are not given feedback about this they have no chance to learn appropriate boundaries.

There is an increasing incentive to GPs to remove the 'costly' patient from their lists. There is thus often a double incentive for GPs to abjure responsibility for those with mental health problems - just when the government is realising the problems of keeping contact with them in the community.

Mr Ainsworth notes that GPs are independent practitioners - presumably he thinks they are accountable only to God. The nature of healthcare means that GPs' patients are the most vulnerable people in society. Should there not be checks and balances to protect the most vulnerable from potential abuse by a nationally funded system?

Mr Ainsworth notes that 'in most... cases it emerged that the patients had been less than frank'.

Clearly, both the patient and GP had told their story, but Mr Ainsworth had no problem in applying a consistent ruling that patients were the ones who were less than truthful.

Christina East

Director

Hammersmith and Fulham Mind