The government's manifesto pledge was unequivocal: waiting lists would be reduced by treating 100,000 more patients. But in the seven months to December 1997, waiting lists increased by approximately that number of patients, prompting the health secretary to apologise and suggest that the need to treat more emergency patients in the winter months had diverted resources away from the treatment of elective cases, causing the waiting list to rise. This is the wrong target. What matters is how long patients wait.
1Patients have good reason to worry about how long they will have to wait. They may be in pain and their condition deteriorating. But a long list does not necessarily mean a long wait; a large number of patients could be put through hospitals quickly. In fact, in the first half of the 1990s more patients were admitted within short periods.
But recent months have seen an increase in the number of patients waiting over a year, and even over the Patient's Charter target of 18 months.
At 31 December 1997 the total number of patients waiting to be admitted to NHS hospitals in England was 1,262,300 - an increase of 54,700 (4.5 per cent) on the previous quarter.
This represented an increase of 14.2 per cent on the same quarter for 1996.
The number of patients waiting more than one year had increased to 68,300 - up 19 per cent on the previous quarter.
Under the Patient's Charter patients are guaranteed admission within 18 months of being placed on the waiting list. At 31 December, 974 patients had been waiting longer than 18 months, compared with 123 at the end of December 1996.
The mean waiting time in the 1960s and 1970s was between 13 and 14 weeks, according to a study published in 1980.
2Our own analysis of the 1990s shows the mean waiting time was still around 13-14 weeks.
But the government persists with its target of reducing numbers on the waiting list. Can it ever expect to hit it, and if so, when?
The government committed itself to reduce the size of the waiting list by treating more patients, as if the waiting list were a backlog of untreated patients who could be removed by a short-term burst of increased activity.
This backlog theory of waiting lists is clearly false, as an examination of the historical record makes clear. The number of patients treated in the NHS is now several times higher than in 1948 (even allowing for changes in the unit of measurement) yet, as figure 1, adapted from the work of Rhiannon Edwards shows, the numbers on the waiting list are now more than twice as great as at the NHS's birth.
3The waiting list continued to grow even during the period of the waiting time initiative. Record increases in the amount of elective activity were more than matched by increases in the number of patients being referred on to the waiting list.
We need to understand the underlying factors at work.
Elective admission can be considered as a process, as figure 2 explains. The waiting list is a measure of the number of patients who are between the outpatient consultation and the inpatient admission. Thus, the size of the waiting list is as much affected by the number of patients placed on the list as the number taken off it. To understand and control the list, both the amount of elective activity performed and the number of patients being referred to the list must be considered.
Figure 3 presents this model using real data to show how activity levels and flows between different parts of the system changed between 1990-91 and 1994-95.
Despite an increase of over 800,000 in the annual rate of treatment of patients on the waiting list between 1990-91 and 1994-95, the waiting list lengthened by over 100,000. This is due to an excess of a million more patients being referred to the waiting list.
While the number of people seeking a GP's advice has remained fairly constant, and the proportion of patients seen in an outpatient clinic and referred to a waiting list has declined slightly, the proportion of patients seen by GPs and referred to an outpatient clinic has increased by nearly a third.
That the proportion of patients seen in outpatients who were referred for treatment remained constant over the four years suggests that either GPs were spotting more people with the same degree of need (that is, they were spotting previously unmet demand), or specialists used the greater availability of elective activity to lower their thresholds and offer operations to less sick patients - or both.
Why are referrals increasing?
There are two elements in the increased demand for services: external factors, which may be beyond the control of management action or national policy, and internal dynamics - that is, changes in the behaviour of the people involved in providing elective care, in response to available capacity and the size of the waiting list.
Figure 4 shows potential causes of an increase in the numbers of referrals. These may take effect regardless of which policies have been implemented to alter levels of elective activity. These are labelled as increased morbidity, intelligence, social attitudes and expectations, new technologies and new therapies.
Any combination of these factors could be responsible for the changes noted in figure 3. The number of patients seeking a consultation with a GP increased only slightly over the period; most of this increase is associated with less serious conditions. But increased clinical intelligence could explain the rise in the proportion of patients seen by GPs who were referred for treatment, as could developments in medical technology.
Changes in behaviour due to changes in numbers waiting, the so-called internal dynamics, may also influence demand.
An increase in activity to reduce the size of the waiting list may therefore influence the number of people being placed on the waiting list. An increase in elective activity may increase GP and specialist referrals, reduce them, or have no effect at all. Given the historical record, neither a reduction in referrals nor nil effect seem plausible.
More activity being followed by an increase in referrals implies that there may be a waiting time acceptable to GPs and specialists, and that if increases in activity seem likely to reduce waiting times to below this level they refer more patients. List size and activity levels remain in equilibrium to ensure that waiting time remains unchanged, regardless of actual levels.
Therefore an increase in activity will be met by an increase in the referrals on to the list so that waiting list and activity are once again in proportion, ensuring the acceptable waiting time is maintained.
The implication is that if activity increases, the size of the waiting list must also increase. Thus, an increase in activity, far from reducing the size of the waiting list, encourages an increase.
But there will be a time-lag in this process. Clearly, it takes time for GPs and even specialists to become aware of the state of the waiting list, and hence to react and change their behaviour. Thus, the initial effect of increasing activity may well be to reduce the size of the waiting list. This is why initiatives to reduce waiting lists may initially seem successful.
Unfortunately, historical and international evidence suggests that, in time, increases in referrals to the list ensure that the list grows, until it is even longer than at first.
Conclusion The government's pledge to reduce waiting lists by increasing activity is based on the misconception that waiting lists are a backlog of unperformed work, rather than the measurement of part of a dynamic system at a point in time. It takes no account of the importance of changing levels of referrals to the list. It is only now that the government is publicly acknowledging this, with the health secretary asserting that the rise in the waiting list in the three months to December 1997 was due to an increase in referrals from GPs.
The importance of understanding why referrals to the waiting list increase cannot be overestimated. Any policy for elective care must be mindful of the pressures we have outlined. By not acknowledging the importance of referrals to the waiting list, the government has decided to follow a policy which is very likely to increase the number of patients being referred to the waiting list, and, eventually, the size of the waiting list itself.
We cannot know what the future will bring. This is obviously true of external factors such as the development of medical technology and changes in social attitudes. But it is compounded by the general ignorance of how relationships in the system may change and alter the demand for care. The health secretary has offered two partial explanations for the rise in the number of patients waiting: a knock-on effect from increased demand for emergency care, and a rise in referrals from GPs. A recognition of the full range of forces is needed.
So can the government honour its pledge? Unless it is prepared to increase core health service funding by several billion pounds, it is left with two options. Neither is particularly attractive. The first is to fund a large, temporary increase immediately before the next election. With luck, the waiting list will still be reduced by polling day, and referrals will not have increased to a level where they have overridden the increase in activity.
But this policy does not offer a permanent solution. If it is pursued, expect record increases in the size of the waiting list after the next general election.
The alternative is to limit the number of patients referred to the waiting list. This will not be comfortable for the government.
At best, it will bring forward the rationing debate it has sought to avoid. At worst, it will prevent patients receiving the care they need, achieving the opposite of what the government intended when the pledge was made.
External influences on demand for elective care Increased morbidity may seem an unlikely cause of an increase in referrals for elective care in the context of increased life expectancy. But the success of health services in reducing mortality may mean that an increasing cohort of people who would, in the past, have already died are now heavy users of health services. Two complementary factors are at work - an increase in the absolute number of older people and an increase in their ability to benefit from treatment.
Intelligence refers to enhanced clinical intelligence, primarily on the GP's part.
Increased training and education of GPs may increase the number of patients diagnosed as potentially needing treatment. It has been assumed that an improvement in primary care would lead to a reduction in the demand for hospital services. This view underlay key health strategic planning documents such as the Tomlinson report. But more recently it has been challenged.
5The other three explanations overlap. The development of new therapies and the alteration of treatment threshold due to technological development may be described as a new technology set. The two are subtly different. New therapies are treatments that were not previously available. Patients who would not previously have entered the system as they could not be treated are placed on waiting lists for a newly available therapy. Joint replacement in the past 20 years is a good example.
New technologies refers to the introduction of techniques which allow available therapies to be provided to wider groups of people, such as new forms of anaesthesia making surgery safer for older, sicker patients. This results in an increase in the number of patients being placed on the waiting list. Social attitudes and expectations are difficult to define and almost impossible to measure. One example is the increased expectation that age should not be a barrier to any form of treatment.
Key Points
The numbers now waiting for treatment in the NHS are more than double what they were in 1948 despite huge increases in activity.
Increased activity has not reduced the time patients wait.
Mean waiting times in the 1990s were 13-14 weeks, the same as in the 1960s and 1970s.
An increase in activity to reduce the numbers waiting for treatment may, in fact, increase the number being put on the waiting list.
Government targets should concentrate on how long individual patients have to wait, rather than reducing the numbers on the waiting list.
REFERENCES
1 Hamblin R, Harrison A, Boyle S. The supertanker's not for turning. The Lancet 1997; 350 (9090): 1,493-94.
2 Frost C. How permanent are the NHS waiting lists? Social Science and Medicine 1980; 14C: 1-11.
3 Edwards R. NHS Waiting Lists: towards the elusive solution. London: Office of Health Economics, 1997.
4 Hamblin R, Harrison A, Boyle S. Access to Elective Care: why waiting lists grow. London: King's Fund, 1998.
5 Harrison A. The London Health Care System. London: King's Fund, 1997.
Richard Hamblin is research officer, and Anthony Harrison and Sean Boyle are fellows in health policy analysis at the King's Fund.
No comments yet