Feature

New queues for old

The rapid rise in waiting lists since the general election has been hailed by the health secretary as “proof that the NHS changes are working”. But the truth is stranger even than this fiction, explains Penny Mullen

Although waiting lists are in the news again, they have been a major issue since the NHS began. Behind the ‘headline figures’, what is really happening to waiting lists? Are the current changes making them more ‘hidden’? Is the whole nature and role of waiting lists altering?¹

While the majority of hospital patients receive immediate treatment as emergencies or urgent cases, most hospitals have waiting lists for non-urgent treatment covering a relatively limited range of surgical procedures. Their existence has led to many theories. The simplest is that demand exceeds supply and waiting lists would disappear with more resources. The backlog theory argues that waiting lists consist of a backlog of cases, which could be cleared by a temporary increase in treatment rate. Empirical evidence does not support the suggestion that failure of patients to turn up wastes resources and thus causes longer waiting lists. There is, however, evidence for the argument that demand is influenced by supply: when more resources are available demand increases, maintaining the length of the waiting list. Long waits, Frankel suggests, arise because some conditions are given so low a priority as to create a ‘mortlake’ of patients, who wait many years for treatment and may never be treated at all.² The most contentious argument is that long waiting lists enhance consultants’ private practice by their prestige and by encouraging patients to opt for private care to avoid long waits.

Waiting lists have some positive features. Rationing by waiting list is considered fairer than rationing by price. Waiting lists help even out fluctuations in demand and permit scheduling to ensure efficient use of resources, balanced case loads and appropriate case mixes for teaching. But long waits for treatment which has already been judged clinically necessary are considered unacceptable. Patients’ condition may deteriorate and their pain and distress may be worsened by uncertainty about how long they may have to wait.

Most attempts at reducing waiting lists have focused on increasing, either temporarily or permanently, the rate at which patients are treated, by providing additional resources, improving the balance of resources and/or by better scheduling; reducing demand by validating waiting lists; changing the priority system for the patients selection and by introducing booked admissions systems to reduce the uncertainty involved in waiting. With the NHS changes, the government has claimed that increased efficiency arising from competition, money following the patient, and specified targets in contracts, will ensure that waiting lists and waiting times will fall. But the influence of the changes on ‘demand’ for treatment could prove far more important than increased efficiency for the future of NHS waiting lists.

Before April 1991, while GPs normally referred patients to consultants within their own district health authority (DHA) boundaries, there were many referrals to consultants and hospitals elsewhere. Adjustment to DHAs’ allocations to compensate for cross-boundary flows (i.e. treating non-resident patients) was crude and usually based on historical data. Hospitals normally received a fixed financial allocation, with no additional money for treating additional cases.

In the new NHS, funds are allocated to DHAs to ‘purchase’ services to meet the needs of their own population (i.e. with no prior allowance for cross-boundary flows), with some of this resident-based allocation going directly to GP fundholders (GPFHs) to purchase a limited range of hospital services for their registered patients. Hospitals obtain their income by selling services, mainly via contracts but also by individually billed extra-contractual referrals (ECRs), to DHAs and GPFHs. Now, before a GP referral is accepted, the hospital must go through a series of checks to ensure the patient is covered by a GPFH, a DHA contract or DHA approval for an ECR. If a patient is not so covered, the GP may seek referral to another hospital. Where this is not possible, some patients seek private treatment.

In the new NHS, if a hospital is judged by waiting time or by the length of its waiting lists, it has an incentive to decline to add a patient to a waiting list if its contract has already been fulfilled. The hospital may decline to accept even the initial referral if the contract numbers have already been accepted. Currently there is no requirement to collect statistics of refused cases, but there is already some anecdotal evidence of such refusals. The strong possibility thus exists that waiting lists will decrease, not because of additional treatment, but because patients are not allowed to join them, or not even allowed to get an initial outpatient referral. A hidden, pre-referral waiting list could result. This scenario only arises with ‘cost-and-volume’ contracts, whereas in the first year of the internal market block contracts prevailed. However, in future it is unlikely that providers will be prepared to enter into block contracts for services such as surgery, since such contracts mean they carry all the risk.

Extra-contractual referrals might appear to solve the waiting list problem. Since they bring real additional money, hospitals have an incentive both to accept ECRs and to provide prompt treatment. But such referrals represent a potentially uncontrolled drain on DHA resources and a distortion of their priorities, so elaborate control mechanisms have been established. In most districts limited funds have been provided and elective ECRs have to be individually approved, resulting already in many reports of refused ECRs. This strict control of ECRs makes ‘shopping around’ for a hospital with shorter waiting lists of little use if the DHA refuses to pay for treatment at that hospital. Recent Department of Health guidance limiting the grounds on which DHAs can refuse ECRs may alleviate this problem but will bring financial problems for DHAs.³

Will GP fundholding get around these difficulties? Crump et al suggest that GPFHs may hold back referrals if they are uncertain about their financial position.⁴ By maintaining their own, non-recorded, waiting list for referrals, the size of hospital waiting lists will be artificially depressed. There are fears of the emergence of a two-tier system, with GPFHs negotiating contracts for quicker treatment for their patients. In addition, there have been reports of a two-tier service arising when hospitals treat ECRs ahead of patients covered by a contract, or continue to treat patients from a DHA with which the contract is not yet fulfilled, ahead of patients with greater clinical priority, who come from districts where the contract for that year has been completed.

Such events are the result of rational behaviour on the part of providers under the new system. In the old NHS each consultant operated (at least for NHS patients) a single queue or waiting list, with patients selected for treatment on the basis of a mixture of medical priority, length of time on list, operating case mix, and consultant preference. In the new system, by contrast, the queue/waiting list for any consultant can be represented as a series of queues, one belonging to each purchaser and ‘owned’ by that purchaser. Members of each queue can be treated only if their DHA or GPFH pays for their treatment either by contract or as an ECR. Thus, if the contract for one DHA has been completed, it would be irrational for the consultant or hospital to refuse to treat lower priority cases from other DHAs or GPFHs whose contracts have not been completed, or to refuse lower priority cases for which DHAs are prepared to pay as ECRs. This problem is unlikely to be resolved by national guidelines while providers are under financial compulsion to act in this manner.

The perverse incentives of the purchaser/provider split may lead to difficulties in honouring the Patient’s Charter’s guarantee of ‘admission for treatment by a specific date not later than two years from the date when the consultant places the patient on a waiting list’. Although responsibility for honouring the guarantee lies with the purchaser, hospitals can be penalised where a patient is not treated within two years, giving them an incentive to limit acceptance for treatment to the contracted numbers and/or to re-order clinical priorities. An additional problem might arise because many patients receive their treatment in a different financial year from that in which they were placed on the waiting list. A provider may add names to the waiting list at a rate which accords with the current contract, only to find that in the following year(s) the number of in-patient cases purchased has been reduced, or even eliminated. So the provider is being asked to honour the guarantee, but the purchaser controls the amount of treatment it will purchase to enable that guarantee to be honoured.

Concern about waiting lists is unlikely to diminish. Theories will continue to be put forward for their existence and attempts will still be made to cut them and reduce waiting times. But in the new NHS the nature and role of waiting lists may dramatically change. However the NHS is funded or organised, measures to increase the treatment rate and to eliminate ‘phantom’ demand by list validation will result in shorter waiting times and/or more patients being treated. Yet however successful such measures are, if the incentives in the system lead to administrative reductions in demand, it could be that fewer patients, overall, obtain treatment, but that those who do have shorter waits.