Health: True price of the waiting game

Health Check

THE FIRST question the surgeon asked my father before he had his coronary bypass was: "How old is your youngest child?"

The question was not "How do you feel?" or: "Where does it hurt?" or: "How far can you walk before you get angina [chest pain]?" No, something altogether more direct, more personal - a question that could fairly be summarised as: "Give me a good reason why I should save you rather than the next patient on my list."

"Nine," my father was able to answer, which was fortunate, as he got his operation within a month when he had been told the average wait was four months. He was then 61 and lived another 13 years. But I have often wondered since what might have happened had he not had a late fourth child in his early fifties, with his new wife.

This week, almost two decades after my father had his operation, an editorial in the journal Heart says that as many as 500 patients a year may be dying while still on the waiting list for heart surgery.

Indeed, the risk of dying on the waiting list, at more than 2 per cent, is almost the same as the risk from the surgery itself.

So what can surgeons do? Ben Bridgewater, who is a cardiothoracic surgeon at Wythenshawe hospital in Manchester, and author of the Heart editorial, says the average wait for heart surgery in his unit in the late Nineties is 175 days, almost six months, and much longer than the wait that faced heart patients in the early Eighties.

Selecting the patients who are at greatest risk of sudden death, and operating on them first, would clearly be the best option. Attempts to do this have, however, proved hopeless. In New Zealand, a scoring system based on severity of symptoms, extent of coronary artery disease, exercise test results and other factors failed to predict who would die first. Other measures have had limited success.

Mr Bridgewater is pessimistic. Efforts to judge the severity of a patient's heart condition are never going to be better than making an educated guess. That is the nature of heart disease. It is both unstable and unpredictable.

There remains, therefore, the question of what surgeons tell patients - and how they prioritise them. Most surgeons manage their own waiting lists - and they do not always select patients on a first-come, first- served basis. Most explain the risks of the operation, but few dwell on the risks of waiting. What would they say? "Well, Mr Smith, we will put you down for an operation, but there is a one in 50 chance you will die before you get it."

If surgeons do not treat patients strictly in order of their arrival on the waiting list, then it is of some interest to discover what criteria they do use. Personally, I think that taking account of a patient's family responsibilities was, and is, a humane way of allocating scarce resources.

But I am biased. And it leaves open the possibility that other, less palatable choices might be made. Does a captain of industry get priority over an unemployed car worker? Or does it depend solely on the ages of their children?