One promise that Labour really ought to break

Cutting NHS waiting lists
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The Independent Online
"Waiting lists will be shorter." That's what Labour promised in election posters up and down the land. Those who know about these things shook their heads: expensive, difficult and probably wrong. But there it is, Tony Blair is the promise-keeper and the five pledges will be kept, even if it distorts NHS spending and undermines some of this week's excellent NHS White Paper. Even if it means treating the wrong people for the wrong reasons, for this is a political not a medical imperative.

What is the absolute minimum that pledge commits them do? Could they just reduce the number of people waiting over a year? After all, if millions are on the list it doesn't matter. What people care about is how long they wait. But no, apparently that won't do. The politicians say the pledge means there must be fewer people on the total list by the next election.

Taking the pulse of the NHS is well nigh impossible. For every story of heroic new treatments, there are matching anecdotes of hospitals running short of sheets, over-stretched nurses in under-staffed wards and exhausted junior doctors doing operations way past their bedtime and their competence. How are we to tell if things are getting better or worse, overall?

The only easy measure every news editor and politician understands is the number of patients on the waiting list, although it may reveal little of importance. Mightn't people rather wait longer for better treatment, supposing that was a choice? The best aspect of this week's White Paper was the new drive towards excellence. The National Institute of Clinical Excellence (NICE) will insist on national standards, making sure that all doctors know and use the best treatments. Currently standards vary frighteningly, with some surgeons killing five or six times more than others. (How NICE forces doctors to obey the standard, we don't yet know but at least they'll have national authority to intervene.)

Clinical effectiveness is the new watch-word, striking out useless and outdated treatments, pushing for the best. But measuring the success of that process and presenting it in a way everyone can understand will be difficult. It will also be a lot harder to achieve if too much money and attention is squandered on waiting list reductions.

Here's the size of the problem: At the start of the NHS in 1948 there were 500,000 people on the waiting list, rising ineluctably upwards to over a million now. There have been occasional slight dips, but even in years when the Tories made most effort to clear out defunct old lists - which included the dead, those who'd already been treated or those who no longer wanted treatment - the figures barely changed. Even when they introduced their market reforms with a vast injection of cash, the list went up. Through super-human efforts, with list-busting budgets and expensive initiatives, Clark and Bottomley did manage to clear out everyone waiting over two years, which was quite an achievement. But total numbers still rose.

Getting total numbers down has eluded everyone so far. Lists keep rising because there are new treatments to queue for and more old people who need more operations. Patients are more demanding now, less patient. And whenever local waiting lists shrink, GPs just refer more patients and fill them up again. The explosion of day-surgery units should mean lower waiting lists, but this appears to have created more demand.

Dr Alastair Lack in Salisbury has pioneered a new priority waiting list system, awarding patients points on four scales: they get points for their rate of deterioration (so cancer scores high), for the pain they suffer, for their level of disability, and for time already spent waiting. So time is only one factor. Without significant points on the other measures, some minor conditions might never be treated and the patient would be warned accordingly.

But it hasn't worked. The hospital wanted to bring it in, but found they couldn't. Why not? Because their contracts with local health authorities demanded everyone on the list be treated within one year. That meant that firefighting was all they could do - treating only emergencies and long waiters, with no money to treat anyone else. So a one year varicose vein has to be treated before someone in agony in a wheelchair for need of a new hip. The hips never get treated until they hit the one year deadline. The Government has now tied its hands in the same way by demanding reduced lists and not prioritising treatments. (Prioritising sounds dangerously like rationing to the politicians.)

A national list-buster has been appointed, Stephen Day, who worked miracles in the West Midlands. However, he spent pounds 30m in one region alone, while the Government has allocated just pounds 5 m for pilot schemes for the whole country. So how is he going to do it? He's blunt: "It can't be done without money". He only managed what he calls "tail-gunning" the back end of his list by using extra money, to ensure the priorities of the list were not distorted. So he's putting systems in place now, hoping for more money in two years.

And there is plenty that can be done. Consultants are the key to it all, because they control the lists, but getting control of them has eluded every government. Here the new Clinical Effectiveness team will be monitoring how well they do: if the worst surgeons improved, there'd be fewer re- admissions for bungles and infections and so lower waiting lists. Consultants are expensive but often their time is wasted: some orthopedic surgeons do just one or two operating lists a week while others do four. Some ENT consultants do only 300 operations a year while others do 1200 identical ones. Usually this is not laziness, but management ineptitude and failure to rationalise. (Though managers might ask why so many surgeons take a full day off the NHS for private practice, for only one eleventh less salary?)

If everything in the white paper worked miraculously to plan, in theory waiting lists should come down, simply through better practice. But history suggests otherwise. Far more likely that as the next election approaches, there will be another panic "waiting-list initiative". Money will be bunged at tailgunning the lists, draining resources from geriatrics or mental health - which can't be measured except in schizophrenic murders. So when Blair mounts the podium to boast he's kept his promise, it may be yet another vow that might have been better honoured in the breach.

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