The million-year wait

What do waiting lists measure?

The newspaper headlines which tell us there are now a million people on NHS waiting lists are rightly shocking. The figure means that one in sixty of us are now waiting for medical treatment. And by no means all of us are even ill. Of those who actually need the NHS to do something for them, it is more like one in six who are condemned to wait.

Waiting lists are the inevitable consequence of a politically-driven, tax-funded, centrally-run health service. Users have no customer power over the system. Since the amount which people pay (through taxation) is unrelated to the volume of services they use, they have every incentive to demand as much service they can get, however marginal or even unnecessary. And because – unlike almost all other goods and services – there is no price mechanism to inhibit the over-demand, the central authorities have to resort to the only other strategy open to them, that of rationing.

Waiting lists are merely the symptom of this. They represent unmet demand. They are rationing by queuing.

Undoubtedly, this strategy has some success. Some people do not bother to see the doctor because they cannot face a long wait, while others fail to turn up to consultants’ appointments because they have simply got fed up waiting. A growing number choose to dip into their own savings and pay directly for their treatment in the private sector. A quarter of cardiac patients actually die before it is their turn to be called in, which reduces the burden of demand even more.

But the headline figure for waiting lists conceals a great deal too. There are wide variations in waiting times in different areas, between different doctors and hospitals, or for different kinds of illness. So what is the real story behind the headline figures?

How long are the waiting lists?

What patients are concerned with is not so much the number of other people who are on the waiting list, but the length of time which they themselves will have to wait. Obviously, in principle it is possible for the waiting list to be small, but for each person to have a long wait; or for the waiting lists to be large, but for each person to be seen very quickly.

The National Plan for the NHS published in 2000 states that by 2005 “no one will wait more than 13 weeks for an appointment and 6 months for admission”.

That was two years ago, but in fact the position has worsened slightly since then. The slide in performance suggests that, however determined the policy objectives might be, today’s centralized control structure cannot in fact deliver even these modest goals.

In-patient waiting lists. Most urgent cases, however, are actually seen quite quickly. Consider in-patient waiting times – the period between a consultation with a senior doctor and admission for treatment. There are roughly ten million admissions for in-patient treatment each year. Just under half (4.3 million, in England) are emergencies and as such are treated quickly. Just over half (5.7 million) are for other sorts of treatment

Taking only the figures for England, the one million people on this waiting list at any moment, it is estimated that: 155,000 are seen within 4 weeks.

However, non-urgent cases can have very long waits indeed. Of the remaining 845,000 who are seen after 4 weeks:

* 345,000 are seen before 13 weeks, but * 500,000 are not seen until after 13 weeks, and of those: * 250,000 are not seen until after 26 weeks.

Out-patient attendance. There are around 44 million outpatient attendances each year. These are people waiting to see a consultant. The biggest delays are in getting to see the consultant in the first place: once you have had a first consultation, subsequent attendances tend to follow more quickly.

But of the (roughly) 11 million first attendances with a consultant:

* 8.4 milllion (78%) are seen within 13 weeks, of whom: * 3.8 million (35%) are seen within 4 weeks; but * 2.4 million (22%) are not seen until after 13 weeks.

How much time do we waste in waiting?

Of course, we can probably never entirely get rid of waiting time in any service – either in health care or even at the supermarket check-out. But for the population as a whole, today’s NHS waiting lists add up to a very long wait indeed. As Professor Richard Feachem showed in the British Medical Journal of 19 January 2002, they compare very unfavourably with waiting times in Kaiser Permanente, a California health plan whose spending per patient is remarkably close to that of the NHS. In Kaiser, though, 90% of in-patients are treated within 13 weeks, and 80% of out-patients are seen within two weeks.

But let us set a more modest target for the NHS and say merely that a wait of over 4 weeks is unsatisfactory – and given the pain and anxiety that people may suffer, it clearly must be. So how much time do NHS patients spend in this ‘clearly unsatisfactory’ state of waiting more than 4 weeks?

Let us also assume that people reach the top of the waiting lists at a fairly regular rate as indicated by our raw statistics, so that all out-patients are seen within 20 weeks and all in-patients are treated within 36 weeks. (Though as a number of hip-replacement patients will testify, this is perhaps an over-generous assumption.) We can then calculate that, in rough terms:

* the in-patients on the NHS waiting list will spend 235,000 years waiting in excess of 4 weeks for their treatments; and * NHS out-patients will wait 830,000 years waiting beyond 4 weeks to be seen.

That is, a total of 1,065,000 years of unsatisfactorily long waiting.

What are the knock-on costs?

Of course, this is not the whole story. Waiting lists cost people a lot more than just time. Dudley Lusted, chief economist at PPP Healthcare, undertook a major exercise on the economic cost of waiting lists. His starting point was to estimate the cost to employers of working days lost – counting the period after the first 4 weeks’ absence – where the individual remained too incapacitated to return to work and was awaiting medical treatment.

Averaged across the workforce, Lusted estimated two days being lost per employee per year. With a workforce of about 22 million that suggests 44 million work days lost due to delays in medical treatment. With a weighted average pay of £15,000 the cost is therefore £660,000,000. As a rule of thumb, the consequential cost of lost work time or covering for absence will be the same again, to give a total cost close to £1.5 billion for employers. This does not include the productivity losses of below-par workers or the management costs of dealing with absence.

The cost of anxiety and limitations on activity for the patients themselves has been estimated by Professor Carole Propper of Bristol University. Taking this at £5 a day (the mid-point of her estimated range) then the unseen cost of the 1,065,000 years that people spend waiting beyond 4 weeks is approximately £19.4 billion.

There are, of course, other costs too. A MEDIX survey identified the extra burdens on GPs and their patients. Among the key results were:

* Worsening conditions – 66% of GPs had patients waiting as outpatients admitted as emergency because their condition worsened * Increased burden – 90% of GPs had patient consultations arising out of waiting list delays and 70% of GPs dealt with problems arising from that – an estimated 1.5 million extra consultations.

What should be done?

Although all these costs are necessarily estimates, it is clear that the cost of NHS waiting lists – in terms of anxiety, incapacity, time off work, the cost of absence to employers, the extra costs to the NHS whose condition worsens and the cost to GPs of seeing patients who are waiting for treatment – is well over £20 billion.

But rough as they are, these calculations do tell us something about the real human scale of the waiting lists and the costs to individuals and economy. Unfortunately, fewer people are being put on the waiting list, fewer of those are being treated in good time, and the total queue is not getting any shorter. Clearly, productivity is falling, despite a real increase in funding of about £5,000 million in the past two years. The inescapable conclusion is that the current structure simply cannot make the improvements that we all want, and that radical reform is inevitable.

Pumping more money into a failing structure will not deliver the benefits. Importing clinicians or exporting patients is a marginal stop-gap. We need to change the system.

Most healthcare can be delivered locally, and there is a strong case for managing that delivery locally too. More local management, greater diversity of provision, and methods to make the financial rewards come upward from the patient, rather than downwards from Whitehall and through the health bureaucracy, could all produce a more patient-centred system where there was a real downward pressure on waiting times both from patients and providers.