NHS waiting lists: reasons to be careful

Rajan Madhok

The focus on waiting lists is good news for people who have waited for a long time, and it seems wrong to question the efforts being made to help them –surely we must do whatever it takes to alleviate their suffering.

Equally, it is important to understand the implications of making this decision.

Briefly, here are some of the reasons why we should be careful, and how we could do better.

There is additional money for waiting lists, so it is alright? Except that the money that is going into waiting lists initiatives is coming from depriving other, equally necessary, services – mental health, children’s or care of the elderly for example.

After all almost all services ‘need’ more investment, so why the focus on waiting lists only?

Next, when one talks of ‘Waiting’ – what does it mean? Since people are waiting for all services: from seeing a GP, or getting into an A & E, or for tests or operations.

‘Elective surgery’

The discourse, however, focusses on ‘elective surgery’ mainly, but why is this the most important aspect?

Should NHS be defined by how much elective surgery it provides, or by the overall population health gain?

Well, one has to start somewhere, and so let us continue with elective surgery waiting lists, and where the main reason given is the lack of capacity- both physical and manpower in the NHS, but is that true?

Has anyone done a stocktake of what physical capacity exists – in terms of space or equipment and especially if hospitals actually worked efficiently as 24/7, seven days a week units.

Re manpower, where exactly are the shortages- is it doctors/nurses/theatre staff etc, but how are the existing staff being deployed currently?

Consultant surgeons I speak to complain about not be being able to operate enough in the NHS.

Based on the presumption, not evidence, that the NHS cannot cope, there is no choice but to bring in the private sector.

Yes, the sector does bring additionality – physical assets and some workforce, though the critical element is medical staff, where most of the consultants who work in private sector are from the NHS anyway.

The ISTCs (independent Sector Treatment Centres) set up as part of Blair Modernisation Plan, initially were clear and mandated that existing NHS staff could not be deployed, since if they were available then why was the NHS not using them- good principle, except it did not last.

Private sector

And private sector involvement comes at a cost – it is worth reading the reports from Centre for Health and the Public Interest and Royal College of Ophthalmologists about one of the commonest procedures- cataract surgery – where private sector has profited handsomely and weakened the comprehensive NHS eye services including compromising training of future surgeons.

By the way, the private sector does not contribute to training of any staff- so the State/NHS pays, and they benefit.

Finally, have alternatives been considered before resorting to the private sector?

How about investing in social care so people can be discharged home, rather than kept in  hospital beds – a sure win: win for the NHS and patients?

Or creating permanent NHS capacity- one of the fastest movers when Blair government introduced ISTCs was someone who rented NHS theatres and staff and did the work (sic), of course making a profit, and later on set up mobile operating theatres quickly and at low costs.

His consultants used to routinely do 17-18 operations in a day as compared to 3-4 they would do in their NHS practice, and yes, these contracts had stringent quality and safety requirements.

My intention is not to catalogue all the issues, but only to point out that there is a danger of falling into the trap that H L Mencken described: “For every complex problem there is an answer that is clear, simple and wrong.”

There is a prevailing mindset that NHS is already doing its best, more money is needed, and private sector is the solution. We must strongly challenge this narrative.

So, should we abandon the idea of addressing elective surgery waiting lists. NO. But we can do it better. Let me begin by sharing two relevant experiences.

Low back pain

In 1992, as a new consultant in public health in Teesside, I was tasked to look at the orthopaedic waiting lists (given that I had trained in orthopaedics earlier).

After detailed analyses of long waits, we found that a significant proportion of outpatient referrals were patients suffering from low back pain. Long story short, after a lot of work with all the relevant parties, we managed to introduce a nurse led back pain clinic which not only brought down the waiting times but also offered timely support, since after a few months the condition becomes chronic with lesser chances of recovery and these patients need to be seen early.

In 1994, I went to work in Tyneside and found the same situation, and again it took two years to set such a service up. In 1998, it was a repeat, in Hull this time. In 2012, I was chairing the Northwest of England Conference of the three HIEC’s (Health Innovation and Education Clusters – another great idea at the time, not sustained) when the prize for innovation went to a nurse from south of England for establishing a nurse-led back pain clinic.

The work on these clinics, and other projects at the time, led to the development of the ‘Specialty Management Approach’ in 1996 in Tyneside whereby we proposed that every clinical specialty should be subjected to detailed review of its processes from the time referrals are received to final interventions and discharge – end to end process maps – and at each stage asking why this step was necessary – business process reengineering, and how could it be made more effective and efficient – evidence base and innovation.

We piloted it in two specialties: dermatology and orthopaedics, and proved the concept, which led to improvements.

In 2024, I was given a book by Dr Alex Anstey, a leading dermatologist in Wales: Under the skin where he described his Integrated Care Model which he had developed in 2017, and it was not very different to the SMA above.

The reason for sharing these two stories is to point out that problems with waiting lists are not new, and that we have stopped doing proper science and operational research, and have neither the systems for local innovations nor for faster adoption of proven practices.

Aggrieved

There is another aspect to the nurse led back pain clinic story. I had mixed feeling about giving the award in 2012, I felt aggrieved that we were still talking about it then.

However, on the other hand, I knew what it would have taken the team to set it up – introducing ‘disruptive’ models is very hard in the NHS, so the nurse and her colleagues must have struggled, and I was happy to note that they had stood up to the pressures and created the model. Just as Dr Anstey probably had to do.

How many more such examples exist out there? Should we not be pulling them together as in the Specialty Management Approach mentioned, and not wait for 30 years to bring the benefits to patients? Sadly, we have stopped learning from each other or from history – NIH (Not Invented Here) problem means every generation starts all over again.

There is so much we can learn from the works of John Yates (mandatory read) in Birmingham or Liam Donaldson and Brendan Devlin in the north-east in the late 1980/90s, or indeed from setting up ISTCs in early 2000s, for example. It is not just the waste, which is inexcusable but the fact that patients are made to suffer as a result of the system’s inability to get it right which makes it morally unacceptable. The way things are is not the public’s fault, and they deserve better.

What can be done then? I propose three things, and in doing so I am trying to reconcile practical with the ideal. I am restricting my comments to elective surgery waiting lists, though these apply equally to other aspects of NHS services.

Framework

One, there should be a clear framework for how to involve the private sector – which services to be outsourced and on what basis should be clear; and how to avoid the downsides and secure best value – how much profit is right? In addition, I suggest an ‘independent’ arrangement for oversight of such contracts and in particular to look at patient experience, quality and safety of services. I do not see any such mechanism at present- commercial confidentiality is one thing but transparency is equally important; these are public funds.

Two, we should design an overall, Wales wide system, which builds on all successful models – I have referred to two, but there are others, and create a way of harnessing what is already known and using whatever assets already exist. Wales is a small country, like an average regional health authority of the old days in England, and should be managed as one for this purpose, in so far as designing this overall system is concerned; implementation, of course, would be local.

I do not know enough details though I am aware of initiatives like the Prudent Health Care or Better Value Health Care, Bevan Commission Fellowships and Health Education and Improvement Wales – why not link all these, effectively? There are emerging mentions of surgical hubs, better referral management, using technology etc and which are all necessary, but they need to be a part of an overarching plan, and which I have not seen so far.

Three, bring the workforce on board with the changes, starting with doctors. Both, a top down approach setting out clear policies, roles and responsibilities, and a bottom up approach to how any plans will be delivered locally, with their help and support. Currently, the hospital sector is split – although all consultants are on the same contract salary wise, there are those who earn extra, largely through private work, and those who do not, and the private incomes vary.

Apart from devaluing some specialties, it can also alter future provision as ‘less lucrative’ specialties become non-attractive. How to bridge the gap between GPs and hospitals is another important matter, and rather than winners and losers we need to demonstrate that everyone is valued. Managing health care workforce is a global challenge, but we can be ambitious and create a much more socially responsible workforce if we get certain things right.

Pride

Cymru is on the rise, the pride amongst young people is palpable – the Welsh history and values are an under-exploited strength.

When I hear stories or see programmes of staff working under stressful conditions, and patients being upset – like in the recent Ysbyty progamme, I have mixed feelings. One of admiration and thankfulness – for the staff who continue to provide care, and the other of frustration and anger – who has put them in these positions, and why?

The current NHS is a badly designed and operated system, and we should stop using staff as cannon fodder. Health care is not manufacturing, people are not widgets; it is a human industry, needing a humane approach.

Are these things new – no. Are they doable- yes. Have I advocated them before –yes. Have these been accepted – no. Am I therefore wrong? Of course, if they have not happened then maybe I should show insight and accept that my analyses and proposals are wrong.  I will let you be the judge.

The problem with the NHS is that the urgent, and self-interest, drives out the important – short term, piece-meal, quick fixes at the expense of sorting out the underlying problems. The aim (ambition!) to stop anyone waiting over two years is defeatism, and should be unacceptable; we must do better, and it can be done.

There is a saying in golf (I am a beginner): Do not Compensate but Correct; players  fall into the trap of compensating for their bad habits, because they want to get on with the game, while correction requires awareness, attention to detail and then practise, practise. The latter is hard work, but the result is much more enjoyable. Same with the NHS, we are now constantly working around the systemic faults, rather than sorting them out.

If I am wrong about what I have written, I will apologise, but do show me properly analysed and worked up alternatives, which demonstrate value for money, better care for patients and well looked after staff, and a comprehensive NHS.

Keep this article and read it in five years’ time, since the current situation will repeat itself, unless we act now. I may or may not be around to say: I told you so, and anyway it will be a very sad consolation.

Rajan Madhok is a retired Public Health Doctor. This article is written in his personal capacity.

You can read more of his work here  www.ramareflections.com