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13 November 1998

The perils of a sound-bite health policy

Whatever ministers say, smaller waiting lists do not make a better NHS, argues Neil Pettinger

By Neil Pettinger

The Secretary of State for Health is fond of likening the NHS waiting list to a supertanker. Frank Dobson introduced the analogy because waiting-list trends, like supertankers, take a long time to turn round – as new Labour, to its embarrassment, has found. Although one of its election pledges was to shorten waiting lists, the government spent its first year in office presiding over a waiting-list growth of more than 100,000.

This summer and autumn have seen the injection of large sums of government money into the NHS to solve the waiting-list problem. When August’s waiting-list figures were published, Dobson was able to announce that they were “falling faster than at any time in the history of the health service”. And this week Dobson could claim that the September drop was the largest monthly fall ever recorded.

The importance for the government of this sort of hyperbole cannot be over-stated. If it succeeds in its mission to shorten waiting lists, new Labour believes that it will also have demonstrated successful stewardship of the NHS as a whole.

For the NHS waiting list – on the face of it simply a count of the number of people waiting for hospital operations – has acquired a deeper significance. When Alan Milburn, minister of state at the Department of Health, argued earlier this year that additional funds were needed to treat patients on waiting lists, he said that it was not just because a long queue of patients was a bad thing, but also because waiting lists are associated in the public’s eye with a dysfunctional, bureaucratic system. “Lengthening waiting lists,” he stated, “are a powerful metaphor for the state of the health service.”

Taken at face value, it is difficult to argue with Milburn’s point. Most people’s experience of the NHS is of long periods of queueing for service, punctuated by the occasional contact with clinical staff. No wonder a proportion of the public feels frustrated and disappointed.

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But a closer look at the government’s concentration on waiting lists shows the danger of relying on these figures alone. The money that new Labour is throwing at solving the “list problem” is only directed at those parts of the NHS – mainly hospital surgical specialities – that have waiting lists; the “list-less” parts – general practice, maternity services, community nursing, hospital emergency services . . . most of the NHS, in fact – don’t get the extra money.

Moreover, because of new Labour’s eagerness to target the worst waiting lists first, some surgical specialities will miss out. Gynaecology, for example, though it has one of the largest waiting lists, will probably not attract too much in the way of extra funding because people don’t usually have to wait very long. In Scotland, 92 per cent of non-emergency patients are admitted after no more than a three-month wait.

Orthopaedics and ophthalmology, by contrast, can expect large windfalls as a result of the government’s commitment. In these specialities, fewer than two-thirds of routine patients are admitted within three months, so they will get a disproportionate amount of the extra money.

To make matters worse, the parts of the NHS that do have waiting lists and are attracting the extra money are those parts that many feel are already generously funded, compared to the “list-less” services. They are also precisely those parts of the NHS where there is most competition from the private sector.

Moreover, a waiting-list crusade goes against the grain of new Labour’s general health policy. Until the announcement in March of the extra waiting-list money, the government’s overall direction for the NHS seemed clear: a continuation of the move away from hospital-based services and towards a boosted primary- and community-care sector.

How did new Labour get saddled with an election pledge that is tangential to its real policy direction? The answer is bound up with populism and the symbolic properties of waiting lists.

Only a few health statistics have any meaning for the public. Waiting-list statistics have become the focus of public attention because they are user-friendly – “sound-bite-compatible” – but, above all, because of the scarcity of other understandable performance indicators.

This may explain the government’s growing tendency to concentrate resources only on those areas with “sound-bite-compatible” statistics. Although, to its credit, the government has shown that it wants a new, broader framework for measuring performance in the NHS, its proposals to date are marred by the same flaws as waiting-list statistics.

For example, the government wants to publish outcome measures for the NHS – it proposed 15 such measures last summer. These will compare the performance of different hospitals, using indicators such as wound infection rates, mortality and readmission rates following surgery.

Better than waiting lists to be sure, but still with the same bias towards hospital surgery: 11 of the 15 proposed measures concern hospital surgical specialities, which have a virtual monopoly on waiting-list statistics and lend themselves more readily to being measured.

“If you want to get ahead, get a waiting list.” That, cynics argue, is the message that new Labour is sending to staff in the list-less, non-surgical areas of the health service. But it’s not more waiting-list statistics that are needed. We need statistics that are as “user-friendly” as waiting lists, but that also apply across all sectors of the NHS.

Only statistics like that can be used safely as metaphors.

The writer is the performance review manager at the Royal Infirmary, Edinburgh

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