A discussion document prepared by a sub-committee for the S.M.A. Central Council
Published by The Socialist Medical Association 13 Prince of Wales Terrace, London, W.8 6d.
It is not necessary to be a socialist to realise that the National Health Service is being strangulated by lack of money. A vast sum is required to develop its potential into a service capable of utilising the increasing possibilities of modem techniques and discoveries for the treatment and prevention of disease. Money is required to train sufficient doctors, nurses, technical and administrative staff; to build and equip hospitals and health centres; to launch an effective occupational health service; to finance home welfare services, and so on. As socialists we must continue to campaign for right priorities in our national expenditure.
We know well enough that socialism is impossible so long as the basic principles of capitalism remain untouched. Whilst the class structure in our society persists, our health programme pays little more than lip-service to the idea of equal opportunities for all. We must be prepared to watch and attack practices which prevent the National Health Service living up to its original ideals. In no other feature is this danger so marked as in the phenomenon of the hospital waiting lists.
We set out here to ask whether hospital waiting lists are really necessary? Could they be abolished? In what way does private practice effect the waiting lists ?
Types of Waiting Lists
Hospital waiting times are of three types:
(1) the time out-patients wait to see consultants;
(2) the waiting time for a first appointment for an out-patient;
(3) the waiting time for admission.
These times vary throughout the country, from region to region, hospital to hospital, speciality and consultant. The first, the wait in out-patient departments, has been almost eliminated in well-organised hospitals; in others patients must resign themselves to a half-day or even a whole day spent on each visit. Many refuse to attend at all but request their general practitioner to arrange a private consultation —if they can afford it! Clearly, if the waiting time were cut down, money would not flow so readily to consultants, and one wonders whether the greatest effort is always made to organise an efficient appointment system which would eliminate waiting.
In many parts of the country patients wait weeks or even months for a first out-patient appointment, and sometimes months and even years for a bed. These waiting times and the reputation they have created are together responsible for a great part of the demand upon the private sector and private insurance schemes. Consequently the efficiency of the non-paying services is threatened and patients must suffer even longer waits, whilst those seen privately “jump the queues”, often not even into pay-beds.
The Evils Caused by Waiting Lists
The evils which these waiting times cause are even more widespread than would at first appear. The most serious, of course, is the medical aspect. Possibly vital time is lost awaiting the out-patient appointment and again awaiting admission, when early attention might at least facilitate treatment, at most prevent death. The psychological effect of waiting is difficult to assess but probably greater than is usually estimated. In this respect it is unlikely that any disease should be classed as “not urgent”. Likewise waiting lists may cause hospital patients to believe that those with money to pay receive not only quicker but also better attention.
Many “minor” complaints which could be easily cured in hospital are no longer referred at all. A conscientious general practitioner knows that by sending these patients he would only swell the waiting lists. Also it might in fact add to his patients’ distress to know that treatment could be given but is not possible “at present”. So numbers of people throughout the country, in addition to those actually counted on the waiting lists, are condemned to carry on in unnecessary discomfort. We may find, in addition, a very awkward situation created by the demand for legal abortions in departments already carrying a heavy waiting list.
Not the least of the evils is the stress on the hospital staff. It is usually lay staff who must bear the brunt of enquiries from anxious general practitioners, patients and relatives, and who are obliged to operate a system which they know to be unfair and suspect to be avoidable. Without the waiting lists many administrative workers would be freed for other duties. Medical staff, too, are often dis¬tressed to have to turn away patients whom they would admit if a bed were available. From time to time the newspapers make the most of inquest reports which cast blame on casualty officers for failing to admit patients who subsequently die. In fact, hospital doctors are faced day after day with decisions which depend primarily on lack of beds and not on medical necessities.
The Causes and Prevention of Waiting Lists
These are some of the evils of the system. What are the causes and prevention? No one can deny the difference which more money spent on the Service would make. More beds, more operating theatres, more staff, new and better equipped hospitals—all these are needed. But the growth of private practice and private insurance schemes are vested interests which depend for their existence on the maintenance of waiting lists. Most of the “private patients” of today would gladly accept National Health Service treatment if waiting lists were abolished. But because of the interests vested in them waiting lists may be kept longer than is necessary, even with our existing resources.
How can hospitals be run more efficiently without much additional cost, and how can patient-turnover be speeded without detriment to the patient?
Computer statistics make it easy to estimate average duration of hospital stays for varying diseases, and whilst obviously no hard lines can be drawn, it is clearly possible to pinpoint hospitals where bed- usage falls far below average. When beds are empty because of lack of nurses it is almost certain that matron belongs to the “old school” where “discipline” is a first priority. Many hospitals still insist on resident nurses although adjacent flats or other accommodation would give greater freedom. Enough encouragement is not yet given to married nurses to return to work because there are still matrons who refuse part-time workers or who will not allow off-duty times compatible with family life. Male nurse recruitment and promotion is not yet sufficiently encouraged.
Improvement of organisation in every sphere of hospital work through consultation by all grades of staff can greatly increase efficiency. Surveys have shown that high staff turnover produces low patient turnover! Thus good staff relationships, for instance through Joint Staff Consultative Committees, are essential.
Some hospitals send short notice for admission to patients who have been waiting months or years and finally may be prevented from coming in because of absence, family commitments, treatment elsewhere, or even death. A preliminary letter could save this waste in bed-occupancy. Some consultants clearly make less use of beds than younger ones with more modern ideas, and, although criticism is not usually possible, the use of statistics should make adjustments easier.
We have knowledge of consultants who bar the appointment of new consultants to their hospitals although they are overworked and have long waiting lists, and it is hard to believe that this is for any reason other than the fear of competition for their private patients. Regional Boards must insist on the appointment of new full-time consultants where needed. When appointed part-time, consultants can see private patients in the remaining time. There are special income-tax concessions which at present favour part-time consultants and which could easily be amended by the Chancellor of the Exchequer. Efficiency in hospitals would be increased by having full-time consultants only and the private patient system would not be perpetuated.
The method of allocating a fixed number of beds in a ward to individual consultants (known as “the firm”) must go. Increasing use is being made in up-to-date hospitals of the principle of “progressive patient care”. Staff and equipment are concentrated in a special ward for patients requiring “intensive care”. When less attention is required the patient can be moved to another ward less fully equipped for “intermediate care”, and finally when ambulant moved again for “self care”. This method is both economical on staff and beneficial for patients who no longer need lie in beds adjacent to those desperately ill or coming round from anaesthetics.
The visiting hour is now frequently regarded as a necessary evil by the authorities. It is possible that, instead, use could be made of relatives visiting; for instance, assisting in feeding or other duties. In addition to relieving the nurses this could help to teach the relatives how to cope on the patient’s return home. A change of heart and habit might first be needed, however!
Some hospitals already have computer analysis of daily activities and it becomes apparent even in efficient hospitals that a very great improvement in bed-occupancy and use is possible. Nurses and theatres can be more economically deployed, the type of case for admission more carefully selected, and many tests can be performed prior to admisison both to the benefit of the patients and the economy of bed-occupancy.
Treatment outside Hospital Wards
More general use should be made of the “day-patient” method of dealing with minor operations. In some hospitals this method has long proved successful, and again statistical evidence should be supplied in pressing more hospitals to adopt such procedures. An efficient ambulance service is a pre-requisite to such methods of treatment.
Indeed, we believe that the best attack for the elimination of waiting lists would be a programme for better facilities and use of out-patient departments for investigation and treatment, and “open access” arrangements to general practitioners for use of X-Ray, laboratory tests, etc., thereby saving consultants’ and patients’ time. Since lists for out-patient attendance remain generally static it is reasonable to believe that these improvements could greatly reduce, if not eliminate lists altogether.
The better use of Health Centres as well as of out-patient departments must also be borne in mind. Many consultants would welcome the opportunity of closer co-operation with general practitioners. In suitable areas consultant sessions at Health Centres could eliminate the need for hospital out-patient attendance entirely for some patients. The presence at Health Centres of district nurses and other ancillary staff could make possible more and more treatments at home—not, we maintain, as a make-do method but as a desirable step forward into the future. We commend the greater use of statistics in the field of general practice, which will reveal for the first time the natural course of disease and make possible the knowledge of the most efficient, desirable and economic forms of treatment.
Another attack in the same direction could be a reduction of bed- occupancy for patients for whom hostels and half-way houses serve equally well. After recovery from operations there is frequently no need for full hospital treatment although the patient may not be ready for home, or the home may be unsuitable. Use could perhaps be made of existing buildings for this pre-convalescent type of patient. Such accommodation could also serve patients requiring treatment of a special nature such as radiotherapy, but who live too far away to travel daily to hospital. Good nursing and medical care might be required, but less intensive than at hospital.
Local Authority Services
Many hospital beds could be vacated earlier if local authorities supplied home services which would enable patients ready for discharge to be cared for adequately. Home helps must be better paid so that supply meets demand. Night home helps would make possible more home nursing for patients anxious to be at home. Expensive though this may sound it is cheaper than the cost of hospital accommodation. Meals-on-wheels, laundry, supply of equipment are all supposed to be available but would need to be more easily attainable throughout the country.
Who benefits from Private Practice?
The consultant who accepts the fee benefits financially. The insurance companies thrive. The hospital does not benefit because the actual money paid for accommodation goes back to the Exchequer. The benefit to the private patient himself is of very doubtful value. Apart from the fact that he avoids waiting times he has very few genuine advantages. On the contrary, the best treatment may well be more difficult to attain for the private patient than for the ordinary hospital patient. It is important to realise the truth of this because private practice flourishes on the myth that better service for payment is available.
Modern medicine needs expensive modern equipment and requires team-work by medical, nursing, and ancillary staff. Isolation in private wards prevents the advantages already mentioned of progressive patient care. The consultant in charge of the paying patient is, of course, paid for his services, but every additional doctor he might call in for advice is also entitled to a fee. The consideration as to whether the patient can afford this additional expense and whether it is wise to bring in another, perhaps “rival”, consultant plays its part in treating paying patients. Payment should be made for X-Rays, laboratory tests, physiotherapy, and so on. The National Health Service patient has access to all these more readily than the paying patient.
Very few consultants would honestly deny that the best way to treat a patient is to be free from all considerations of money. It is strange that this principle is accepted readily for university teaching. Even the medical professors in Teaching Hospitals are freed from “the burden” of private practice. What is acknowledged as best for progressive university teaching can surely be seen to be best for medical care, both in respect to hospital and the general practitioner service. No university lecturer suggests that he will give better lectures if his students paid him individually or that he would hold special private sessions for “paying students”. In this context payment sounds ludicrous.
Patients attending Teaching Hospitals should realise that “lack of privacy” caused by medical student teaching can be to their own advantage. Consultants teaching students must explore every channel for reaching the right diagnosis and instituting the best treatment. Consultation in isolation as in private practice can lose this advantage.
Awareness of these facts is essential if the public is to attack the pernicious evils which seriously undermine the efficiency of the Health Service.
What can be done?
(1) The Minister can agree to appoint only full-time consultants in future.
(2) The Chancellor of the Exchequer can arrange that tax concessions favour full-time practice. Payment of tax-free private insurances should not be permitted as a “fringe benefit”.
(3) The general public can bring pressure to bear against any unfair practice. Question such statements, whoever makes them, as “Your case is urgent, you will have to wait . . . months as an ordinary patient, but you can come in at once if you pay.” All urgent cases should be admitted urgently regardless of pay, and the statement is often an effort to obtain more paying patients. In many hospitals pay-beds are not full and legally should not be reserved if urgent cases are waiting.
(4) Complaints can be made by individuals, or better still, through organisations such as Trade Unions.
(5) Complaints can be made at all levels, i.e., Hospital Secretaries, Regional Hospital Boards, Member of Parliament, Minister of Health.
(6) Precise facts must be given; no fear should be entertained about giving names. Reprisals are not one of the weapons in use in the Health Service.
Finally, either as individuals or as organisations join the Socialist Medical Association who will continue to fight on your behalf.
For we maintain that, as long as there are waiting lists, private practice will grow, and as long as private practice flourishes, waiting lists will persist. The ring must be broken.
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No date. Probably around 1970.