To what extent are consultant surgeons to blame for waiting lists for surgery in the NHS?
This essay examines the arguments surrounding the cause’s of waiting lists, initially concentrating on the reasons that relate specifically to consultant surgeons before expanding to address the reasons beyond their power and influence. The short summary and conclusion includes a glimpse of some new initiatives being developed to combat waiting lists and fortunately some of the particular issues raised here.
“I cut it in half, just by eliminating those on the list who’d moved or couldn’t be contacted. Half of the remaining patients didn’t need to have the procedure anymore, and for the half that did, I told them to go and ‘fall over’ outside and I’d see them in casualty and do it as an emergency…. Anyway, I quickly eliminated the waiting list and trotted off to tell my boss the good news. He was not amused. ‘Don’t you ever, ever, touch my waiting list again. It’s my power base within the hospital and my passport to private practice outside.'”
(Junior orthopaedic surgeon quoted in Hammond, 1999.)
This quote is illuminating because it highlights a marked attitude difference between doctors and the public toward waiting lists. In this instance a doctor is demonstrating a very strong desire to preserve the length of his waiting lists and clearly citing self-interest as the reason. In comparison, a study by Canlan et al (1993) found that only 1 percent and 9 percent of their study group found the hospital waiting lists for non-emergency operations very good or satisfactory respectively. Conversely they found that 87 percent of the public surveyed (extracted from 1688 completed returns) are to some degree dissatisfied with waiting lists with 51 percent saying that they were in need of a lot of improvement, the most critical option available to them.
Assuming that the consultant referred to above is somewhat representative of a sizeable body of consultant surgeons, the question arises of how consultant surgeons are able to manipulate waiting lists.
Yates (1995) describes five ‘coincidences’ that are worth taking as a starting point to this question.
“The poor are more prone to illness and early death, and it is the poor who have to wait longest for treatment
The regions that have the most private beds are those that have the worst waiting lists
The specialities that have the longest waiting times are the ones that have the highest earnings from private practice
The conditions that involve the longest wait on NHS lists appear to be the mainstay of private sector workload
The surgeons who work in the private sector are thought to have the long NHS waiting lists.”
Leaving the first ‘coincidence’ aside for the moment, the latter four are suggestive that surgeons not only have a vested financial interest in retaining long waiting lists, but also have many mechanisms with which to achieve this aim.
Of particular relevance is the fact that many surgeons working in the NHS are the very same surgeons working in the private sector (Hammond, 1999, Powell, 1997, and Yates, 1995), indicating that as no-one can be in two places at the same time, the more private work a surgeon undertakes, the less NHS work they can do.
Added to this is the control that surgeons have over their waiting lists in terms of who is allowed on and who isn’t as well as some control over how frequently operations are actually performed. In particular, Yates (1995) found that there is a significant variation in the number of operations carried out by different NHS consultants in the same speciality despite having a similar case mix. Implying that either there is a large discrepancy between the resources available to different surgeons or that individual surgeons are working a lot harder for the NHS than others.