I suspect that many of you have had, appropriately during the season of Advent, experience of waiting for a medical appointment. The verb, to wait, apparently came across with the Normans although the French are generally averse to the letter W, so perhaps Walloons or Bretons among them were responsible. I hope one of you will enlighten me.
The first use seems to have been military, guarding against danger, and then it expanded to describe a more general period of anticipation. I have occasionally, while waiting in a hospital to see the doctor, joked to my fellow sufferers that this is why we are called patients – because we need to be. In fact this is correct. The term patient was first applied to us in the Middle Ages to describe the characteristic required to endure the suffering of illness, known to the Romans as
patientia, patience.
Throughout my 41 years in the NHS hospital service and over the 30 years I have been an intermittent patient myself, I have watched the numbers of patients increasing and the number of available hospital beds decreasing in the name of efficiency. I have also seen many more doctors and nurses employed in increasing numbers of specialties, but gradual reduction in the hours worked by the medical staff both in hospitals and general practice, leading to greater intensity of workload in the available time.
Over the same period, from cancer care to heart attack, from diabetes to arthritis, from intensive care to terminal care, across medicine and surgery, the amount that can be done to help ill patients has increased to an extent we could never have dreamed of in the 1960s.
Most importantly, I have seen a massive transfer of acute work from general practice to the hospital sector, including the ambulance service, as general practitioners moved out of weekend and night work and house calls. At the same time, general practice has taken over much of the long-term care of patients from hospital out-patients and has shouldered more responsibility for preventive public health. As may happen in the private sector in pursuit of profits, in the public sector the pursuit of efficiency in dealing with increasing demand has led to an over-stressed system and consequent inefficiencies. These are most obviously manifested in the pressure valve of the NHS, waiting times. Waiting times are determined by systemic bottlenecks.
This is where we wait as a patients:
1. To see a GP, save in emergency. Now one may have to wait weeks even to speak to a GP over the phone. As there are no overnight or weekend services, patients are diverted by telephone advice and often unnecessarily, to hospital A&E departments.
2. To get an out-patient appointment for diagnosis. This varies greatly between specialties, but generally depends on the same staff who provide care on the wards and carry out special investigations or surgery, so is very dependent on their available time. This is the area most responsible for the length of the waiting lists – it is influenced moreover by competition from private practice where some doctors may have conflicting interests.
3. Being admitted after out-patient diagnosis for treatment or management. This is dependent on the availability of beds and time in operating theatres and investigation equipment such as scanners. During winter epidemics and after unusual numbers of emergency admissions, the beds available are filled and the waiting patients wait longer. This problem is most severe if you have a non-urgent condition – possible cancer gets priority and those with orthopaedic conditions, though painful and disabling, may wait much longer. Most non-surgical conditions do not require admission and if they do it usually occurs with little delay.
4. Getting an ambulance. The waits for episodes like fractured bones or chest pains at home can be hours but are usually short, especially at night. Ambulances regularly queue for hours outside A&E to admit the patient; emergency treatment may have to be given in them, delaying their return for the next call.
5. Getting through A&E into a bed. A succession of nurses and doctors ask you the same questions before action is taken, and this is often followed by a search for an available bed. However, once in a ward or treatment area, most things go smoothly most of the time.
6. Getting out of hospital. This is the most serious bottleneck, as many patients admitted are frail and have multiple conditions requiring continuing attention after discharge. The breakage of the initial link between hospital and social services and the progressive relative underfunding of the latter has proved a disaster. It is a problem that will inevitably get worse as the population ages further and advances in medicine increase the complexity of diagnosis and management of illness.
Put simply, all these problems are theoretically soluble by more staff, availability of more beds and facilities, and fewer patients in the wrong place. But staff are expensive and take years to train to the necessary standard, hospitals are not very flexible, equipment requires appropriate facilities, and potential patient numbers are increasing. Public health measures on obesity, bad diet, smoking and alcohol are aimed at reducing potential patient numbers but work slowly.
So, what can be done to ease the current problems and proof the system for the future? This is the problem that Ministers of Health have to wrestle with and may be the reason the possibility of a two-tier system has been mooted and purchase or hire of facilities and staff from the private sector.
The possibility of a two-tier service has been discussed in the upper echelons of the NHS, presumably as part of our governments' wish to seek means of controlling the overall costs or, as they are sometimes characterised, the burden on hard-working people. Crudely expressed, this suggests that the well-off would be required to pay towards the costs of NHS services they require. But who would be the well-off and what services would be covered? Therein lies the rub.
Readers will be aware that there are already two tiers of health care, the NHS and the private sector. Success of the latter is dependent on failure of the NHS to achieve its ideals, this failure being defined most clearly by waiting times for diagnostic appointments and complex/costly treatments.
Thus, Mr Sunak and many other middle-class people fearing that they would have to wait weeks or months for an operation would take health insurance or raid their savings to go to a private clinic, or even subscribe to a private general practice. The doctors they will see and pay in those well-furnished surroundings are usually the same NHS consultants they would have seen some months later in the crowded NHS outpatient department. This practice is commonplace, lucrative and in line with their NHS contracts, and must constitute a temptation.
Logically, a two-tier NHS would compete with the current private sector using the same NHS facilities and staff. It's difficult to see how this would reduce the bottlenecks that cause waiting lists but easy to see how its administration and need for profit would eat up any revenue derived from patients.
It is also easy to see that the better-off patients would purchase priority over the poorer, worsening the latter's health disadvantage. Same staff, same facilities, a bit more NHS funding from the insurance industry, some more rich doctors, and a nightmarish administrative problem. Two tiers are costly, inefficient and inequitable, three even worse. Private medicine takes doctors and nurses from the NHS to deal with the easy bits and the wealthier patients.
The problems of the NHS are well known and derive simply from its ambition to care for us from cradle (indeed before) to grave. Its success has been to increase our average life expectancy, to reduce infant mortality and morbidity, introduce mass immunisation programmes, and generally to ameliorate much suffering from chronic disease and disability. It has allowed the UK to lead the world in development and assurance of safety of drugs and surgical procedures. It has achieved this at a remarkably low cost compared to most other countries.
Its main failure has been inability to satisfy increasing demands from the ageing population and of a younger impatient generation brought up to expect the State to provide everything at little cost to the taxpayer. This is the equation that politicians must try to solve.
It must be clear that there is no quick or easy solution. It is also clear from the current unrest among staff at all levels and indeed patients that a solution must be found. I do not think that the problem is primarily salaries, although the pay at the lowest levels must at least be better than is obtained by nurses in the private sector. The main problem is working conditions, currently exacerbated by staff absence from illness and stress. This will only be relieved if bottlenecks are opened up, and the only place we can start from is where we are now. Everything that must be done will cost money, and we taxpayers can expect to foot the bill. If we do not, more of us will be forced to pay directly into the private sector and health equity will deteriorate further.
Undoubtedly, as they return to their offices, Ministers of Health in our governments will be considering their options in the light of the constraints put on them by the London Treasury and our Finance Minister. They will be hoping to do something for as little as possible, which will mean a search for efficiencies. How they measure the effectiveness of their interventions is something they will be considering. The ultimate measure is the health of the population and whether or not this is improving or deteriorating, and in which sectors. Unfortunately, no intervention is likely to have a noticeable effect during the lifetime of a government on this, so measurement is likely to be based on the simplest one – how long are waiting times? This can be influenced quickly, and I shall return to this next time.
Meanwhile, we can but hope that 2023 will be a better year than the awful ones we have all recently been enduring.
Anthony Seaton is Emeritus Professor of Environmental and Occupational Medicine at Aberdeen University and Senior Consultant to the Edinburgh Institute of Occupational Medicine. The views expressed are his own
