Bookmarkers beware: Bookmarks to pages other than the home page may not work after we change our server in April Editor's Choice | This Week in BMJ | Press releases BMJ No 7132 Volume 316 Editorial Saturday 28 February 1998 New government, same narrow vision It's time to move beyond the numbers on waiting lists See News, p 650 Reduced waiting lists for NHS hospital treatment was one of the five main promises Tony Blair made to the British electorate before his election. Last week we learnt that since he came to power the numbers waiting have increased by 100,000. The time has surely come for the government to acknowledge the inevitability of rationing health care and to shift the debate on the NHS to something more important than numbers on waiting lists. Even on waiting lists, there is scope to copy New Zealand and do a better job of managing them. Britain experienced a disorientating period of optimism after last May's election. Many sensible people, including observers of the health service, deluded themselves into thinking that all would be different. Old problems would be solved and a new Britain - and a new health service - would emerge. In fact most problems, including those of the health service, are deep rooted and not easily solved. Furthermore, the seemingly unstoppable process of globalisation means that economies are controlled by international economic forces and governments have ever less room to manoeuvre: they have to occupy a middle political ground whether they like it or not. Globalisation is also tending to increase the gap between rich and poor both within and among countries, with serious effects on health. Gradually reality has dawned in the new Britain. Waiting lists have risen. The winter crisis has been averted not by a new government but by a mild winter. The government appointed a new minister of public health but then vacillated over banning tobacco advertising. Smoking rates are now rising among young people. The government accepted that inequalities in health are important but declined in its green paper to set any targets for reducing them. The white paper on the health service cleverly steered a route between keeping the Conservatives' changes and returning the NHS to its old monolithic structure, but it may well prove to be a triumph of spin rather than of substance. As always, the devil is in the detail, and we must be sceptical that substituting white coats for suits will save money, that primary care groups will function well, that clinical governance will prove to be more than this year's phrase, and that NICE and CHIMP will be more than clever acronyms. To Americans the NHS is "health care run by the Post Office," distinguished by long waits and brusque service. Almost since the NHS began the main political battles have been over money and waiting lists, with the implication that more money means less waiting. Politically the main output of the NHS seems not to be better health but shorter waiting lists. In fact, waiting lists have some things to recommend them. Delay is one of the main ways that the health service rations care, and it has to be rationed somehow. The health service also rations by dilution (two nurses on a ward not three, 8 minutes for a consultation, not 12), diversion (sorry, we don't do acute dentistry or long term care anymore), and denial (no tattoo removal, no assisted conception, no donezepil). The NHS's problem is not only that this rationing is fudged but also that the government denies its existence. The fudging leads to inequity, lack of accountability, and poor decisions, while the government's line that all clinical needs can be met leads to a credibility gap - felt acutely by those working in the service. The politicians at the top, like some occupying power, talk of providing everything within a high quality service, while those on the ground are conscious of cutting corners and denying. In last week's BMJ David Sellu described graphically the pressures on his outpatient clinic: "How," he asked, "do you explain to a patient in six minutes that the tumour in his rectum is cancer - what is cancer anyway?" (1) The good things about waiting lists are, firstly, that they are rationing for all to see and, secondly, they are rough justice. So long as they are not arbitrarily manipulated (as with the last government's requirement that no one should wait longer than a year) generally those with the greatest need come to the top of the list, although any local newspaper will be able to find some poor person who has waited in pain for a year or more. If waiting lists were acknowledged as a crude form of rationing they could then be managed much better - as has happened in New Zealand.(2) The public could debate the criteria to be applied to decide who waits how long, and the lists could be openly managed. The trouble with concentrating simply on reducing the numbers on lists is that rationing by dilution, diversion, and denial increases. Furthermore, giving priority to those who have been on the list longest often means giving priority to those with the least clinical need. New Zealanders have generally welcomed their government's attempt to tackle waiting lists creatively. The Dominion described the move as "a welcome step toward reducing waiting lists for non-urgent surgery in a responsible way....The new system is designed to ensure that people with the biggest need and greatest potential benefit will have their surgery first, that the same rules apply throughout New Zealand.... All this is light years ahead of rationing surgery by making people wait indefinitely for it, and with marked regional variations." (3) Britain is still light years behind. The first challenge to the government is to change their thinking on waiting lists. The aim should not be to reduce them at all costs but to manage them openly as a form of rationing. The second - ultimately more important - challenge is for the government to redefine its political vision for the health service. It should be about much more than reducing waiting lists. Richard Smith Editor, BMJ References 1 Sellu D. Have we reached crisis management in outpatient clinics? BMJ 1998;316:635-6. 2 Hadorn D C, Holmes A C. The New Zealand priority criteria project. Part 1: overview. BMJ 1997;314:131-4. 3 Editorial. Dominion 1996;10 May: 8. Home | Current issue | Past issues | Classified ads | Career Focus | Feedback Collections | About this site | About the BMJ | BMA | Medline