Community care waiting lists and older peopleBMJ 2001; 322 doi: https://doi.org/10.1136/bmj.322.7281.254 (Published 03 February 2001) Cite this as: BMJ 2001;322:254
Community services lack a measure as visible as surgical waiting lists
- John Young, professor (, )
- Stuart Turnock, senior manager, public services research
The surgical waiting list is a simple summary statistic representing a barometer for the NHS in the United Kingdom. Its rise or fall is an important measure by which politicians and managers gauge the effectiveness of policy and the adequacy of resources. It has a highly visible public profile and is clearly influential in triggering additional resources—as, for example, in sporadic waiting list initiatives. But there is a further fundamental component to health service provision, community care, which is not represented by any simple statistic and is therefore strategically disadvantaged in claiming the public's and politicians' attention.
The surgical waiting list as a performance indicator has been criticised for ascribing equal importance to unequal situations such as cancer and varicose veins. Also it distorts healthcare planning and provision through an excessive and unbalanced focus on elective surgery which directs attention away from acute care services. Nevertheless, the acute services have their own global indicator, which is the number of emergency beds (including intensive care beds) relative to demand. Seasonal overdemand ensures that acute care services remain in the public, and therefore political, eye.
In contrast community care has low public visibility. Community care is formed by an amalgam of services, some from health (such as rehabilitation, nursing, continence, chiropody) and some from social services (day care, home care, housing adaptations, aids to daily living), which help support and maintain disabled people in their own homes. Although several client groups are the focus for these services, the exponential relation between disabling conditions and age results in older people being the most frequent recipients of community care. There is therefore a triple jeopardy of old age, chronic disease, and unglamorous services that may detract from community care services achieving their full potential to help the people they serve.
Because of community care's lack of visibility the playing field between it, acute care, and elective surgery is inherently uneven. This is unfortunate because, as we have been slow to learn, the various sectors of health care are critically interdependent. Yet our conventional conceptions still deny this reality. “The hospital is full” is a more palpably demanding alarm bell than “the community is full”—but both need adequate capacity for mutual effectiveness.
Although the politicians may wish it, it is unrealistic to expect the surgical waiting list to lose its dominance as the barometer of health care. The requirement from the community care perspective therefore is a levelling up by equivalent public visibility. Strangely, waiting lists abound in the community,1 but they are covert lists—known principally to those who have to endure the wait and to the service providers, who for obvious reasons are inclined to keep them quiet. Yet it is doubtful if the distress engendered by enforced confinement to home is any less because the wait is for a wheelchair access ramp2 rather than, say, a hernia operation. Moreover, for many disabled older people the experience of community care is one of multiple waiting lists—one for each of the range of services or equipment they require.
Example of a global indicator for community care
Number of people within each health authority waiting for:
Home adaptations (eg rails, access ramps)*
Day centre places*
Nursing home or residential care places*
Complex needs assessments*
Total No of people waiting
Items have been selected because: (a) considerable variations in provision, (b) mainstream for disabled older people and their carers, (c) routinely available data.
Items 1, 2, and 3 represent a whole system approach—that is, the sum of individuals waiting for assessment or waiting for delivery or installation. Item 4 is valued by users and provides respite for carers. Item 5 is an indicator both for adequate primary capacity and for depth of home support services. Delayed responses on item 6 contribute to carer strain or hospital admission.
Information on community care waiting lists is already collected3 but is somewhat lost amid a range of other performance indicators and presented in an indigestible format. Correction requires a simple summary statistic recording the number of current waiters for community services. The box gives an example of a possible format. Some will argue that we should distinguish between health and social services. Despite arduous attempts to clarify the boundaries, however, there is now increasing acceptance that community health and social care should be considered as a single entity.4 This is certainly true from the user's point of view, for whom the distinction between a “social bath” and a “health bath” was always cranky. A single summary statistic would act as a barometer of community care which will allow us to make a more holistic understanding of health care services and allow community care to become a visible contender at the resource allocation table.
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