Intended for healthcare professionals


We need to develop scoring systems to determine clinical need

BMJ 1998; 317 doi: (Published 05 December 1998) Cite this as: BMJ 1998;317:1594
  1. Nicholas Odom, Consultant cardiothoracic surgeon
  1. Manchester Heart Centre, Manchester Royal Infirmary, Manchester M13 9WL

    EDITOR—I know little about New Zealand and even less about spin doctoring. I wish, however, to dispel some myths about waiting lists that have been quoted as fact in recent letters.1

    Myth 1). “Waiting lists are a form of rationing.” They are not a form of rationing; they are the result of our failure to ration when demand exceeds supply. A waiting list is a backlog, nothing more. If it is regarded as a form of rationing it will continue to expand indefinitely or until the rate at which patients die while waiting equals the difference between the rate at which patients are referred and the rate at which they can be treated.

    Myth 2). “Priority is based on clinical grounds.” Not so. Priority is based on listing order or waiting time. As a cardiac surgeon, I operate a simple clinical priority system in my waiting list. My efforts to implement this are, however, in direct conflict with the misguided government directive aimed at limiting waiting times. As soon as patients have been waiting for 18 months I have to give them priority over all but the most dire emergencies. Patients waiting for urgent cardiac surgery who are not actually occupying hospital beds get an extremely rough deal under the present system.

    The only logical way to manage the shortfall between demand and supply is rationing on the basis of clinical need. This will require the development of scoring systems that express clinical need as a quantitative measurement. I read in another letter, “We fear further manipulation of lists on the basis of points scored rather than clinical need.”2 If the New Zealand scoring system is not a measurement of clinical need then it needs to be altered so that it is.

    New Zealand's health system may be far from ideal. At least the New Zealanders have faced up to their problems in a rational way and have produced a system to manage the situation, even though it may be imperfect. So far we in Britain have steadfastly failed to face the problem. Until we do so, waiting lists will continue to grow indefinitely according to the elementary principles of supply and demand, and no amount of spin doctoring or government directives can prevent this.


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