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Why some people on elective waiting lists may never reach the front of the queue

Back in the 1990s, when waiting times were measured in months not weeks, I sat down with a team of consultant urologists to conduct what we called ‘urgency profiling’.

The process was straightforward, and we were repeating it with teams of consultants all over the UK. We were going to go through a list of their most common procedures, and reach a consensus about the rough proportion of patients who needed to be treated within one month, and within three months, with the balance being ‘routine’.

The Royal Colleges have recently done the job more authoritatively and comprehensively with the national P1-P4 categories, but back then we were breaking new ground and it was turning out to be really valuable. It provided a basis for planning the recovery of elective waiting times. It made it easy to spot wayward colleagues who hogged capacity by over-declaring clinical urgency. And perhaps most usefully, it got consultants thinking about the order in which they treated patients, and the effect that had on overall waiting times.

The urologists were whizzing down the list. Urology is a high cancer specialty so many of the top procedures were urgent within a month – no debate needed. The trouble started when we got further down, and suddenly there was an edge to those measured voices.

The lowest clinical priority

The argument was this: which has higher priority – a religious circumcision, or a hypospadias?

Down at the management end of the table, where I was sitting, the answer seemed obvious: the kid who was spraying on his shoes every morning took precedence over the kid who had nothing wrong. But to the consultants (who, in fairness, had actually met these kids and their families) it wasn’t that straightforward.

Why was the argument so heated?

The first reason is that waiting times were very, very long – more than two years, as they are again today. There are good reasons why neither of those procedures should have to wait so long, and it is understandable that the consultants should have felt strongly about it. If waiting times had been short, there would have been no issue and these ‘routine’ patients could simply have been treated in date order. But when waiting times are years long, the finer distinctions between one ‘routine’ patient and another become painfully clear.

But there was a second reason – one that also applies today. The waiting list was growing. Thinking back on that meeting a quarter of a century later, I think this might even have been the dominant reason (although none of us realised at the time). Let me explain.

‘Never’ is a broken promise

If the waiting list is growing, it means the service is not doing enough activity to keep up with demand. The shortfall might be tiny – apparently insignificant. Let’s say it is only 1 per cent.

Now let’s say that circumcisions are a few per cent of the demand in urology, and repair of hypospadias is 0.25 per cent, and that these are the two lowest-priority procedures. And let’s say the circumcisions win the priority debate, and they come first if the patients have waited longer than a year.

Something dramatic happens now: no hypospadias patient will ever get their operation. Why?

We are only doing enough activity to treat the top 99 per cent of demand. The hypospadias are in the bottom 0.25 per cent. There is a constant stream of circumcision patients tipping over the one year mark, and they all take precedence over the hypospadias. So the kids who spray on their shoes in the morning will never reach the front of the queue – they are constantly being leapfrogged.

It is the word ‘never’ that causes the trouble – unlike a long wait, ‘never’ is definitively a broken promise.

Small step from vicious to virtuous cycles

This puts us into a vicious cycle. Activity falls short of demand. The waiting list grows. Waiting times grow. When waiting times become very long, the ‘routine’ category starts subdividing into slightly more and slightly less urgent patients. The least urgent patients are always at the back of the queue, so their waiting times grow faster. The subdivisions multiply. Until eventually you end up with some patients who will never be treated.

Then the vicious cycle intensifies. Clinicians start to declare some routine patients as ‘urgent’ in the (correct) belief that otherwise they will never see them again. That creates queue-jumping which pushes up waiting times even more for the others. Before we know it, waiting times are being measured in years.

There is a way to break this vicious cycle. If activity gets ahead of demand, even slightly, we are suddenly in a much better world.

The waiting times for circumcision fall fairly quickly, and become equal priority to hypospadias. Now we can start tackling the hypospadias backlog, starting with the longest waiters. There is no longer any bottom priority who will never be treated, and there is no need to classify patients as ‘urgent’ to avoid keeping them waiting indefinitely.

The vicious cycle has turned into a virtuous one. It works in any specialty. And all by turning a small shortfall in activity (compared with demand) into a small surplus.

Here in 2021, the government’s recent announcement of extra cash for the NHS may or may not be enough to restore 18 week waits as quickly as they would like. But it probably is enough for the NHS to get ahead of demand and end these vicious cycles. That alone may be enough to restore hope to patients and morale to clinicians.