Medicine Waiting lists John Rowan Wilson
When Mr Enoch Powell was Minister of Health he developed the interesting hypothesis that the demand for medical care was for practical purposes infinite. Attempts to improve the Health Service were, in his view, rendered almost entirely ineffectual by virtue of this fact. Everything that a benevolent government provided in the way of improved facilities was instantly cancelled out by an automatic increase in demand.
Mr Powell used his theory to explain the baffling enigma of the surgical waiting-list. It has been the experience of most people concerned with this problem that whatever you do to increase facilities, hospital waiting lists never seem to get any shorter. To this day, in spite of all the money we have spent on new hospitals, people are still waiting for three and four years for routine operations on such conditions as piles and varicose veins.
Few doctors and health administrators are prepared to agree with the fatalistic attitud,e expressed by Mr Powell. They cannot believe either that the Almighty has created a new plague of haemorrhoids simply to exasperate the Secretary of State for Health, or alternatively that there is a vast pool of piles in the body politic, the depths of which are unplumbable by ordinary human means. Efforts are consequently made from time to time to work out new methods of getting the waiting-lists under control.
The most common approach has been by means of early discharge after operation. Instead of keeping patients in for a week you send them home the day after operation with instructions to come back in a week or so and have their stitches taken out. When this method was found to produce little improvement, surgeons of a radical standpoint began to go even further by not admitting the patients to hospital at all. Operations for hernia, varicose veins, and so on were done on an out-patient basis. This is an impeccably modern approach since it requires, in the words of the Lancet, "a working partnership between hospital and community-based doctors and nurses." What it means in plain language is that the surgeon acts purely as a technician and dumps his post-operative care in the lap of the GP or the district nurse.
In doing so, he not only changes the character of the general practitioner's work, he changes the work of the hospital, too. A hospital ward in ordinary circumstances contains a small proportion of very sick people, a majority of patients who are only moderately ill, and a few who are almost well and getting ready to go home. It is staffed on that basis. If you eliminate the milder cases and send your patients home the very moment they show signs of being able to stand up, you turn the ward into an entirely different place. It becomes an in
tensive care ward, operating at maximum pressure all the time. You need more nursing staff, and the nurses you use need far more consideration and time off.
So you will gain something by this method as far as hospital beds are concerned, but you will find yourself limited by a shortage of nurses. And, indeed, of surgeons, if it comes to that. The argument that a surgeon can do twice as many operations if he is given twice as many beds contains an obvious fallacy. It would only apply if he were standing idle at the present time, which he is not. A surgeon's working week is divided up into half-day sessions, all of which are occupied by operating lists, out-patient clinics, or ward rounds. You cannot simply throw extra sessions at him because you have made more beds available — and you should not, if you want him to do decent and conscientious work, persuade him to work longer than three or four hours at a time.
So the rush-them-in-and-chuck-them-out assembly line approach clearly isn't going to work. Does that mean that Mr Powell's theory of the everlasting waiting list is correct? I think not. It merely shows that it is no use attacking a problem until you have studied all aspects of it. It is futile to provide more beds unless you provide more nurses, more surgeons, and more theatres for them to operate in. If you do all these things together, you will cut down the waiting-list. Whatever political philosophers may say, there isn't really any cosmic law covering the supply of haemorrhoids or varicose veins. Medicine may be difficult — but it's not that difficult.
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