Table Of ContentRATIONING AND RATIONALITY
IN THE NATIONAL HEALTH SERVICE
ECONOMIC ISSUES IN HEALTH CARE
General editors
Professor Gavin Mooney Dr Alistair McGuire
Health Economics Research Unit Dept of Sociological Studies
Dept of Public Health Wolfson College
Medical School University of Oxford
Aberdeen AN9 2ZD Oxford OX2 6UD
The Challenges of Medical Practice Variations
Edited by Tavs Folmer Andersen and Gavin Mooney (1990)
Private Exchange and Public Interest
By John Forbes (1990)
Rationing and Rationality in the National Health Service
Edited by Stephen J. Frankel and R. R. West (1993)
Just Managing- Power and Culture in the NHS
By Stephen Harrison, David J. Hunter, Gordon Marnoch
and Christopher Pollitt (1993)
Dental Care: An Economic View
By David Parkin and Brian Yule (1990)
RATIONING
AND
RATIONALITY
IN THE NATIONAL
HEALTH SERVICE
The Persistence of Waiting Lists
Edited by
Stephen Frankel
and
Robert West
M
MACMILLAN
©The editors and contributors 1993
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First published 1993 by
THE MACMILLAN PRESS LTD
Houndmills, Basingstoke, Hampshire RG21 2XS
and London
Companies and representatives
throughout the world
ISBN 978-0-333-49007-5 ISBN 978-1-349-22553-8 (eBook)
DOI 10.1007/978-1-349-22553-8
A catalogue record for this book is available
from the British Library
Copy-edited and typeset by Cairns Craig Editorial, Edinburgh
Contents
List of Tables and Figures vi
List of Contributors vii
1. The Origins of Waiting Lists 1
Stephen Frankel
2. Waiting Lists and Health Policy 15
John Cullis
3. Joining the Queue: Demand and Decision-making 42
Robert West
4. Opening the Gate: Referrals from Primary to
Secondary Care 63
Stephen Farrow and David Jewell
5. Entering the Lobby: Access to Outpatient Assessment 80
Stephen Frankel and Margaret Robbins
6. And So to Bed: Access to Inpatient Services 96
Ian Harvey
7. What is to be Done? 115
Stephen Frankel and Robert West
Bibliography 132
Index 149
v
List of Tables and Figures
TABLES
1.1 Patients on selected in-patient waiting lists 5
1.2 Critical categories of patients on selected in-patient
waiting lists 6
1.3 The index of interest in various diagnoses 11
2.1 UK NHS expenditure as proportion of Gross 18
National Product (GNP)
2.2 NHS hospitals - number of in-patients on waiting list 19
2.3 An 'imputed' waiting list for California 24
2.4 A change in the 'implied' US waiting list 1979-82 26
2.5 Waiting lists and waiting times for Denmark 29
2.6 Illustrative service cost per QAL Y data 33
2.7 Mean and median waiting time (weeks) for
typical waiting list conditions 1985 34
2.8 'Non-urgent' waiting in England and Wales (Sept. 1986) 35
2.9 Approaches to defining an optimum waiting list 39
FIGURES
1.1 Inpatient waiting lists and hospital throughput, England 4
2.1 Dealing with shortages: market v. state 17
2.2 California's medically uninsured, 1985 25
2.3 Health care systems: pictorial taxonomy 28
2.4 Waiting list management of QALYs 31
vi
List of Contributors
John Cullis
School of Social Sciences
University of Bath
Claverton Down
Bath BA2 7AY.
Stephen Farrow
Barnet Health Authority
Colindale Hospital
Colindale A venue
London NW9 SHG.
Stephen Frankel
Health Care Evaluation Unit
Department of Epidemiology and Public Health Medicine
Canynge Hall
Whiteladies Road
Bristol BS8 2PR.
Ian Harvey
Health Care Evaluation Unit,
Department of Epidemiology and Public Health Medicine,
Canynge Hall
Whiteladies Road
Bristol BS8 2PR.
David Jewell
General Practice Unit
Department of Epidemiology and Public Health Medicine
Canynge Hall
Whiteladies Road
Bristol BS8 2PR.
vii
viii List of Contributors
Margaret Robbins
Health Care Evaluation Unit
Department of Epidemiology and Public Health Medicine
Canynge Hall
Whiteladies Road
Bristol BS8 2PR.
Robert West
Department of Epidemiology and Community Medicine
University of Wales College of Medicine
Heath Park
Cardiff CF4 4XN.
CHAPTER 1
The Origins of Waiting Lists
Stephen Frankel
The central observation underlying this book is that the National Health
Service (NHS) appears to have selected for relative neglect those few con
ditions where treatments are unequivocally effective, can be delivered at
comparatively low cost, and are desired by the population. This outcome
for over forty years' investment in health care would appear to fail any
simple criteria of rationality.
All health systems are now compelled to address the question of
what are the true priorities amongst the range and volume of services
which might ideally be provided. The broad thrust of the health econo
mist's argument- that rational grounds must be sought for allocating
finite resources in the face of overwhelming demands - is now broadly
accepted. The current debate is concerned almost exclusively with how
to make choices in resource allocation, rather than whether choices should
be made. This intellectual consensus is now broken only by those phi
losophers who point to the conflict between utilitarianism and the rights
of individuals (Harris, 1988). The implication of the health economist's
argument - that explicit rationing is preferable to the implicit rationing
which characterises all health systems - is politically more contentious,
but this too has been expressed in policy initiatives, both in the United
States (Oregon Health Services Commission, 1991) and in Britain (Dean,
1991).
The National Health Service was established as a 'comprehensive
health service designed to secure improvement in the physical and men
tal health of the people ... and the prevention, diagnosis and treatment
of illness', and to do so 'free of charge' (NHS Act, 1946). Prior to the estab
lishment of the NHS, health care rationing was determined by income,
employment status and sex. Subsequent to its establishment, rationing
for certain treatments has been ordered by willingness to wait. Waiting
lists offer a device for blurring the boundaries of available provision by
offering treatments where there may be no prospect that these treatments
will be delivered. The recent reorganisation of the NHS (National Health
Service and Community Care Act, 1990) was intended to redirect activity
1
