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Tackling waiting lists and getting people back to work: is it a good idea to multitask?

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In his speech to the Labour Party conference in September, Wes Streeting announced a new waiting list initiative. Nothing surprising there: the idea of ‘crack teams’ of clinicians spreading out across the country to help NHS hospitals use their operating theatres more efficiently was trailed during the election campaign and echoes previous improvement initiatives focused on ‘patient flow’ and clinically-led reviews.  

The new (and most interesting) bit of the announcement is where the crack teams will be heading. Rather than spreading out across the country, they will march north, to 20 hospitals located in towns and cities identified as having the highest numbers of people ‘off work sick’ – from Birmingham up to Newcastle. This is interesting because the government is taking a decision about where to spend NHS money by looking at where it will help the economy most (rather than, for example, where waiting lists are longest).

It sounds like a new flavour of health policy – but will it work and is it a good idea? 

Will it work? 

This question depends on what you mean by ‘work’? If you mean getting people into ‘work’, the answer is: not as much as it might. Most people out of work due to ill health don’t need surgery, they need things like mental health support. For example, ONS data shows that depression and other mental health issues are by far the most frequent reason people are not working due to long term sickness or disability.  

If you mean getting waiting lists down, the answer is: it might. High intensity theatre (HIT) lists – as this approach is known – increased the number of patients operated on in a particular day by at least 150% when piloted at Guys and St Thomas’ Foundation Trust. The intention is for the new initiative to also focus on reducing missed appointments – something we have seen hospitals making great progress on. 

The government wants to ‘take the best of the NHS to the rest of the NHS’ – a welcome focus on spreading what works. The biggest unknown is whether this initiative can be dragged from a major teaching hospital and dropped in different settings without extra cash to invest in things like staff engagement and management support (the announcement does not have extra funding attached, beyond the travelling improvement specialists). The ‘crack team’ is described as being a group of ‘clinicians’. I hope that is shorthand for a wider group of management and admin professionals – particularly given a key success factor of this initiative is ‘meticulous planning’ rather than any change in clinical approach. Good admin is essential in getting waiting lists down, but admin staff are the often forgotten lynchpins of any successful initiative.  

Is it a good idea?

As a signal of intent, the focus on hospitals is out of step with the much talked about ‘shift’ from hospital into the community that is guiding development of the new 10-year health plan. To show clear leadership on that agenda, the government could have used the platform of party conference to focus attention on spreading innovation in community or preventative services. 

The ethical issues are also complex and have the potential to ‘hurt our brains’. People have different views about whether it is right to consider ‘non-clinical’ factors when making decisions about health care. If an operation will help someone get back to work, should they be prioritised for treatment? Is the answer different if the decision affects a single patient (individual fairness) or – as with this policy – patients using a particular hospital (group fairness)? And is it right for the desired outcome of health care to be framed as employment, rather than health and happiness? These ethical debates have stalled work in some hospitals to reprioritise patients on their waiting lists.  

It was the recognition in this announcement that health and work are linked that made me sit up and listen – a co-ordinated approach to policy that considers how a decision can contribute to more than one of the government’s aims – in this case the ‘missions’ on ‘health’ and ‘wealth’. This is an approach being taken by combined authorities that we will be publishing more on soon. The link has also been written about extensively by others (including the Institute for Public Policy Research commission on health and prosperity and Health is Wealth – an action plan for the new government) 

Our vision for population health sets out four pillars that contribute to health (including wider determinants, like stable employment, and an integrated health and care system) and calls for action at national, regional and local levels at the joins between these pillars. This policy could be seen as one situated at a ‘join’. While trying to do two things at once can lead to an imperfect solution for each, it might make a more positive contribution overall. I don’t know if that will be the case with this policy, but a signal that health care and wider determinants can be considered together and that policies can focus on more than one thing at once to help local communities prosper is positive to me.  

The conference speech announcement on waiting times is one of the first major health policy announcements from the new government, so gives hints about their overarching approach. I hope that approach will involve policy decision-making based on how all the levers of government can be co-ordinated to support a healthy more equal society. 

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