WAITING LISTS

A comparative overview

Only 24% of the Irish population expressed itself satisfied with our health services in a survey published last month by Eurostat, the statistical office of the European Commission in Luxembourg¹. That compares to 70% in the Netherlands, 71% in Austria, 78% in Finland.

¹ Key data on health, Eurostat, September 2000

Waiting lists are clearly a major reason behind this low satisfaction rating.

The Eurostat data also records the highest death rate for males in the EU from both respiratory and circulatory diseases among Irish men. Among females, Irish women have the highest rate of deaths from respiratory diseases and the second highest for all cancers.

It is difficult to draw precise correlations between long waiting times and high death rates from cancer and respiratory and circulatory diseases. We are forced to conclude, nonetheless, that the link is more than purely coincidental.

A look at some facts
31,851 people are currently waiting for hospital treatment in this country. Many are debilitated by unnecessarily prolonged illnesses. Some die before they have the treatment.

This 31,851, however, indicates only part of the problem. Only those who have already seen a consultant and who have been diagnosed as needing hospital treatment are counted on waiting lists. In marked contrast to the practice in the UK and Northern Ireland, public patients here must also undergo a pre-list wait where they are undocumented for a period of three months as they wait to be added to the official list. This is often subsequent to an initial long wait to see the consultant.

What’s the point of waiting lists?
Waiting lists are used to ration health services, although supposedly only for certain non-urgent conditions. What happens in fact is that waiting lists are also used to apportion treatment to seriously ill patients—cancer and heart surgery, two of the biggest killers in Ireland and the UK included. The waiting list may ultimately be so long as to actively exclude access to specific services, because the patient dies or otherwise removes him/herself from the list, opting out of treatment altogether or seeking other avenues within the private sector.

Everyone has a statutory entitlement to free public hospital care in Ireland. Yet this entitlement cannot be met and is not met by public hospital services, as evidenced in particular by the existence of waiting lists.

We have reached the extraordinary point where 45% of our population is covered by private health insurance—quite simply to ensure (according to recently published ESRI research) that quality care can be accessed when needed.

How do we compare internationally?
We experienced significant difficulty in drawing a comparative picture of waiting lists across Europe because of the lack of available information. According to the office of the European Commission in Luxembourg, comparative data on waiting lists simply does not exist. We were therefore prevented from drawing comprehensively on the resources of knowledge and experience available within the Union.

In addition to Ireland and the UK, where the problems of waiting lists are most acute, we know, for example, that the Netherlands, Spain, Sweden, Finland and Denmark have each endured differing degrees of waiting list difficulties. Often, it is a regional and/or sectional problem—as opposed to a national problem across all areas in Ireland. Outside the EU, problems with waiting lists in Canada and New Zealand are often cited.

However, we also know that waiting lists are not an inevitable result of necessary rationing and prioritisation in public health care systems—as evidenced by the examples of France and Germany where, apart from organ transplantation, waiting lists as we know them do not exist.

So, all countries are not in the same boat?
Let’s look at the example of France

Recently assessed as being the best healthcare system in the world by the World Health Organisation, France does not have the problem of waiting lists. This is not to say there is no waiting period. Rather, under a "booking" system (similar to the system introduced in New Zealand in 1996), all patients are immediately given a date at which surgery will be carried out, thus reducing uncertainty and stress for the patient and family.

The French system copes with emergency surgery cases by running bed occupancy rates at around 75% so that the system runs, normally, under full capacity. Thus it can mange periods of peak demand without disrupting the booking system. In addition, the expansion of day care surgery has also helped in avoiding the problem.

To make some comparisons with Ireland: among French males, the death rate from circulatory diseases is 54% of that affecting Irish men (255 per 100,000 opposed to 465 per 100,000 in Ireland). Among French females, it is 52% of the rate affecting their counterparts in Ireland (146 per 100,000 and 279 per 100,000 respectively). Comparative death rates for men and women from respiratory diseases run at 46% and 32% of Irish death rates. In other words, France suffers less than half the rate of death for men and less than one third for women from respiratory diseases than we do in this country.

Close to 99.9% of the French population has medical cover through social security payments. Insurance is mandatory², whether employed, unemployed or self-employed and resources are not divided between the kind of two-tier system of health care we have in Ireland.

² 90% have cover through state medical insurance programme; remainder through other welfare bodies.

What’s the biggest problem with waiting lists?
Indisputably, the greatest problem with waiting lists in Ireland is the actual length of time spent waiting.

If we look at the examples outlined in the HOPE report on Measures to reduce surgical waiting lists (Appendix 1), in which regional initiatives in Finland and Spain and the national Waiting List Initiative in Ireland were examined, we see just how unfavourably the Irish situation compares. (Figures in this report were for the 1996-97 period).

(i) Finland
In 1997, the South Karelia region in Finland experienced waiting times ranging from 90 days for ENT procedures to 325 days for gynaecology (sterilisation). There was no waiting period incurred for cancer surgery, coronary bypass or minor orthopaedics (Appendix 1, HOPE Report, section 4).

(ii) Spain
In the Spanish study, covering a region of 15 million people which included the city of Madrid, 148,224 people were on waiting lists in December 1997. Of that number, only 826 waited more than 9 months (0.005%) while the average wait was just 98 days.

Those figures compared to 21,525 people waiting more than one year out of a total of 168,265 on waiting lists just 18 months previously (see p.8, Appendix 1). Average wait times for the earlier period had been 217 days.

These reductions were achieved by a number of measures including standardisation of waiting list registration systems, standardised criteria for placement of patients on waiting lists, prioritisation of list and selection of patients from lists and incentive payments to hospitals for day cases.

(iii) Ireland
In December 1996, just under 26,000 people in Ireland were on waiting lists. 74% of those waiting for cardiac surgery waited more than 12 months, as did 64% of those waiting for vascular surgery, 45% waiting for orthopaedics and 58% waiting for plastic surgery (see Report of the review group on the waiting list initiative, p.5). This was despite the additional £12 million invested under the Waiting List Initiative in 1996.

Target specialities in Ireland
If we look at what’s happened in Ireland since the HOPE report was written, with the implementation of target specialities for waiting time reduction in certain key areas, the stagnation within the system is even more apparent.

Table 1.0 below indicates significant increases since 1996 in the percentage of people on waiting lists who are forced to wait in excess of one year for each of the target specialities outlined—except for cardiac surgery where the situation has changed little in the four intervening years. This increases have persisted notwithstanding the increased funding and reform measures implemented since that date.

Table 1.0 percentages of total number on waiting lists waiting 12 months and above

So numbers haven’t actually come down under the Initiative?
Irish waiting list figures suggest that investing additional specifically targeted resources and providing incentive payments to hospitals, even with enhanced list management, reviews and prioritisation, will at best arrest the rate of growth or provide periodic drops in the total numbers waiting.

Despite a total of £124.57 million invested in the Waiting List Initiative since its inception in 1993 (see table 1.1 below), extraordinarily long waiting periods still persist.

Without structural reform of our two-tier system of access to health services with its in-built system incentives against rapid patient throughput (such as fear of going over fixed hospital budget or greater financial incentives to treat private patients) we will not solve the problem of waiting lists 3.

³ The private patient population in Spain and Finland is negligible in comparison to Ireland—e.g. in Finland, only 0.5% of patients are private.

Table 1.1
Waiting lists numbers and investment under the Waiting List Initiative

If it was simply a matter of extra cash and better management, much greater inroads would by now have been made on the numbers waiting.

What do these figures mean in real terms?
The attached report, Waiting lists for healthcare in developed countries—Initiatives for long term management, notes that "targeted funding such as this is a short term measure. Such initiatives will not address the underlying cause of the waiting list growth" (p.33).

The most recent figures available show a drop of one sixth, from 36,855 in December 1999 to 31,851 last month, achieved with the enormous investment of £34 million this year and concurrent list audit measures. Going on previous years, this rate of throughput will only be sustained if the same level of investment is sustained.

If we look at the history of funding under the Waiting List Initiative since 1993, the temporary nature of improvements effected with targeted funding is borne out—especially given increased waiting times and the increase in total numbers waiting by over one-fifth since December 1993.

In March 1993, waiting lists stood at 39,423. £20 million additional moneys were invested under the Initiative in 1993 and by December of that year, the numbers had fallen to 25,373. By December of the following year, with a further investment of £10 million, the lists numbered 23,772, a proportionately much lower decrease.

The net effect of the Initiative appears to have plateaud by 1995 when, despite another £8 million specifically targeted at waiting lists, they had actually risen to 27,752 by December. It would seem that problems of capacity also set in.

As noted in the Report of the review group on the waiting list initiative (p.i, Executive summary, Appendix 3), "some hospitals have reached full capacity with existing resources in relation to elective work"—whereby hospitals are simply physically incapable of increasing throughput even with the additional resources offered through incentive payments.

With £12 million invested in 1996, waiting lists fell again to 25,969 only to rise to 32,206 by December 1997, despite the £8 million invested that year. With another £32 million shared between 1998 and 1999, the numbers waiting had further climbed to 36,855 by December 1999—highlighting the very temporary nature of improvements effected.

So it’s not simply a question of money?
It is interesting to compare and contrast, in the attached report from the Irish Medical Times of December 1998 (Appendix 2) concerning "Health services in each of the EU member states", not only differences in number of inhabitants per doctor, number of hospital beds per 1,000 inhabitants and total expenditure on health as a percentage of GDP across the EU, but also how health services are funded in these countries; in short to see whether we can draw correlations between infrastructural provisions and waiting lists ⁴.

⁴ See also Appendices 5 and 5a for OECD health system structure comparatives and analysis of Irish system within that perspective.

We do not have adequate information to draw definitive conclusions on the relationship of health system structures to waiting lists. However, the apparent absence of waiting lists particularly in France and Germany, suggests that the equality of access underpinned by the social insurance model found in these countries may well contribute to more immediate care for everyone. In addition, the relatively high levels of per-capita spending on health in each of these countries must also be counted as hugely significant.

What about countries with waiting lists?
The attached report, Waiting lists for healthcare in developed countries—initiatives for long term management, takes three countries, namely the UK, New Zealand and Canada where waiting lists are or have been problematic

In Canada, waiting lists have resulted from a range of factors—from financial cutbacks to uneven levels of access to care across the country and poor list management.

In the UK, 75% of waiting list cases are concentrated among the five specialities of general surgery, orthopaedics, ear, nose and throat, gynaecology and ophthalmology. While considerable numbers of people wait for treatment under the NHS for unacceptably long periods of time, waiting lists also show significant local variations in the length of lists and waiting times.

Although only 10% of Britons access healthcare via the private sector ⁵ (compared to 45% in Ireland), private medicine in Britain is also used as an avenue to skip queues in the public system—particularly at times when the public system is least able to cope with demands for its services.

⁵ Fallen recently from 11% due to NHS reforms

As already indicated, waiting lists in New Zealand have been countered with the introduction of a booking system in 1996 for surgical procedures—preceded by investment of NZ$130m to clear surgical waiting lists. At the same time, priority criteria have been developed to encourage treatment of most needy patients first. Resulting in greater efficiency and more productive use of resources, this has also had the added benefit of encouraging greater integration between general practice and the acute hospital system as patients with less serious conditions are treated locally by GPs.

Why are Irish reforms not working in the same way?
Too often in our society, decisions on healthcare are made in the interests of the most powerful. Nowhere is this more evident than the disproportionate level of care paid for and provided by the state to the private patient.

A recent report by the Economic and Social Research Institute, Private Practice in Irish Public Hospitals, revealed that private patients in public hospitals have half their costs covered by the taxpayer; that their health insurance covers just 50% of the actual costs incurred. Although private patients only account for one-fifth of all in-patient stays in acute public hospitals, one quarter of the hospitals’ total expenditure on in-patient care is spent on them. Private patients are also subsidised by the state through tax relief on health insurance payments.

Public hospitals are allowed to take private patients up to certain limits. Even if public beds are closed, these limits are not affected. As public hospitals operate on fixed budgets, private patients enhance hospital earnings and thus under the current system they are unlikely to wish to reduce their number in favour of their public counterparts.

We cannot, however, lay blame on the private patient. This is quite simply how the current system works. It is the structure which needs to be tackled to enable equitable and timely access to necessary care as need dictates, irrespective of patient status.

The public/private mix—who benefits?
Both the attached document, Waiting lists for healthcare in developed countries—Initiatives for long term management, and a 1998 report prepared for Health Canada suggest that "greater access to private care appears to be generally associated with longer public sector queues—particularly where physicians operate in both sectors", as in the UK and particularly in Ireland.

We are fortunate in Ireland that the professionalism of our consultants has moderated the negative effects of the structure of our health system.

Over 80% of consultants in this country are engaged in both public and private practice. While contracts in the public service engage consultants for 33 hours per week, there is no limit on the time that can be devoted to private practice.

There is in effect an inherent incentive within the system for consultants to create waiting lists for treatment. Although everybody in this country has a public entitlement to care, those with health insurance will use it to pay for treatment, while those who do not will (if they can access the necessary moneys) either pay up front or take out health insurance in anticipation of future need. Such queue-jumping is now an integral part of the Irish healthcare system.

Private hospitals piggyback on cash-strapped state-funded institutions as they rely hugely on consultants from the public sector. Financial incentives available to consultants in the private sphere, coupled with the lack of monitoring of work carried out under public contract, leaves open the potential for disproportionate time to be spent with the lucrative private market, further shifting the balance against the public patient.

The government review group which examined the problem of waiting lists two years ago (and which included five consultants among its 12 members) commented: "some hospitals or consultants may find it attractive to maintain a public waiting list because a proportion of those waiting may opt to be treated privately".

In 1989, the Commission on Health Funding said that some consultants did not fulfil their responsibilities to public patients because they could make so much more money in the private sector. The Commission recommended monitoring of consultants’ obligations to the public system. The Department of Health are still attempting to reach agreement with consultants’ representatives on a monitoring procedure.

Shortage of consultants
The negative effect of consultants dividing their attentions between the public and private sphere is compounded by the serious shortage in their number employed throughout the system. Nationally, we have more than twice the number of Non-Consultant-Hospital-Doctors (doctors in training, often young and inexperienced) as consultants, a fact which has serious adverse consequences for the health service, not least of which are waiting lists.

NCHDs actually keep many of our hospitals going. Supposedly in training, they regularly carry out unsupervised work tending to public patients on behalf of absent consultants. Inappropriate admissions via A&E by the less experienced NCHD often means that both treatment and discharge are delayed as NCHDs are understandably reluctant to take decisions necessary to progress patients through the system. Therefore, through no fault of his own, the public patient inside the system blocks admission for those still waiting on the outside by spending unduly long periods in in-patient care—evidenced statistically in the high number of bed-days used by Irish patients in comparison to their counterparts internationally.

Primary care
The Report of the review group on the waiting list initiative, (Executive summary, Appendix 3), said that "a satisfactory response [to waiting lists] must reach beyond the acute hospital services alone" and further called for an "improved flow of information between primary and hospital care regarding the status of patients on waiting lists".

Apart from inevitable cost implications, the development and expansion of healthcare at the primary and community level, in line with our European neighbours, and a greater integration of primary and secondary care, will have significant follow-on improvements for more rapid processing of patients through the acute hospital system and therefore for the length of our waiting lists.

• The lack of centrally collated data on waiting lists within the European Union points to a significant gap within our knowledge. It points to an urgent need for statistical research within this area. The generation of data-based knowledge will assist in moving towards basic agreed standards in care across Europe while respecting our rights as individual countries to provide a system of healthcare most appropriate to local needs, cultures and traditions.

• As noted by the Report of the review group on the waiting list initiative (p.i, Executive summary, Appendix 3), "there are no simple short term solutions which, on their own, will have a significant impact". In addition to the range of solutions outlined in the attached documents, as derived from international research and experience, we need to recognise that we will not solve the problem of waiting lists in Ireland until we accept, as legislators and as citizens, that our two-tier system of healthcare is a significant part of the problem. Built into its basic structure is an acceptance that public patients should wait long periods for care while private patients have fast-track access.

• In the short term. greater investment, centralised control and management and prioritising and auditing waiting lists will help reduce the numbers still waiting for treatment. In the longer term, however, it is only by systematic, planned and gradual reform of our health system itself that we will ensure appropriate and timely access to care for all patients.

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