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Blog: Treating people on waiting lists: who decides what is fair?

Peter Spilsbury, Director of the Strategy Unit

There are millions of people waiting for treatment. How should we decide who gets called first? Peter Spilsbury, Director of our Strategy Unit, discusses in this blog how waiting lists are currently prioritised and how looking at richer data around complex socio-economic factors can help improve equity.

Waiting lists for elective care are in the news. The national plan has been issued, with the expectation that lists will continue to rise for some years – and that long waiting will not disappear anytime soon. Addressing this ‘backlog’ will remain a fundamental challenge for some time to come.

This raises the question of how people on the lists are prioritised. There are millions of people waiting for treatment. How should we decide who gets called first?

Previous Strategy Unit work showed that there is already inequity: richer people tend to get better access to elective treatment than poorer people. This trend emerged over the last decade. And, if we aren’t very careful, the final reckoning of how the NHS ‘recovers’ will see these inequities made much worse.

Who gets treated ahead of whom is a value judgement. No one has a monopoly on those – and there are no right or wrong answers.

To date, the NHS has largely worked by prioritising based on length of wait. During lockdown the NHS/government worked with the Royal Colleges to establish a clinical priority weighting system. So decisions about who to treat started by considering clinical priority, then length of wait.

This seems utterly reasonable, but is it sufficient?

Let me explain why it might not be.

Imagine that two people are waiting for a procedure that has a non-urgent clinical priority. In both cases, they have pain that seriously limits their mobility. The first, Patient A, has waited for 50 weeks. The second, Patient B, has waited for 20 weeks. A slot is available for the treatment they both need. Who gets called?

Based on the information you have at this stage, who would you choose?

Now let me add some more information. Patient A lives in an area that is in the upper quartile of socioeconomic status; Patient B lives in an area from the lower quartile. People living in upper quartile areas typically get greater access to this treatment (relative to need) than people living in the lower quartile.

Would that change your judgement?

Now some more information. Patient A is otherwise well and has a job that allows them to work from home at a desk. Patient B works on a building site, on a zero hours contract, and has underlying mental health issues.

Would that change your judgement?

These are complex considerations. And they are value judgements, so they entail difficult debates where final positions are hard to justify using evidence. So many of us might want to avoid this discussion, treating ‘clinical priority’ as though it were a single, neutral and over-ridding consideration.

But this is an illusion. Carrying on just doing what we’ve always done is as much a value-based position as changing it. There is no ‘neutral’ position. Choosing purely on time waited is a deliberate decision to NOT take into account other issues. So we MUST engage in the question.

And that is why I’m really excited that the Strategy Unit is helping to inform these debates. We are starting with two exciting pieces of work.

Read Peter’s full blog on the Strategy Unit website.