Undercover Economist

Why the NHS doesn’t know what it isn’t doing

When is a wait not a wait? When a bureaucrat holds the stopwatch. That is my conclusion, based on my experience of trying to get a cancer scan on the National Health Service. The NHS commitment is that – with some narrow exemptions – no patient will wait longer than 18 weeks for treatment. I’ve been waiting for a year.

My point is not to claim that the NHS is an institution on the brink of collapse, nor that the figures are being fiddled. Something subtler is going on here: we are bumping up against the limits of what any bureaucracy can know.

The way waiting times are measured by the NHS has evolved over time, as Nick Timmins explained in this magazine on March 13. The latest metric is Referral-to-Treatment, or RTT. The clock starts when a general practitioner (GP) refers the patient; it stops when the patient receives initial treatment. It’s a reasonable enough measure, but it does not tell the whole story.

Take my own case. My mother died in middle age from the same type of cancer that killed her brother and several other relatives. Standing on the brink of middle age myself, I concluded it was time to ask for a precautionary scan.

So I called my GP. I couldn’t get through. I called again. I couldn’t get through. After many failed attempts I made a note to try again in a few days. I wasn’t on the waiting list, but I was waiting.

My first appointment with the doctor generated not a referral but a second appointment. (“Come back with more details of your family history.”) The dance continued for four months, delayed by my own procrastination, the doctor’s part-time schedule, and above all, the understaffed reception desk.

Eventually I secured a hospital consultation, but arrived to find that the computers were down and the scan itself could not be booked. A few weeks – and pestering phone calls – later, I was sent an appointment out of the blue. It was on a day when I was in New York. I called, left messages and wrote to rearrange, but nothing penetrated the bureaucratic fog. I was noted down as a missed appointment, and the clock stopped at fewer than eight weeks.

I’ve no idea how typical my experience is. Nobody does. It is hard for a bureaucracy to measure delays if the delays are caused by an inability to be noticed by the bureaucracy.

(I recently tried again to book a scan, but the online booking system couldn’t find me a slot.)

Friedrich Hayek would not have been surprised at any of this. His 1945 essay “The Use of Knowledge in Society” emphasised the importance of local knowledge: the receptionist is overworked; the patient is in Manhattan; the computer has a bug. It is hard to centralise and process such information. In some cases it is impossible.

I am largely with Hayek, although the point can be pushed too far. John Appleby, chief economist at the King’s Fund, points out that centralised waiting list targets, combined with plenty of extra cash, have pushed NHS waiting times down so far that delays are no longer the chief concern of patients.

Yet the NHS data on waiting times remains a cautionary tale for me. Faced with any statistic, it is always worth asking exactly how the raw data can possibly have been gathered, and what might be missing.

I don’t even know, now, whether I am on a waiting list. I do know that I have been waiting. But this morning, an appointment suddenly appeared in the post. Perhaps by the time you read these words, my invisible wait will have ended.

Also published at ft.com.