Personal views: The two tier syndrome behind waiting lists
Authors: Donald Light
Journal: BMJ (2000)

The Labour government is making a serious effort to shorten the waiting times for specialist assessment and treatment. But if real progress is to be made it must tackle the two tier syndrome.

Past governments have formally sponsored private practice as a second tier by assuring long waits for NHS services and by writing contracts that provide consultants with incentives and ample time to induce patients to pay high fees for the treatments they should receive free.


Waiting lists have been attacked piecemeal and it is a pointless effort. Charges that lists are artificially reduced by pressurising general practitioners not to refer, or removing people from the lists, or by making more serious cases wait longer, are shuffling exercises that leave underlying causes untouched. 


This is a blatant conflict of interest, an invitation to mischief



The two tier syndrome has six elements that have reinforced each other so well that the public and doctors think that long waits are as much a fact of life as waiting nine months for a baby to be born. The first element is the maximum part time contract. This is a government issued commercial licence, sold for several thousand pounds a year to consultants to build highly profitable businesses on the foundation of their NHS practice. Meanwhile, they keep a lifetime salary, six weeks' paid holiday, an indexed pension, and ready access to resources and networks with which to build their upper tier practice. The two tier syndrome is set up so that consultants can double their NHS salary seeing private patients for a day a week; surgeons can double it in half a day a week.

The second element is the minimal obligations that the government sets so that full time consultants have plenty of free time to build up private practices. Data collected by the Audit Commission and John Yates show that whole time NHS surgeons operate less than one day a week on NHS patients. Some patients are told “Mr G does not work for the NHS on Thursdays and Fridays.” Yet if surgeons operated just one more day a week on NHS patients, waiting times would plummet to three weeks or less.

These two elements make up what I have called previously the “sweetheart contract.” They are reinforced by a third element, to allow hospitals to set prices for extra theatre and other sessions well above their actual marginal costs, so that purchasers cannot “afford” to buy two to four extra theatre sessions a week. Marginal costs should be about a quarter of average costs, just as an extra night at a hotel costs only a fraction more, after all the fixed costs are covered by their break even occupancy at the regular rate.

While surgeons and anaesthetists are short changing the NHS, other specialists work hard without coming close to treating all in need, because they are in short supply. This is the fourth element, government induced shortages in most specialties that guarantee long waits in the lower public tier and a generous supply of private patients for the upper tier in Britain's two tier system.

These four elements are joined by a fifth, control by consultants of the waiting lists and over how long different kinds of patients will wait. This is a blatant conflict of interest, an invitation for mischief. Consultants have told me how other consultants exploit the NHS in many different ways. And some routine practices in the NHS help to drive patients into the upper private tier, such as notifying NHS patients when they have been given an appointment in ways that minimise the chances they can actually show up; scheduling theatre sessions to end an hour early; or allowing team members to take days off without careful planning for a replacement, so that sessions have to be cancelled.

These practices are no accident. They would not exist if every cancelled session, every shortened session, and every patient who does not turn up meant less income to a unit and its members. But instead, these officially permitted practices mean less work at full pay and more patients ready to queue jump and pay large private fees.

The sixth element is that past governments have denied or obfuscated the government's two tier policies by focusing on just one or two elements and calling for yet more studies.

A heartening change seems possible with the new Labour government. But so far it is treating the symptoms, not the causes, and the current negotiations over a new consultant contract include a proposal to give a licence to all consultants to build up private practices. That would make the two tier syndrome even worse.

Will this government also perpetuate the two tier British healthcare system? Or will it demand that consultants see NHS patients three days a week as a minimum, set productivity goals, and reward specialty teams for exceeding them, allow purchasers to buy extra sessions at true marginal costs, and start training or importing more specialists? Ending government practices that support an upper private tier and long waiting times should be a major goal of Alan Milburn's newly formed leadership team.