Towards a systemic understanding of a hospital waiting list : boundaries, meaning and power : a thesis presented in partial fulfilment of the requirements for the degree of Doctor of Philosophy in Management Systems at Massey University
Hospital waiting lists are a feature of public health care services that result when demand appears to exceed supply, and serve as mechanisms to ration health care resources. While waiting lists are usually conceptualised as rational queues, the dynamics of waiting lists, especially radiology waiting lists, are more complex and still poorly understood. The present study has attempted to better understand a problematic waiting list by adopting a systems approach known as boundary critique. A case study of an ultrasound waiting list was undertaken in which in-depth and semi-structured interviews were conducted with a variety of stakeholders. Viewing the ultrasound waiting list systemically highlighted the role that a radiologist boundary surrounding the detection and confirmation of abnormal pathology played in constructing the ultrasound waiting list as a problem. This boundary was enacted through the process of double scanning, a symbol of radiologist expertise. General practitioners and patients employed a wider boundary, which focused on the management of clinical uncertainty. When the system in focus was widened to include this boundary, the process of double scanning became problematic. Double scanning contributed to the growth of the ultrasound waiting list and exacerbated the difficulty faced by general practitioners and waiting patients in managing diagnostic uncertainty. To manage the tension created between radiologist and general practice boundaries, non-radiologist stakeholders undertook unrecognised and under-valued work that helped maintain the radiologist-centred systems of process and structure. Radiologists also employed a discourse of inappropriateness that downplayed the significance of delayed general practitioner referrals, which served to reinforce the primacy of the radiologist boundary. Conflicting boundaries highlighted that the ultrasound waiting list was managed in a way that did not act in the interests of non-radiologist stakeholders such as general practitioners and waiting patients. Stakeholders proposed a number of interventions to manage the growing ultrasound waiting list. However, these primarily served to further strengthen the radiologist boundary and viewed as such represented a narrow improvement in terms of the interests of non-radiologist stakeholders. The process of boundary critique helped to reframe the ultrasound waiting list in terms of radiologist dominance. Interventions based on the boundary judgements of general practitioners, waiting patients and sonographers were developed. The present study argues that the ultrasound waiting list can be better understood in terms of the role that boundary judgements play in constructing notions such as expertise, illness and appropriateness, which underlie a common-sense understanding of need, demand and supply.