The Last Shortage Work, worth and the health system we are a

Chapter 1

The Last Shortage Work, worth and the health system we are actually building Faculty of Health Sciences, University of Pretoria Full reading text. Approx. twenty-two to twenty-four minutes at a measured pace, including pauses.

MOVEMENT ONE: THE QUEUE

Let me begin with a confession. I am not a clinician. I have never run a ward, read a scan or written a script. I study work: how it changes, who it changes for, and what happens to people and institutions when the technology underneath them shifts. So everything I say this morning is said from the outside. I ask in advance for your patience where I get the medicine wrong, because my argument is not about the medicine. It is about the work.

And I want to start with something everyone in this room has felt, on one side of the desk or the other.

When your patient needs a specialist, and you know exactly which one, and the first available appointment is months away, you are frustrated.

When you know which procedure is needed, and you know the theatre exists and the machine is working, and the patient still cannot get onto the list before next year, you are frustrated.

And when you are the registrar on a fourth consecutive shift, or the nurse running a ward built for half the people currently in it, you are frustrated too. Possibly more than anyone, because you are the person all the other frustration is aimed at.

Here is what interests me, as someone who studies work.

In every one of those moments, someone eventually says a sentence. Not out of malice. Usually out of exhaustion. The sentence is:

We don't have the capacity.

I want to suggest that this is the most powerful sentence in our health care system.

Not because it is false. For most of its history it has been entirely, painfully true. It is powerful because of what it does to a decision.

Think about a wall. Nobody argues with a wall. You walk around it, and after a while you stop noticing it at all. It simply becomes the shape of the building. But every wall began as a pencil line on someone's drawing. A person chose to put it there, and could have put it somewhere else. The wall has an author. We just cannot see the author when we are standing in the corridor.

"We don't have the capacity" is a wall. Behind it are pencil lines: budget lines, staffing decisions, purchasing choices, all drawn by someone, all drawable differently. The sentence takes decisions with authors and presents them to us as architecture. And once something is architecture, we stop arguing with it. We plan around it. We build institutions around it.

Which is precisely what this sector has done, and rationally so. The hospital exists because expertise was scarce and had to be concentrated in one place. The referral pathway, the waiting list, the gatekeeper, the specialist's fee, the appointment book: every one is a rationing device. From where I sit, a health system looks like a very sophisticated set of walls built around a queue. And after enough decades, we started calling the queue the system. That was the only rational response to genuine scarcity.

But for the first time, the end of that scarcity is visible. Not everywhere, not evenly, and not tomorrow. But visibly. Diagnostic capacity that does not sleep. Triage that runs before the doors open. Documentation that writes itself. Interpretation, monitoring, screening, follow-up, at a marginal cost that trends towards nothing.

If that arrives, and I think some version of it does, then you are living through the last shortage. The last era in which that sentence will be true.

That should be the best news this faculty has heard in a century. I want to spend the rest of my time explaining why I am not sure that it is.

I am not going to give you recommendations. I am from another sector; you would be right to ignore them anyway. I am going to try to do something smaller and, I hope, more useful. I am going to try to spoil this sentence for you. I am going to try to show you the pencil lines.