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Progress towards reducing waiting times

Country: 
United Kingdom
Partner Institute: 
London School of Economics and Political Science
Survey no: 
(6)2005
Author(s): 
Adam Oliver
Health Policy Issues: 
Access, Responsiveness
Current Process Stages
Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no no no no yes no
Featured in half-yearly report: Health Policy Developments Issue 6

Abstract

In its 1997 election manifesto the current Labour Government promised that it would reduce waiting lists by 100,000 people over the course of its first administration, that was in fact met. Through The NHS Plan and the Wanless Review the Government has proposed a number of waiting time targets, for example to reduce the max. inpatient waiting time down to three months by 2008-09, and to two weeks by 2022-23.

Purpose of health policy or idea

Waiting lists and waiting times have, over a protracted period, been viewed by the general public and the media as the number one problem facing the NHS. Over the past 15 years, successive Governments have attempted to tackle this peiceived problem. For example, in previous Conservative administrations, waiting times were a focus within The Patient's Charter in the early 1990s, which guaranteed admission to treatment within two years. The Charter was extended in 1995 to guarantee a maximum waiting time of 18 months. Over time, these targets were largely achieved. Recent Labour Governments have been concerned with both waiting lists and waiting times. In its 1997 election manifesto the Government promised that it would reduce waiting lists by 100,000 people over the course of its first administration, and did in fact meet this target. More recent Goverment aspirations have been to have a maximum inpatient wait of 6 months by 2005-06 and 3 months by 2008-09. Government rhetoric suggests that these targets will be met by, for example, offering patients greater choice of provider at the point of inpatient referral, and through a new inpatient booking system, whereby patients themselves can book their place and time of treatment. However, waiting times have fallen substantially over recent years in the absence of these incentive mechanisms suggesting that it is the increase in NHS expenditures in the period since the turn of the century that has been the driving force towards these ends. The latest Government statistics on inpatient waiting times will be presented below. The fact that the Department of Health announces these figures in the form of press releases on a regular basis highlights their importance in health care policy (it is interesting to note that in Department of Health press releases, issues that are 'perceived' to be of the most importance in the media - e.g. waiting times; BSE and it's human variant; cancer treatments and outcomes - come up time and time again).

Main points

Main objectives

See above. The main objectives are to improve responsiveness to what the public (and the press) seem to focus upon, and to improve access for those who would otherwise face particularly long waits.

Type of incentives

Again see above. The rhetoric seems to be focussed mainly on financial incentives, since a new DRG-type payment system will mean that the money will follow the patient to the provider of their choice (and will therefore, in theory, offer providers the incentives to reduce waiting times). Moreover, patients will, in theory, be allowed to go to providers where there is spare capacity and thus where waiting times are already low. Thus far, however, the success in reducing waiting times appears to lie less on incentives and more on increasing NHS expenditure.

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Characteristics of this policy

Degree of Innovation traditional traditional innovative
Degree of Controversy consensual consensual highly controversial
Structural or Systemic Impact marginal neutral fundamental
Public Visibility very low very high very high
Transferability strongly system-dependent system-dependent system-neutral

It was a good idea to reduce wait times initially, as waits were unacceptable long. There is a danger that reducing wait times can be taken 'too far', and may have detrimental consequences in terms of the unassessed opportunity costs of the policy. The jury is still out on the benefits (or otherwise) of policies such as more provider choice (principally because these policies have yet to be introduced), but choice may not fit into the institutional structure of the NHS (however, the inpatient booking system may well be appreciated and used by many patients). It will be interesting to see whether the Government mischievously attributes reductions in wait times that have been brought about by increases in NHS expenditure to its controversial choice proposals. 

Political and economic background

As noted above, the targets to reduce waiting lists and waiting times have been a Government policy now for many years, and have spanned several administrations (I would not therefore describe policies to reduce them as a directional 'change' - it's probably better described as policy continuity, particularly since the Labour Government plan to use market-based mechanisms, which before 1997 was perceived to be the domain of the Conservatives). However, the emphasis has probably been heightened under recent Labour governments, particularly since 2000, partly due to their 'traditional' focus as the 'political party of the NHS', and partly (I suspect) due to their need to demonstrate that their large increases in NHS expenditure are, in some sense, 'paying off'. Since waiting times are quite easy for the general public to understand and for the media to convey, they have high political visibility.

Purpose and process analysis

Current Process Stages

Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no no no no yes no

Origins of health policy idea

The policy to reduce waiting times arose many years ago, due to the perception (which was probably a fair perception) that waiting times in the NHS were unacceptably long. The policy to massively increase NHS investment is widely perceived to have it's origin in Tony Blair's statement at the end of the 1990s that his Government would increase NHS expenditure up to average health care spending in the EU. The policy to introduce choice, partly as a mechanism to reduce waiting lists, probably has it's 'formal' origin in the NHS Plan (2000), and has been championed by recent Health Care Policy Special Advisors to the Prime Minister. The choice proposals, whereby patients will be offered the choice of four or five health care providers by their GP should to be referred for inpatient treatment, is due to be introduced at the end of 2005. 

My focus in this report is waiting time reductions as a whole (a policy which has been applied nationally for many years), rather than provider choice per se. Choice has, however, been piloted in a few areas. The results are mixed. In some studies, most people tend to prefer their local provider, which is where their GP would refer them in any case. However, in London, people seem to want to take more advantage of choice, but then in a large city such as London, the choice is not a 'strong' one - i.e. patients are offered shorter waiting times at an alternative hospital, but then since London has an abundance of hospitals the alternative hospital tends not to be much further away than their local hospital, and therefore the patient is not required to make much of a  'trade-off'.

Initiators of idea/main actors

  • Government: The Government has a very powerful influence over all NHS health policy in England and Wales, and thus, by definition, it will be very supportive of any policy that it implements.
  • Media: As mentioned earlier in this report, the general public and the media are important influencers on the particular issue of waiting times policies, because the media has for many years used these figures as an indicator of whether or not the NHS is ?succeeding? or ?failing? (when waiting lists and times were longer, my impression is that the media paid more attention to this issue, probably because ?bad? stories on the NHS sell more newspapers and increase viewing figures), and waiting lists/times are a very simple metric for the general public to understand.

Innovation or pilot project

Stakeholder positions

These issues have been discussed above. It may, however, also be worth noting that some academics (including me) are a little concerned that the focus on reducing waiting times has unassessed opportunity costs, as it draws resources away from other policy initiatives. Also, the success in reducing waiting times has probably been brought about by the increases in NHS resources over recent years, and therefore is not a consequence of a 'policy reform' per se. It is therefore possible that when the country is no longer in a position to increase NHS resouces to the extent that it has done in the recent past, the success in reducing waiting times, and the (overly) ambitious targets that have been intimated in this area for the future, may raise unrealistic expectations among the general public, and may ultimately damage the NHS. After all, when implemented properly, waiting lists/times serve as a perfectly reasonable rationing device, and rationing devices over one sort or another are always needed when demand outstrips supply.

Actors and positions

Description of actors and their positions
Government
Governmentvery supportivevery supportive strongly opposed
Media
Mediavery supportivevery supportive strongly opposed

Influences in policy making and legislation

Government in the UK implements NHS policy and it is very unusual for the legislative process to block proposed policies in this area. The intention to reduce waits is set out in Government announcements, press releases and policy documents.

Legislative outcome

success

Actors and influence

Description of actors and their influence

Government
Governmentvery strongvery strong none
Media
Mediavery strongvery strong none
Government, Media

Positions and Influences at a glance

Graphical actors vs. influence map representing the above actors vs. influences table.

Adoption and implementation

This is already discussed above.

Monitoring and evaluation

The Department of Health monitors progress on waiting lists and waiting times, and issues regular press releases on developments in this area.

Review mechanisms

Mid-term review or evaluation

Results of evaluation

The latest Government figures on inpatient waits show that 16 English residents were waiting for over 9 months for treatment at the end of June 2005, and 3 of these had been waiting for over 12 months. The number of patients waiting over 6 months was 43,200, a decrease of 31,600 over June 2004. By the end of July 2005, the numbers waiting for more than 6 months, more than 9 months and more than 12 months, were, respectively, 15, 2 and 40,700. Perhaps around 5% of patients now wait for more than 6 months for inpatient treatment, down from around 25% at the turn of the century. Thus, the Government has almost achieved its 2005-06 target of a maximum inpatient wait time of 6 months.

Expected outcome

The Government will probably continue achieving decreases in wait times, at least whilst the increases in NHS expenditure continue. The effect of the policies of provider choice and inpatient booking systems are, as yet, unclear, and the 'hidden' (possibly detrimental) effects of continually raising expectations on the health care system as a whole are, at this point in time, unknown.

Impact of this policy

Quality of Health Care Services marginal rather fundamental fundamental
Level of Equity system less equitable neutral system more equitable
Cost Efficiency very low neutral very high

References

Sources of Information

  • Department of Health. The NHS plan. A plan for investment. A plan for reform. The Stationery Office: London, 2000.
  • Wanless D. Securing our future health: taking a long-term view. Final report. HM Treasury: London, 2002.
  • Yates J. UK evidence on waiting. In: Appleby J, Devlin N, Dawson D (eds.). How much should we spend on the NHS? Issues and challenges arising from the Wanless review of future health care spending. King's Fund, Office of Health Economics and Centre for Health Economics, University of York: London, 2004.
  • Oliver A. The English national health service: 1979-2005. Health Economics 2005; 14: S75-S100.
  • Department of Health. Statistical Press Notices: NHS Waiting List Figures. Department of Health: London, July 29 and August 26 2005.

Author/s and/or contributors to this survey

Adam Oliver

Suggested citation for this online article

Adam Oliver. "Progress towards reducing waiting times". Health Policy Monitor, September 2005. Available at http://www.hpm.org/survey/uk/a6/4