Waiting in the NHS: Part 1--a diagnosis

Abstract

The denial of potentially beneficial treatment is a characteristic of all health systems. In a tax-funded cash-limited health system providing services irrespective of ability to pay—such as the NHS—waiting lists are a key means of rationing access to treatment. Understanding this is critical to the design and implementation of policies concerning waiting lists. A commentary on UK waiting-list management in the 1980s and 1990s stated: ‘None of the policy initiatives have been based on an adequate account of the nature of the problem to be tackled. The simple view...that the waiting list is a backlog, which extra resources and better management could clear, was never fully dispelled’1. The notion of infinite demand for elective surgery is questionable2. Nevertheless, the view that demand for surgery is both static and completely unresponsive to changes in waiting time is an inadequate basis for policy, for two reasons. First, the wait faced by patients is a determinant of their demand for taxpayer-funded treatment3. Second, potential patients can substitute privately funded treatment for publicly funded treatment at high waits (and vice versa). Demand for publicly funded elective surgery is more usefully characterized as being neither infinite nor fixed but responsive, to some degree, to waiting times and other factors. Despite a range of new initiatives since publication of the NHS Plan4, including a massive injection of funding to increase capacity, strategies for better waiting-list information and management5 and new waiting-time targets, the Government is unlikely to ‘solve’ the waiting-list problem. We go on to argue, in part 2, that a more explicit and comprehensive strategy is required to prioritize patients for treatment in a manner consistent with NHS aims.