Equity, waiting times, and NHS reforms: retrospective study
BMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b3264 (Published 03 September 2009) Cite this as: BMJ 2009;339:b3264
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
We question the paper’s conclusions that reforms including patient
choice, provider competition and expanded capacity, did not harm equity.
The authors failed to consider the effect of incomplete data on their
analysis and lack of private sector returns on HES data.
Although the paper does not state the source of routine data, we
assume the authors have used Hospital Episode Statistics (HES), to
determine whether changes in waiting times occurred for certain key
elective procedures between 1997 and 2007 in the NHS in England and to
analyse the distribution of those changes between socioeconomic groups as
an indicator of equity. These data are very incomplete for NHS patients
receiving elective surgery in the private sector.
It is surprising that the authors do not refer to the five billion
pound Independent Sector Treatment Centre (ISTC) programme, where
treatment is delivered to NHS patients by for-profit companies in mainly
private facilities for cataract surgery, knee and hip replacement. (1,2)
Although all ISTCs are required to submit HES data on all NHS patients
treated they do not do so in practice. These data should include
diagnosis and procedure, age, sex, ethnicity, residence, date of admission
and discharge, and where treatment took place. Healthcare Commission
(predecessor of the Care Quality Commission) has noted that poor quality
data returns from the ISTCs prevents comparative analysis between the NHS
and independent sector and renders analysis futile. (1,3,4) Crucial to the
findings of the Cooper paper for the period 2005-07, the Healthcare
Commission reported in July 2007 that for financial year 2005-06, 32.7% of
patient episodes from ISTCs had a missing primary procedure code and in
5.3% of episodes the primary procedure code was invalid. In a second
report dated July 2008 they found the situation to be even worse for data
returns from 2005-06 with 43.4% of episodes containing a blank primary
procedure code and a further 7.6% of episodes where this field was
invalid. For 2006-07 they reported in July 2008 that 18.8% of episodes had
missing primary procedure codes and 1.2% were invalid. By comparison, in
2006-07, NHS Trusts and NHS Treatment Centres, were found to have 11.5%
and 3.4% of primary procedure codes left blank. (3,4) There are no data
available from HES on how much total ISTC activity is accounted for by
hip, knee and cataract operations.
In other words the data from the private sector are deteriorating
dramatically to the extent that more than half of all surgical procedures
are missing or incomplete for 2005-06. Given the size and scale of the
ISTC programme this is a serious oversight and deficiency in the paper
especially if there is a social class bias if routine and straightforward
elective cases, i.e. those without complications and co-morbidities
experience less social deprivation and shorter waiting times. The authors
are therefore incorrect to say that missing data would be unlikely to lead
to the clear results they have observed.
There are other more general points to be aware of when interpreting
waiting times data.
• Unlike official published waiting times figures, Hospital Episode
Statistics relate to patients who have actually been admitted, so do not
include information on those who are still waiting.
• Waiting statistics provide only a partial view of the patient
experience in accessing healthcare. Around half of patients admitted to
hospital are not included as they are emergency admissions.
• The focus on reducing waiting lists can have the effect of
prioritising conditions that are included, whilst healthcare services
outside of those measures are not subject to such pressures.
• Current government policy may be to substitute beds from the
private sector rather than to provide extra capacity within the NHS.
Overall, NHS capacity is decreasing, with a fall in the average daily
number of available beds in NHS hospitals in England (including day beds)
of over 23,000 between 1999-00 and 2007-8.
1. Pollock AM, Godden S. Independent sector treatment centres:
evidence so far. BMJ 2008; 336(7641):421-424
2. Pollock AM, Kirkwood G. Independent sector treatment centres:
learning from a Scottish case study. BMJ 2009; 338:b1421
3. Healthcare Commission. Independent sector treatment centres: the
evidence so far. 2008.
4. Healthcare Commission. Independent sector treatment centres. A
review of the quality of care. 2007.
Competing interests:
None declared
Competing interests: No competing interests
Waiting times are ultimately a by-product of the battle between
supply and demand and can be tackled by
1) Increasing supply
2) Reducing demand
More and more we see attempts to concentrate on the latter. This could be
done by stating
a) Some conditions can be dealt by others with less degree of expertise
(No evidence is usually produces for this)
b) Artificial imposition of ratios like New: old stating often arbitrarily
that only X amount of follow ups only are required for said condition
c) Sometimes such diktats cam clash with national policy i.e. NICE says
all Paediatric epilepsy should be seen and managed by specialists vs.
local efforts to "stem the tide” of patients trying to get into specialist
clinics
Ultimately waiting times may be an accolade to people and specialities in
demand rather than a marker for inefficiency as perceived by some powers
to be
Ultimately it comes down to managing demand and supply. Everything else is
rationalization
Competing interests:
None declared
Competing interests: No competing interests
Cooper et al are to be congratulated on addressing the important
issue of the impact of recent NHS reforms on equity. In order to
investigate this they determined the changes in waiting times occurring
for certain key elective surgical procedures and the distribution of these
changes in different socioeconomic groups [1]. They conclude that the
later stages of NHS reforms, including patient choice, provider
competition and expanded capacity, did not harm equity. This is arguably
misleading.
Concerns about inequity arising from patient choice may not be
manifested in waiting times for elective surgery. Firstly, the authors
concede that measures to drive down waiting times for elective treatment
have become increasingly stringent over the time analysed, due to distinct
policy changes from the above reforms [2]. Waiting times will therefore be
an insensitive method to detect inequity resulting from NHS reforms as
hospitals attempt to meet shorter waiting time targets. It is unsurprising
that inequity falls in such a scenario but little inference should be made
of the impact of more distantly related policies.
Secondly, it can be argued that patients in higher socioeconomic
groups are more likely to exercise their right to choose where to receive
treatment [3]. However, such choice may not result in merely choosing the
shortest waiting time but might instead lead to choosing health care
providers that are perceived to excel. The hospitals providing such
elective surgery may even have longer waiting times. What is needed is a
consideration of recent NHS reforms on the equity of quality of care
outcomes rather than waiting times.
The implications of "Choose and Book" and other recent reforms will
be far reaching for the English NHS and much more evidence is needed to
form an adequate assessment of their impact on equity.
1. Cooper, Z.N., et al., Equity, waiting times, and NHS reforms:
retrospective study. BMJ, 2009. 339: p. b3264.
2. The Kings Fund, Cutting NHS Waiting Times: Identifying Strategies for
Sustainable Reductions. February 2005: London.
3. The Kings Fund, What is the Real Cost of More Patient Choice? 2003:
London.
Competing interests:
None declared
Competing interests: No competing interests
A response from the authors
Too often, the debate over the merits of the English Government’s
market-based reforms of the NHS have revolved around anecdotes,
hyperbole and in the best cases, theory. However, now that the reforms
have
been in place for several years, we are in a good position to begin to
analyze
whether the reforms have improved quality, efficiency and equity in the
health service.
The Government’s market-based reforms, which revolve around increased
patient choice and hospital competition cannot be judged without evidence.
To determine how the reforms have performed and to influence future
policy-making in the NHS we need for more quantitative and qualitative
research.
This raises an important point. No research, whether quantitative or
qualitative, is without limitations. There are no perfect data sets,
there are no
fool proof measures of quality and no matter how the reforms are analyzed,
there will always be caveats. However, that does not mean that we should
not continue to try and measure and quantify the impact of policies.
Indeed,
the imperfect nature of research highlights the need for more analysis,
not
less.
Our paper “Equity, Waiting Times and the NHS Reforms: Retrospective
Study” published in the BMJ on September 3rd, looked at one particular
measure of equity: how waiting times were distributed across the
population
in relation to social class over time. We found that based on that
particular
measure, the NHS became more equitable. We certainly agree with Dr.
Katikireddi that more research needs to be done to assess the impact of
the
reforms on other aspects of equity. We are presently in the process of
doing
just that and we encourage others to do so as well.
In their rapid response, Pollock, Godden and Kirkwood question
whether
the incomplete data about Independent Sector Treatment Centre programme
throws our conclusions into doubt; they also the warn against trusting
published waiting times figures.
Our response to Pollock et al has three strands. First, the ISTC
Programme, however dramatic the headlines it has produced, is responsible
for a small sliver of NHS care. The ISTC program is far less than 10% of
total
NHS spending and accounts for less than 3% of total NHS volume. In fact,
the
ISTC programme has not actually cost £5bn as Pollock et al suggested.
Instead, the 5bn pound figure was an estimate of what the program might
spend eventually. To date, since the ISTC programme was introduced
several
years ago, the actual sum is closer to £3.5bn – 1.5bn for Wave 1 and £2bn
or
less for Wave II.
Second, our data, derived from the NHS Clearing Service, did have
data on
Independent Sector Treatment providers, although there was certainly not
data on every case that the ISTCs performed. For knee replacements, in
our
data 3% of procedures performed in 2005, 3.2% or procedures performed in
2006 and 7% of procedures performed in 2007 were marked as having been
performed at ISTCs. Likewise, for hip replacements, in our data 2.5% of
procedures performed in 2005, 2.9% or procedures performed in 2006 and
5.9% of procedures performed in 2007 were marked as having been
performed at ISTCs. The cataract data clearly had a lower percentage of
recorded private cases, with a negligible number of cases recorded each
year.
However, even if we excluded every private sector case and assumed that
they accounted for a larger share of overall care than they did, this
would not
have influenced the patterns we see in our results.
Third, most NHS analysts routinely use HES data for analysis. HES
data is a
rich source of information. Ignoring HES data because of its limitations
is
cutting off your nose to spite your face. We agree that HES data, like
all
administrative data has its problems, as indeed we discuss at the end of
our
paper, but it would be very hard to claim that they are of sufficient
magnitiude to invalidate our results. In many ways, it seems like Pollock
et
al’s motivation to dismiss HES data has more to do with our findings than
the
data itself.
The NHS is facing increasing pressure to do more with less. This
type of
pressure requires creative policies and a realistic analysis of what works
and
what does not. Our paper was not definitive proof that the Government’s
reforms were a success. What our results suggest is that the NHS market-
based reforms did not harm the equity of waiting times. This is good news
for everyone. While we can appreciate some of the skepticism towards a
greater role of the market in the NHS, we would hope that analysts are
driven
by peer review evidence, not by ideology.
Competing interests:
ZC, AJ, and SJ have no
conflicting interests to declare.
JLG worked part time in the
Policy Directorate at No 10
Downing Street from October
2003 to June 2004 and full time
from June 2004 until August
2005.
Competing interests: No competing interests