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Some Economics of Hospital Waiting Lists in the NHS*

Published online by Cambridge University Press:  20 January 2009

A. J. Culyer  and
J. G. Cullis
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Abstract

The article concerns waiting for inpatient admission in the NHS and focuses on three aspects of this persistent problem. These are the merits or otherwise of rationing health care through waiting as opposed to pricing, the interpretation of waiting lists as a proxy for excess demand in the ‘market’ for inpatient care, including a critical examination of the logic and empirical evidence underlying the view that inpatients pay a time price for their admission, and the question of an admissions index to replace the largely inconsistent admission criteria currently employed in the hospital service. In particular the construction of an index incorporating the values of fairness and efficiency is discussed and the following characteristics suggested for inclusion: time already spent on the waiting list; urgency based on expected rate of deterioration of the patient's condition; urgency based on the patient's health status; urgency based on the ‘social productivity’ of the patient and the number of economic dependants; and urgency based on other social factors.

The conclusions are that emphasis should be placed on waiting times rather than lists, that systematic admissions criteria should be developed and that the latter should incorporate social judgements which to date have been ignored or dominated by clinical judgements.

Type
Articles
Information
Journal of Social Policy , Volume 5 , Issue 3 , July 1976 , pp. 239 - 264
Copyright
Copyright © Cambridge University Press 1976

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References

1 Cases booked for admission on a certain date or deferred admissions are not included in the official waiting-list data.

2 Cooper, M. H. and Culyer, A. J. (eds.), Health Economics, Harmondsworth: Penguin Books, 1973Google Scholar, Part I.

3 Nichols, D., Smolensky, E. and Tideman, T. N., ‘Discrimination by Waiting Time in Merit Goods’, American Economic Review, 1971, 63Google Scholar; Smolensky, E., Tideman, T. N. and Nichols, D., ‘Waiting Time as a Congestion Charge’, in Mushkin, S. (ed.), Public Priees for Public Products, Washington, D.C.: Urban Institute, 1971.Google Scholar

4 A National Health Service, Cmd. 6502, London: HMSO, 1944.Google Scholar

5 Seldon, A., ‘National or Personal Health Services’, Lancet, 1967, 1.Google Scholar

6 Ministry of Health, Reduction of Waiting Lists, Surgical and General, HM(63)22, London: HMSO, 1963.Google Scholar

7 Aldridge, L. W., ‘Cooperative Effort to Reduce a Waiting List’, British Medical Journal, 1965, 1Google Scholar, and Williams, B., ‘The Use and Misuse of Bed-Occupancy and Waiting List Figures’, Lancet, 1968.Google Scholar

8 Feldstein, M. S., ‘Hospital Planning and the Demand for Care’, Bulletin of the Oxford University Institute of Economics and Statistics, 1964Google Scholar, and Culyer, A. J. and Cullis, J. G., ‘Hospital Waiting Lists and the Supply and Demand of Inpatient Care’, Social and Economic Administration, 1975, Vol. 9, No. 1.Google Scholar

9 Annual Report of the Ministry of Health, London: HMSO, 1964, p. 29.Google Scholar

10 Culyer, A. J., ‘Medical Care and the Economics of Giving’, Economica, 1971, p. 38.Google Scholar

11 Though there is substantial evidence that elasticities are not, in fact, zero.

12 It is possible to imagine some costs that are avoidable: for example, the cost of frustration at failure to be called, or the costs of uncertainty as to the date and time of admission. While these may make private practice relatively attractive to some, they seem too insubstantial to do the work required of them in the time-price hypothesis.

13 Duration of stay is likely to operate much more effectively as a time-price than waiting time if the patient time thus used up (for which he is not, of course, directly compensated) has opportunity cost to the patient in market or non-market activities. This is a price that can be avoided. Even though the average duration of stay has fallen over time it seems unlikely that it would have had much impact on the patient cost of care. Rising wages will, of course, have increased the opportunity cost per unit of time but, similarly, the opportunity cost of other non-work use of time will have increased. Rising real wages would, however, increase the ‘return’ on time spent in hospital if such an ‘investment’ increases the number of healthy working days subsequently available to the patient. For a fuller discussion see Holtman, A. G., ‘Prices, Time and Technology in the Medical Care Market’, Journal of Human Resources, 1972, Vol. 7.Google Scholar In the NHS as at present there is, however, little evidence that such consumer calculations could have any impact on doctors' decisions.

14 A fuller discussion of notions of ‘need’ in health care is to be found in Alan Williams, ‘“Need” as a Demand Concept (with special reference to health)’, in Culyer, A. J., Economic Policies and Social Goals, Aspects of Public Choice, London: Martin Robertson, 1974.Google Scholar

15 See Butterfield, W. J. H., Priorities in Medicine, London: Nuffield Provincial Hospitals Trust, 1968Google Scholar, and Williams, A., 1974, op. cit.Google Scholar

16 Ashford, J. R. and Pearson, N. G., ‘Who Uses the Health Services and Why?’, Journal of the Royal Statistical Society (A), 1970, p. 133.Google Scholar

17 Institute of Hospital Administrators, Hospital Waiting Lists – A Report of the Study and Research Committee of the IHA, 1963.Google Scholar

18 Hicks, D., Waiting Lists – A Review (unpublished report prepared for the OR Branch of DHSS), 1972.Google Scholar

19 Forsyth, G. and Logan, R., Gateway or Dividing Line – A Study of Hospital Outpatients in the 1960s, London: Oxford University Press for the Nuffield Provincial Hospitals Trust, 1968.Google Scholar

20 Op. cit.

21 Op. cit.

22 Ibid.

23 Survey of Inpatient Waiting Lists, DHSS, 03 1971Google Scholar (unpublished).

24 Culyer, A. J., ‘Health: the Social Costs of Doctors’ Discretion', New Society, 27 02 1975.Google Scholar

25 Baderman, H. et al. , Admission of Patients to Hospital, London: King Edward's Hospital Fund, 1973.Google Scholar

26 Luckman, J., Mackenzie, M. and Stringer, J. C., Management Policies for Large Word Units, Institute of Operational Research Health Report No. 1, 1969.Google Scholar

27 Phoenix, C. J., ‘Waiting List Management and Admission Scheduling’, in Abrams, M. E., Spectrum 1971: A Conference on Medical Computing, London: Butterworth, 1972.Google Scholar

28 Fordyce, A. J. W. and Phillips, R., ‘Waiting List Management by Computer’, The Hospital, 1970, p. 66.Google Scholar

29 London Hospital, Selection from an Orthopaedic Waiting List (n.d.), (unpublished).

30 Op. cit.

31 Culyer, A. J., Lavers, R. J. and Williams, Alan, ‘Health Indicators’, in Shonfield, A. and Shaw, S. (eds.), Social Indicators and Social Policy, London: Heinemann, 1972Google Scholar; see also Williams, Alan, ‘Measuring and Effectiveness of Health Care Systems’, in Perlman, M. (ed.), The Economics of Health and Medical Care, London: International Economic Association, Macmillan, 1974.Google Scholar

32 Culyer, , Lavers, and Williams, , op. cit.Google Scholar

33 Op. cit.

34 Op. cit.

35 Rosser, R. M. and Watts, V. C., ‘The Measurement of Hospital Output’, International Journal of Epidemiology, 1972.Google Scholar

36 Op. cit.

37 See, e.g., Cochrane, A. L., Effectiveness and Efficiency: Random Reflections on Health Services, Nuffield Provincial Hospitals Trust, 1973Google Scholar; and Culyer, , 1974, op. cit.Google Scholar