Waiting list dynamics and the impact of earmarked funding

Introduction

The number of people on hospital waiting lists, and the length of time that they wait, are used extensively as performance indicators in the NHS.1 Although there are still over a million people on waiting lists in England, the number waiting over a year has decreased steadily since 1990. Policy initiatives to reduce waiting times include the patient's charter,2 earmarked funds of about £30m a year nationally from 1987 to 1993, and the funding of 100 new consultant posts in 1990 specifically to reduce waiting times.

The effectiveness of these policies is difficult to assess, given the complex nature of waiting lists.3 4 5 6 Waiting list initiatives mostly aim to reduce list size and waiting times by admitting more patients from the list.7 Research studies, however, have so far failed to show a strong inverse correlation between admission rates and list size.4 8

We examined national waiting list statistics from 1987-94 to determine how list size and waiting times changed in relation to changes in the number of admissions from the list. We also considered changes in the number of patients added to the list, information about which has been routinely available only since 1987. We used local data to assess the impact of earmarked waiting list funds on admission rates, list size, and waiting times at an individual district specialty level.

Methods

Aggregated national information on the number of people on waiting lists, and the number admitted from them, is published every six months by the Department of Health.9 The department also supplied us with additional quarterly data for the period 1987-94, including information on the numbers of additions to the list or “decisions to admit in due course.”

Pearson's corrrelation coefficient was used to assess correlations between changes in the number of admissions from waiting lists in England and in total list size, changes in the numbers of those waiting one to two, or over two years, and changes in the number of additions to the lists. Multiple regression analysis was used to control for simultaneous changes when appropriate.

For patients treated in the former Oxford region during 1987-91, the numbers of admissions from waiting lists were obtained from the regional health authority's information system and the numbers waiting, time waited, and numbers of additions to waiting lists from Korner returns. For every elective surgical specialty in each district, these data were examined in relation to the allocation of waiting list initiative funds by the regional health authority, by the Inter-Authority Comparisons and Consultancy Unit directly, and on behalf of the NHS Executive and by the Department of Health when funding additional consultant posts (information provided by the health authority). After 1991 specific specialties no longer received centrally allocated waiting list funding.

Results

Nationally, quarterly changes in the number of admissions from the list and in the number of additions to it correlated closely (r=0.84; P<0.01). There was a corresponding inverse correlation between changes in admissions and changes in list size (r=-0.62; P<0.001 only after controlling for the former relation). Changes in the number of patients waiting over two years correlated with changes in both the number waiting one to two years (r=0.53; P<0.01) and the overall list size (r=0.55; P<0.01). Increases in the number of admissions were significantly associated with decreases in the numbers of people waiting one to two years (r=-0.52; P<0.01), but not with decreases in the number waiting over two years (r=-0.08; NS).

Between 1988 and 1991, 44 waiting list initiatives (total value £3.3m) were distributed among 25 of the 40 district specialties studied in the former Oxford region.

In only six cases was additional funding followed by a rise in admissions and a fall in list size in the subsequent six months (figure). In 11 cases extra funding was followed by a decline in list size but no equivalent increase in admissions (figure). In 27 cases list size either did not change or increased in the six months after extra funds had been allocated (figure). Waiting list initiatives were not consistently followed by a decline in the numbers of patients waiting one to two years, or over two years. Many of the district specialties with substantial reductions in waiting times had received no extra funds.

Discussion

A close correlation between changes in the number of patients entering and leaving waiting lists is not surprising as many of the same resources contribute to both outpatient and inpatient services. For example, waiting list initiatives that increase admissions are likely to increase the number of patients added to the same waiting list, particularly if they involve the appointment of additional surgeons. The net effect would be a reduction in waiting time but not necessarily a change in list size. The data confirm that periods when admission rates increased were also periods when the numbers of people waiting between one and two years fell. The regression analysis suggests that list size would have decreased as well except for the fact that additions to the list tended to increase at the same time.

When the number of patients waiting over two years fell, there was usually a decline in the number waiting one to two years. The policy to reduce very long waits has not, therefore, apparently been at the expense of others on the list, at least at this level of aggregation.

The national study showed that increasing admissions tended to improve waiting times but not list size. The local study showed that it was unusual for admissions to increase after an allocation of waiting list funds. Rather, allocations seemed to reduce list sizes without increasing admissions--possibly as a result of identifying patients on the list who did not require surgery for various reasons.10 The objective of validation of the list alone could not justify the expense of these initiatives.

Numbers of admissions from waiting list in previous quarter and size of waiting list by quarter (September 1987 to September 1991) in health district for three different specialties, showing timing of additional funding

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Waiting list initiatives were intended to act as catalysts to encourage other, more definitive, measures that would improve waiting times. The NHS Management Executive considered that the decline in the numbers of people waiting two years and over owed more to waiting lists having a higher priority for existing resources than to targeted additional funding.11 This study provides further evidence that earmarked funds have often failed to improve waiting lists by increasing the number of admissions.

Waiting list initiatives from central funds have now ceased in line with the government's policy of devolving funding decisions to local health authorities.12 Purchasing authorities are, however, being asked to achieve progressively more stringent waiting time targets for inpatients and new targets for outpatients.13 These authorities are inclined to use their reserve funds for waiting list initiatives towards the end of the financial year, to ensure that these targets are met. The allocation of substantial funds which may not be available in the next financial year is deeply unpopular with managers of hospital trusts, who cannot use these funds to make substantive appointments or to develop facilities. Funds released in the middle of winter are particularly difficult for trusts to use effectively because beds are fully occupied with emergency admissions.

Before purchasers divert further resources into waiting list initiatives they should consider, firstly, the evidence on the effectiveness of this approach14 15 and, secondly, the relative priority of the health need represented by waiting lists for elective surgery.16 17