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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

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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

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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

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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