Feature Data briefing

What’s happening to waiting times?

BMJ 2011; 342 doi: http://dx.doi.org/10.1136/bmj.d1235 (Published 01 March 2011) Cite this as: BMJ 2011;342:d1235
  1. John Appleby, chief economist
  1. 1King’s Fund, London W1G 0AN, UK
  1. j.appleby{at}kingsfund.org.uk

The English National Health Service was once notorious for its excessive waiting times. But is it now winning the “war on waiting”, asks John Appleby?

If there was one thing that characterised England’s National Health Service for many people, it was the inordinate time patients waited to get treatment. At its inception in 1948 the NHS inherited a waiting list of nearly half a million. For decades after, it was all downhill—or rather uphill; numbers on lists rose and time spent queuing grew longer. It seemed that waiting was an inevitable rationing response of a system lacking the market’s equilibrating price mechanism. Inevitable, that is, until the alignment of public opinion, money, and political determination at the turn of the century produced a plan of action to deal with excessive waiting.

The plan was more Baldrick than Blackadder in its cunning—more money, successively tougher targets (not known as “P45 targets” by managers for nothing), and practical help for the frontline in techniques to manage queues efficiently. The outcome is perhaps one of the most significant achievements for the NHS in recent years.

It can be hard to remember the scale of the waiting times problem and the almost daily media headlines. In December 1999, nearly 160 000 patients were still waiting over six months to have their first outpatient appointment and over 50 000 were still waiting over a year to get a bed in hospital.1 Despite the focus of the target regime, it is not just very long waits that have been virtually eliminated. The median waiting time—the time spent waiting by half of those on waiting lists—has also fallen, from around 18 weeks in 2007 to just one month now for inpatients admitted to hospital.1

Another consequence of the single-minded focus on waiting was to establish better measures of waiting—measures closer to patients’ actual experience of waiting, such as the time from referral by general practitioners to treatment in hospital. The scope of the “war on waiting” also widened to include primary care, specific diseases such as cancer, and other hospital services such as accident and emergency.

Regardless of the effect reductions in waiting times have had on patients’ health (possibly rather negligible), waiting is certainly seen by patients as a negative attribute of healthcare; reductions in waiting are valued2 and are likely to have contributed to rising satisfaction with the NHS over the past decade.3

All this makes the suspension of “central performance management” 4 of the iconic 18 week referral to treatment target (and a relaxation of the 4 hour maximum accident and emergency waiting target) an interesting experiment in the power of alternative policy levers to bear down on waiting times: notably, patient choice and the degree to which GP commissioning will reflect patients’ values and their rights under the NHS Constitution. 5

Tracking waiting times since June last year6 gives a mixed picture, somewhat muddied by seasonal effects in changes in waiting times. Latest figures for December 2010 show median waits and the proportion who waited over 18 weeks down on the previous month for those admitted as inpatients.7 But then, that would be expected for December. On the other hand, for patients still waiting (that is, not yet seen in outpatients or admitted as an inpatient) the proportion waiting over 18 weeks increased in December by more than the seasonal effect would predict. Meanwhile, median waits for diagnostic services are now back to the level seen in December 2007, although this largely reflects a seasonal trend.8

The coming months—and particularly the new financial year, when budgets get squeezed—will start to reveal some more consistent trends.

Fig 1 Median waiting times in the NHS. Adapted from Department of Health7

Fig 2 Seasonal trends? Month on month change in median waiting times for patients attenting outpatients. Adapted from Department of Health7

Fig 3 Proportion of patients not yet seen (as outpatients or admitted as inpatients) waiting >18 weeks. Adapted from Department of Health7


Cite this as: BMJ 2011;342:d1235


  • Competing interests: The author has completed the unified competing interest form at www.icmje.org/coi_disclosure.pdf (available on request from him) and declares: no support from any organisation for the submitted work; no financial relationships with any organisation that might have an interest in the submitted work in the previous three years; and no other relationships or activities that could appear to have influenced the submitted work.

  • Provenance and peer review: Commissioned; not externally peer reviewed.