Intended for healthcare professionals


NHS waiting lists and evidence of national or local failure: analysis of health service data

BMJ 2003; 326 doi: (Published 25 January 2003) Cite this as: BMJ 2003;326:188
  1. Richard M Martin, lecturer in epidemiology and public health medicine,
  2. Jonathan A C Sterne, reader in medical statistics and epidemiology,
  3. David Gunnell, senior lecturer in epidemiology and public health medicine,
  4. Shah Ebrahim, professor of epidemiology of ageing,
  5. George Davey Smith, professor of clinical epidemiology,
  6. Stephen Frankel (stephen.frankel{at}, professor of epidemiology and public health
  1. Department of Social Medicine, University of Bristol, Bristol BS8 2PR
  1. Correspondence to: S Frankel
  • Accepted 21 October 2002


Objectives: To investigate the national distribution of prolonged waiting for elective day case and inpatient surgery, and to examine associations of prolonged waiting with markers of NHS capacity, activity in the independent sector, and need.

Setting: NHS hospital trusts in England.

Population: People waiting for elective treatment in the specialties of general surgery; ear, nose and throat surgery; ophthalmic surgery; and trauma and orthopaedic surgery.

Main outcome measure: Numbers of people waiting six months or longer (prolonged waiting). Characteristics of trusts with large numbers waiting six months or longer were examined by using logistic regression.

Results: The distribution of numbers of people waiting for day case or elective surgery in all the specialties examined was highly positively skewed. Between 52% and 83% of patients waiting longer than six months in the specialties studied were found in one quarter of trusts, which in turn contributed 23-45% of the national throughput specific to the specialty. In general, there was little evidence to show that capacity (measured by numbers of operating theatres, dedicated day case theatres, available beds, and bed occupancy rate) or independent sector activity were associated with prolonged waiting, although exceptions were noted for individual specialties. There was consistent evidence showing an increase in prolonged waiting, with increased numbers of anaesthetists across all specialties and with increased bed occupancy rates for ear, nose and throat surgery. Markers of greater need for health care, such as deprivation score and rate of limiting long term illness, were inversely associated with prolonged waiting.

Conclusion: In most instances, substantial numbers of patients waiting unacceptably long periods for elective surgery were limited to a small number of hospitals. Little and inconsistent support was found for associations of prolonged waiting with markers of capacity, independent sector activity, or need in the surgical specialties examined.

What is already known about this topic

What is already known about this topic Many patients wait unacceptably long times for NHS surgery

The size of waiting lists is of little relevance to understanding access to treatment

Evidence is scant for the common assumption that the waiting problem arises from a global mismatch between supply and demand and can be solved either by greater rationing or by increasing NHS capacity

What this study adds

What this study adds Long waiting lists are not an indication of a general failure of the NHS

One quarter of hospital trusts contribute between half and four fifths of the patients waiting six months or longer

Measures of capacity (such as beds, operating theatres, doctors) and independent sector activity are not generally associated with prolonged waiting


  • Funding SF was supported by the Leverhulme Trust during the study period.

  • Competing interests None declared.

  • Embedded Image An extra table appears on

  • Accepted 21 October 2002
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