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Equity, waiting times, and NHS reforms: retrospective study

BMJ 2009; 339 doi: (Published 03 September 2009) Cite this as: BMJ 2009;339:b3264
  1. Zachary N Cooper, PhD candidate in public policy1,
  2. Alistair McGuire, professor of health economics1,
  3. S Jones, chief statistician2,
  4. J Le Grand, Richard Titmuss professor of social policy3
  1. 1Cowdray House, London School of Economics, London WC2A 2AE
  2. 2Dr Foster Intelligence, London EC1A 9LA
  3. 3Department of Social Policy, London School of Economics
  1. Correspondence to: Z Cooper z.cooper{at}
  • Accepted 11 March 2009


Objective To determine whether observable changes in waiting times occurred for certain key elective procedures between 1997 and 2007 in the English National Health Service and to analyse the distribution of those changes between socioeconomic groups as an indicator of equity.

Design Retrospective study of population-wide, patient level data using ordinary least squares regression to investigate the statistical relation between waiting times and patients’ socioeconomic status.

Setting English NHS from 1997 to 2007.

Participants 427 277 patients who had elective knee replacement, 406 253 who had elective hip replacement, and 2 568 318 who had elective cataract repair.

Main outcome measures Days waited from referral for surgery to surgery itself; socioeconomic status based on Carstairs index of deprivation.

Results Mean and median waiting times rose initially and then fell steadily over time. By 2007 variation in waiting times across the population tended to be lower. In 1997 waiting times and deprivation tended to be positively related. By 2007 the relation between deprivation and waiting time was less pronounced, and, in some cases, patients from the most deprived fifth were waiting less time than patients from the most advantaged fifth.

Conclusions Between 1997 and 2007 waiting times for patients having elective hip replacement, knee replacement, and cataract repair in England went down and the variation in waiting times for those procedures across socioeconomic groups was reduced. Many people feared that the government’s NHS reforms would lead to inequity, but inequity with respect to waiting times did not increase; if anything, it decreased. Although proving that the later stages of those reforms, which included patient choice, provider competition, and expanded capacity, was a catalyst for improvements in equity is impossible, the data show that these reforms, at a minimum, did not harm equity.


  • We thank the Dr Foster Unit at Imperial College London for processing the data. We also thank Gordon Hart for his contribution to constructing the original dataset and comments on earlier drafts of this manuscript.

  • Contributions: ZNC had the original idea for the study. SJ obtained and cleaned the data. ZNC wrote the first draft of the paper and wrote subsequent drafts after feedback from the other three authors. All four authors contributed to the study design and the interpretation of the results and gave final approval. ZNC, AMcG, and JLG are the guarantors.

  • Funding: This research was funded through an LSE doctoral studentship and a Morris Finer PhD fellowship.

  • Competing interests: JLG worked part time in the Policy Directorate at No 10 Downing Street from October 2003 to June 2004 and full time from June 2004 until August 2005. He was seconded from his position at the London School of Economics and continued to receive the same salary and pension contributions as at the LSE. His roles at No 10 included assessing inequities in use of services within the NHS and discussing the possible impact on equity of the government’s reforms on choice. He also advised on the rolling-out of the government’ reform policies; the policies themselves pre-dated his appointment. The work consisted of advising the prime minister and other members of the government on health service issues, assembling research evidence as required, discussions with stakeholders, helping with the intellectual content of speeches, and working with civil servants on implementing the reforms.

  • Ethical approval: Not needed.

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