Tradeoffs in Cost, Quality, and Access

The English NHS and Expanding Waitlists

A few weeks ago, I traveled to London for a few days. While exploring the city, I picked up the Evening Standard paper and found an interesting article titled “NHS waiting lists heading for eight million as private sector is called in.” You can read the full article by clicking on this sentence. I will summarize the article below:

England’s National Health Service (NHS) maintains a waitlist for patients seeking non-emergency medical care. That waiting list is growing and is expected to reach 8 million. Health minister Maria Caulfield has stated that the two year and 18 month waits have nearly been eliminated with administrators now focusing on eliminating 15 month waits. Caulfield’s goal to reduce waiting times comes as the result of building additional diagnostic centers operated by the private and public sector. While the British Government currently operates 114 centers, there are plans to open 160 centers by 2030.

Before I continue writing, I want to introduce the NHS and what waiting lists are. English residents have the opportunity to choose between public healthcare (including NHS) which is government-run and taxpayer-funded, or private healthcare which is paid through private insurance (although it is used by less than 8% of the population). (1)

The NHS is one of four National Health systems in the UK (the four are the English NHS, Northern Irish HSC, Scottish NHS, and Wales NHS). The NHS is controlled via the Department of Health and Social Care and is free for all English Residents. (2) Individuals living outside the “European Economic Area” (all European nations except for Switzerland and including Iceland, Liechtenstein, and Norway) may be charged for treatment. (3)

So in this context, what are NHS waitlists? NHS waitlists refer to lists of patients who are awaiting a specific healthcare service be it diagnostic, surgical, or preventative. (4) While waiting for care, patients may receive further tests to ensure they are receiving the care they need and that their condition is not deteriorating further. (5)

In this article, I hope to provide an overview of how the NHS and NHS waiting lists are structured as well as some of the pros and cons of the English NHS.

Let’s jump right in. The English NHS is funded through taxes on residents. (6) These taxes are equal to roughly 9% of each resident’s income. However, the budget for the 2022-23 year for the NHS was 180.2 billion pounds. (7) This budget includes staff costs, administration costs, primary care, and commissioning specialized procedures and technology. (8)

To access care, patients can use their NHS App, contact their general practitioner, visit a local walk-in or wellness center, or receive a referral from another healthcare provider. (9) Patients may also call NHS 111 to receive non-emergency health information. The process by which patients receive care is much more complex. To receive primary care or diagnostic services, patients must first visit their local general practitioner. (10) If the general practitioner believes their patient must receive specialist care, they may submit a referral; otherwise, the patient is subjected to various tests before receiving a medical diagnosis. (11) The patient will then receive treatment or additional referrals for their condition and plans will be made for follow-up care. Throughout this process, healthcare providers will regularly monitor the patient’s health to prevent deterioration.

So how do NHS waitlists actually work? I’ll start this section by describing how each patient is prioritized on national waitlists:

  • Severity: Patients with a severe medical condition are generally prioritized with an emphasis placed on how likely it is that the patient’s current condition will worsen absent treatment. (12)

  • Impact of condition: Individuals who are more debilitated from illness are generally prioritized.

  • Waitlist Time: Individuals who have been waiting for long periods of time to receive care are generally prioritized. (13)

  • Resources: Patients requiring surgical interventions or medical care that is readily available or that need resources that are abundant in hospital systems are generally prioritized.

It is important to note that emergency care is not included within the waitlist system; emergency procedures are treated as soon as possible but prioritized on severity alone. (14) If a patient’s condition worsens while on the NHS waitlist, they may receive an evaluation at an outpatient clinic which may result in waitlist prioritization. (15) Unfortunately, the waitlist has been increasing in recent years, resulting in treatment delays and inadequacies for chronically ill patients.

The NHS states that the maximum waiting list time is 18 weeks from the day of joining the list. However, in recent years, many patients have been waiting longer. In March 2023, waiting lists hit record numbers with over 800 thousand people waiting for trauma/orthopedic care. COVID-19 has increased waiting lists significantly. Since the COVID-19 pandemic was declared, elective care waitlists increased by 45% in a two year period and in September 2022, the waiting list totaled over 7.2 million individuals. (17, 18) This increase in wait times disproportionately affects underserved and marginalized individuals. (19)

What are British officials doing to solve this crisis? As stated in the article, diagnostic centers are being built and implemented to provide patients with scans and quick check-ups, increasing access to certain healthcare services. (20) Patients must be referred by other healthcare providers to access these centers but they provide quality medical care to patients outside of the hospital setting, effectively increasing the rate at which each patient on the waitlist receives care.

Let me break the waitlist down by specialty:

Since geriatric care is easier to come by in England, it takes approximately 17 weeks for 92% of patients on the waitlist to receive care. On the other hand, since neurosurgery and plastic surgery are highly sought after, it takes between 25-30 weeks for 92% of patients on the waitlist to receive care. Long waiting lists are especially concerning for cancer and mental health patients as there are over 300 thousand people waiting for cancer treatment and 1.5 million people waiting for mental health care in England. (22) The government hopes to tackle these issues by allocating 1 billion pounds for cancer care and 2.3 billion for mental health care. Furthermore, the NHS recovery plan is the government’s goal of reducing elective care wait-times of over 52 weeks by March 2025 by implementing diagnostic care centers (many of which will be run by private firms).

As I conclude this article, I hope to discuss the English NHS as compared to the American healthcare system.

How does the US system work? The US has one of the “highest healthcare expenditures per capita in the world”; this statistic includes medical procedures, prescription drugs, and insurance costs. (23) This is because healthcare coverage differs from person to person, with segments of the population covered by private insurance, Medicare, Medicaid, etc. (24) Additionally, US hospital systems are mostly privately owned with insurance firms controlling much of the industry. (25)

I plan to split the health systems comparison into three categories: cost, quality, and wait times.

  1. Cost: The NHS is funded via taxes. This results in care being “free” for all English residents. Because the US system includes many insurance programs, healthcare is not free and is paid for by the patient, government, and insurance firms. (26) Thus, the US system is more expensive.

  2. Quality: While English officials state that NHS and private healthcare provide individuals with the same quality care, long NHS waitlists result in somewhat poorer care for NHS individuals as compared to individuals enrolled in private insurance plans. On the other hand, while US healthcare systems provide patients with advanced technology and a myriad of specialty care options, it appears that the US healthcare system, because of its decentralized and largely inaccessible framework results in higher rates of preventable mortality. (27, 28)

  1. Access: While the US healthcare system offers short waitlists, NHS waitlists often exceed 18 weeks. However, roughly 16% of the American population or 50 million Americans who are uninsured struggle to access healthcare and are often shut out of the system entirely. (29)

Below is a graph comparing American and English citizens’ opinions of their healthcare programs. (30)

Clearly, English residents think more highly of the NHS when compared to Americans and the American system. While many English residents might wait longer than American residents to receive care, cost and access appear to be the major factors that influence perception as American healthcare costs more and insurance plans are more limited.

Ultimately, while the English NHS focuses on universal access and cost-effective high quality care, the American system is organized via collaborations between private firms and hospital systems resulting in inefficiencies for healthcare providers and patients. Looking ahead, we can only hope that American policymakers look to other nations when adapting and reforming health policy while keeping healthcare costs, access, and quality at the forefront of legislative efforts.