Search tips
Search criteria 


Logo of jrsocmedLink to Publisher's site
J R Soc Med. 2002 June; 95(6): 280–283.
PMCID: PMC1279908

Waiting in the NHS, Part 2: a change of prescription

Sarah Derrett, DipCpN PhD, Nancy Devlin, PhD,1 and Anthony Harrison, MA1

Part 1 (Waiting in the NHS: a diagnosis) highlighted the deficiencies of waiting-time targets as the principal means of managing lists and concluded that a more comprehensive approach is required1. Waiting-time targets introduce perverse incentives and are isolated from issues of health sector efficiency and opportunity cost. Furthermore, priority on waiting lists is determined not explicitly but implicitly, by clinical judgments. These vary between doctors and between regions and do not relate strongly to patient-experienced health status1. Consequently, we have a poor understanding of the health status of patients on waiting lists, and variation in general practitioner (GP) referral practices leads to differences in apparent need. Simple target-setting is therefore also divorced from NHS equity goals. In this paper we suggest a way forward. We describe moves towards explicit prioritization of patients in other countries, particularly New Zealand. These experiences suggest new directions for the NHS—and pitfalls to avoid.

Box 1 summarizes the benefits and drawbacks of explicit prioritization in principle. The NHS is not pursuing improved waiting-list management in isolation2,3: explicit criteria for prioritizing access to surgery have been or are being implemented to varying degrees in several countries, including the UK4,5,6,7,8,9. However, to date, there has been little opportunity to evaluate the successes and failures of these systems in practice10. Experience in New Zealand provides an opportunity to explore the outcomes of explicit prioritization.


New Zealand introduced a nation-wide system for explicitly prioritizing and booking patients for elective surgery. Most of the clinical priority assessment criteria (CPAC) include a range of dimensions (clinical health status, patient-experienced health status and social), scored according to severity and added to provide a total score ranging from 0 (lowest priority) to 100. Financial threshold scores indicate the points required by patients to receive treatment funded from existing budgets. The system as it was conceived16, and as it has changed17,18, is described elsewhere. Box 2 presents an example of patients' journeys through the New Zealand ‘booking system’ as it was implemented in 1996.

Box 1: Explicit prioritization: pros and cons


  • Allows health services to be planned in relation to measured patient and population need
  • May reduce unnecessary and inappropriate demand
  • Allows better targeting of patients with the greatest likelihood of beneficial outcomes, thus ensuring maximum improvement in health from limited budgets
  • Can lead to better-informed patients and public and increased participation
  • Equity issues can be identified and addressed
  • Has potential for honest relationships between health professionals and patients: patients are told the truth about access to treatment, and are involved in decision-making
  • Reduces undesirable and variable decision-making
  • Reduces ‘gaming’: where doctors place inappropriately high implicit priority on ‘their’ patients to gain access ahead of other patients or where complaining patients receive preferential access


  • Explicit criteria may threaten doctor-patient relationship
  • Explicit criteria may ignore patients' preferences for and about treatment
  • Explicit criteria may have negative impact in forcing doctors to tell patients they will not receive treatment and in forcing patients to hear this decision
  • Explicit criteria are rational and ‘technocratic’ and may not be responsive to other important factors such as coexisting disease
  • Explicit prioritization may be subject to political manipulation
  • Explicit prioritization may lead to gaming by patients or doctors
  • Explicit prioritization may increase transaction costs to the health service.


Some of the difficulties encountered by the New Zealand system were contextual; it was introduced at a time when health funding was declining19. The existing internal market contributed to the establishment of different financial thresholds, different financial arrangements and the use of different CPAC tools for the same surgical condition17. In appraising the system it is helpful to look separately at the prioritization component and the booking component.

Many of the difficulties were attributable to the CPAC. These were inadequately evaluated before introduction, being assessed only for agreement with clinical judgment16. When CPAC were evaluated they were found to have poor reliability and validity20,21,22, and not to relate strongly to patient-experienced health status23,24 or serious health outcomes, including mortality25,26. Some patients reported that the process of CPAC ‘scoring’ detrimentally affected their relationship with clinicians; the method complicated the path to reassessment and was unresponsive to their preferences regarding treatment23. This drawback was even more obvious when health professionals other than surgeons completed the CPAC. Scoring also seemed to interfere with discussions that ought to occur between surgeons and patients about anticipated risks and benefits of surgery—again particularly when the scoring was undertaken by someone other than the surgeon.

Some clinicians reacted negatively22, and suspected that the motivation for explicitness was not to improve patient prioritization but simply to manage the allocation of scarce resources through financial thresholds27,28. Explicit prioritization highlighted tensions between processes determining access for groups, and traditional doctor—patient relationships emphasizing standards of care for individuals29, leading to concerns that patients and doctors would ‘game’ the system. In practice, a regional study found that few patients received surgery beneath the financial thresholds for surgery—i.e. there was little gaming by patients23. One clinician openly expressed willingness to exaggerate the severity of patients' conditions if he judged that this would ensure surgery for those who needed it; but many clinicians rejected this approach as unfair to other patients.

Box 2: New Zealand's ‘points system’

In New Zealand, patients' journeys through the booking system began on referral to specialist clinics at a public hospital. Letters of referral were evaluated by hospital staff using explicit access criteria for first assessment (ACA), and patients were prioritized for outpatient appointments according to their ACA. At outpatient clinics, if specialists determined that patients were likely to benefit from surgery, patients were prioritized for surgery according to clinical assessment criteria (CPAC).

Financial thresholds (CPAC scores at or above which surgery was to be provided) were calculated for each CPAC tool from historical rates of referral, case complexity and funding provided. People with CPAC scores at or above the financial threshold were to be booked for surgery within six months of their outpatient assessment. Those scoring below the financial threshold were to be referred back to their original healthcare provider for ongoing care and treatment. If their conditions worsened they were to be re-referred, reassessed and rescored by CPAC.

Positive outcomes

New Zealand's system also generated important positive outcomes, many of them associated with the booking of patients for surgery. Patients who scored above the financial threshold, and were guaranteed surgery, seemed much more satisfied than patients on waiting lists under the implicit system23. This tended to be so even when patients were not provided with set dates for surgery far in advance: the certainty of treatment within the next six months (or longer) was the crucial factor.

Many patients expressed support for mechanisms allowing faster access to surgery for those with severe conditions, sometimes even when they personally had been denied access. However, this may change if inadequate funding denies access to many patients with clear needs—or if patients become less altruistic23.

The CPAC, despite their flaws, also provided positive outcomes. More is known about regional inequities and differences in the financing of elective surgery than was known under the previous implicit system30. The system revealed that some patients were not gaining access to surgery simply because financial thresholds were higher in some parts of the country than in others. This observation prompted a debate on equity issues in funding for elective surgery.

Importantly, each of the CPAC included some measures of patient-experienced health status. This contrasts with implicit prioritization, where clinicians vary in the consideration they give to such matters. Further, use of explicit tools permitted evaluation of the health status and outcomes of patients in relation to the criteria. Although research has revealed questionable relationships between CPAC tools and patient health status or outcomes23,24, the strengths and weaknesses of the new system are more clearly identifiable than those of implicit prioritization, in which the three priorities (A, B or C) are assigned without explanation1.


Do the difficulties experienced in New Zealand and elsewhere mean the NHS should steer clear of explicit approaches to waiting-list management? Many of those described above are largely avoidable. By contrast, there is no obvious solution to the problems of waiting-time targets if the NHS continues to rely on implicit prioritization1. The benefits apparent in New Zealand argue for a change of approach to waiting in the NHS, though the way forward must be plotted with great care. The NHS should not simply adopt prioritization criteria from other countries, particularly when these have shown scant relation to patient-experienced health status—the core issue for much elective surgery23,24.

The first step should be agreement on the purpose of waiting-list policy. Is it to reduce the numbers of people waiting for surgery? To reduce the average time spent waiting for surgery? To improve the health status of patients waiting for treatment? Or is it to ensure that those with equal need gain equal access to treatment irrespective of where they live—and that those in greatest need gain quickest access?

Waiting times and numbers targets do not address the latter aim and, as we pointed out in part 1, distort clinical priorities. Explicit ordering of people on waiting lists is necessary both to ensure equal treatment for equal need and to ensure that the NHS budgets yield the greatest possible improvements in health.

Priority criteria could initially be used in conjunction with waiting-time targets, to overcome perverse effects on priorities. Longer-term appropriate thresholds could be determined. Thresholds, together with other current strategies31,32,33,34, could facilitate sophisticated ‘whole systems’ management of waiting lists and resource allocation.

Great caution is needed in development of explicit criteria. No good tools exist to enable prioritization across a wide range of conditions or types of surgery24; and even if such instruments were available, they might not be acceptable to health workers or the public12,13. However, there are patient-experienced health status measures that relate to likely benefit from specific treatments, and these can help inform the ordering of patients. Where such instruments do not exist, clinicians and researchers should work with patients to develop and refine such tools. Explicit health status criteria ought not entirely to usurp clinical judgment: no patient should be prioritized for surgery when the clinician doubts the likely benefit. Clinicians must be actively engaged in the use, development and continuing improvement of explicit criteria35.

Concerns about gaming must be considered when more explicit approaches are contemplated12. However, gaming is not confined to explicit prioritization. Indeed, one of the reasons for implementing explicit systems is to address gaming within implicit systems. Probably a minority of patients and doctors will always exaggerate to obtain benefits at the expense of other patients. Explicit approaches provide opportunities to address this behaviour through clinical governance and through between-hospital and between-region comparisons. Prioritization criteria also offer information to planners and policy-makers about the actual situation for patients on waiting lists, and facilitate debate about the allocation of resources to groups of patients in greatest need—in accordance with the NHS aims of maximizing health gain and minimizing health inequalities.


Rather than building on the gains emerging from the explicit system, New Zealand has in some clinical areas returned to implicit prioritization based solely on clinical judgment18,36. This move is said to have been supported by clinicians. The motivation for the retreat from explicitness has not been clearly stated, but seemingly the reversion was not driven by a perception that the political costs exceeded the benefits3. The British NHS can learn from New Zealand's successes and mistakes and develop better approaches. There have long been calls for improved incorporation of patient-experienced health status: the time is now ripe for such a change—with prospective evaluation of the process and of the outcomes for patients and clinicians.


We thank Paul Zollinger-Read (Director of Demand Management, Modernisation Agency), Ruth Kipping (Primary Care Development Manager, Demand Management Team, Modernisation Agency) and Charlotte Paul (Department of Preventive and Social Medicine at the University of Otago) for helpful comments.


1. Devlin N, Harrison T, Derrett S. Waiting in the NHS, Part 1: a diagnosis. J R Soc Med 2002;95: 223-6 [PMC free article] [PubMed]
2. Holm S. Goodbye to the simple solutions: the second phase of priority setting in health care. BMJ 1998;317: 1000-2 [PubMed]
3. Ham C, Coulter A. Explicit and implicit rationing: taking responsibility and avoiding blame for health care choices. J Health Serv Res Policy 2001;6: 163-9 [PubMed]
4. Western Canada Waiting List Project. From Chaos to Order: Making Sense of Waiting Lists in Canada. Edmonton: University of Alberta, 2001
5. Hanning M, Spångberg UW. Maximum waiting time—a threat to clinical freedom? Implementation of a policy to reduce waiting times. Health Policy 2000;52: 15-32 [PubMed]
6. Naylor CD, Levinton CM, Wheeler S, Hunter L. Queuing for coronary surgery during severe supply—demand mismatch in a Canadian referral centre: a case study of implicit rationing. Soc Sci Med 1993;37: 61-7 [PubMed]
7. Lack A, Edwards RT, Boland A. Weights for weights: lessons from Salisbury. J Health Serv Res Policy 2000;5: 83-8 [PubMed]
8. Harry LE, Nolan JF, Elender F, Lewis JC. Who gets priority? Waiting list assessment using a scoring system. Ann R Coll Surg Eng 2000;82(suppl.): 186-8 [PubMed]
9. Adams P. Points make prizes. Health Serv J 1999; November 25: 30-1 [PubMed]
10. Hadorn D. Setting health care priorities in Oregon. Cost effectiveness meets the rule of rescue. JAMA 1991;265: 2218-25 [PubMed]
11. Doyal L. Rationing within the NHS should be explicit: the case for. BMJ 1997;314: 1114-18 [PMC free article] [PubMed]
12. Edwards RT. Points for pain: waiting list priority scoring systems. BMJ 1999;318: 412-14 [PMC free article] [PubMed]
13. Mechanic D. Muddling through elegantly: finding the proper balance in rationing. Health Affairs 1997;16: 83-92 [PubMed]
14. Coast J. Rationing within the NHS should be explicit: the case against. BMJ 1997;314: 1118-22 [PMC free article] [PubMed]
15. Hunter DJ. Rationing health care: the political perspective. Br Med Bull 1995;51: 876-84 [PubMed]
16. Hadorn DC, Holmes AC. The New Zealand priority criteria project. Part 1: overview. BMJ 1997;314: 131-4 [PMC free article] [PubMed]
17. Gauld R, Derrett S. Solving the surgical waiting list problem? New Zealand's ‘booking system’. Int J Health Plann Mgmt 2000;15: 259-72 [PubMed]
18. Derrett S. Surgical prioritisation and rationing: some recent changes. NZ Bioethics J 2001;2(3): 3-6 [PubMed]
19. Ministry of Health. Waiting Times Fund Review: Implementation Review. Wellington: MoH, 1999
20. Halliwell T. How fair is cataract prioritisation? NZ Med J 1998;111: 405-7 [PubMed]
21. Dennett ER, Kipping RR, Parry BR, Windsor J. Priority access criteria for elective cholecystectomy: a comparison of three scoring methods. NZ Med J 1998;111: 231-3 [PubMed]
22. Dennett ER, Parry BR. Generic surgical priority criteria scoring system: the clinical reality. NZ Med J 1998;111: 163-6 [PubMed]
23. Derrett S, Paul C, Herbison P, Williams H. Evaluation of explicit prioritisation for surgery: longitudinal study. J Health Serv Res Policy 2002;7(suppl) (in press) [PubMed]
24. Derrett S, Devlin N, Hansen P, Herbison P. Prioritising patients for elective surgery: a prospective study of New Zealand's clinical priority assessment criteria (CPAC). Int J Technol Assessment Health Care (in press) [PubMed]
25. Seddon ME, French JK, Amos DJ, Ramamathan K, McLaughlin SC, White HD. Waiting times and prioritisation for coronary artery bypass surgery in New Zealand. Heart 1999;81: 586-92 [PMC free article] [PubMed]
26. Jackson NW, Doogue MP, Elliott JM. Priority points and cardiac events while waiting for coronary artery bypass surgery. Heart 1999;81: 367-73 [PMC free article] [PubMed]
27. Adams J. The national booking list—sliced bread or shuffled deck chairs? NZ Med Assoc Newsl 1998; 26 June: 1-2
28. Bagshaw P. Ration book surgery. NZ Health Rev 1998;1(2): 10-12
29. Wiles A. The booking system—can it be redeemed? NZ Med Assoc Newsl 1998;202: 1-2
30. Ministry of Health. Elective Services Booking Systems Quarterly Reports. Wellington: MoH
31. NHS Modernisation Agency. The Little Wizard. London: Department of Health, 2002
32. Pencheon D. Matching demand and supply fairly and efficiently. BMJ 1998;316: 1665-7 [PMC free article] [PubMed]
33. Murray M. Patient care: access. BMJ 2000;320: 1594-6 [PMC free article] [PubMed]
34. Kipping R, Robert G, McLeod H, Clark J. A Review of Priority Scoring and Slot Systems for Elective Surgery. Birmingham: Health Services Management Centre, University of Birmingham, 2002
35. British Medical Association. Waiting List Prioritisation Scoring Systems. Discussion Paper No. 6. London: BMA, 1998
36. Ministry of Health [ ] (accessed 17 April 2002)

Articles from Journal of the Royal Society of Medicine are provided here courtesy of Royal Society of Medicine Press