title: Do English NHS waiting time targets distort treatment priorities in orthopaedic surgery?
abstract: OBJECTIVE
  To assess and quantify the impact of guarantees on maximum waiting times on clinical decisions to admit patients from waiting lists for orthopaedic surgery.
  
  
  METHODS
  Before and after comparative study, analysing changes in waiting times distributions between 1997/8 and 2001/2 for waiting list and booked inpatients and day cases admitted for elective treatments in trauma and orthopaedics in English hospitals.
  
  
  RESULTS
  The 2001/2 maximum waiting time target of 15 months did change the pattern of admissions for trauma and orthopaedic elective inpatients, with a net increase in admissions in that year, compared with 1997/8 (and over and above the 30,259 (7.6%) overall increase in all admissions) of patients who had waited around 15 months, of 9333. There was little indication that these additional admissions displaced shorter wait patients. In absolute and proportional terms, admissions increased for all waiting time categories except very short waiter-- one to two weeks (an absolute fall of 2901 and a relative fall of 6591), and those waiting 40--41 weeks. The latter fall was only 111 patients in absolute terms (or 577 relative to the expected increase), however. The former much larger reduction may be an indication of clinical distortions, but it is unclear why very short wait (presumably more urgent) patients should disproportionately suffer compared with longer wait (presumably less urgent) cases. In addition, there was little indication that more minor cases usurped more major cases: 57% of the increase consisted of knee and hip replacement procedures, for example.
  
  
  CONCLUSIONS
  While the 2001/2 waiting times target demonstrably changed admission patterns (and was a major contribution to the reduction in long waits), the extent to which this represented significant and clinically relevant distortions is questionable given the lack of widely accepted admission criteria. However, as targets become progressively tougher, there is a need to monitor consultants' concerns more closely.
authors.affiliation: King's Fund, LSE health and Social Care, London School of Economics, London, UK. j.appleby@kingsfund.org.uk
authors.forename: John
authors.initials: J
authors.lastname: Appleby
authors.forename: Seán
authors.initials: S
authors.lastname: Boyle
authors.forename: Nancy
authors.initials: N
authors.lastname: Devlin
authors.forename: Mike
authors.initials: M
authors.lastname: Harley
authors.forename: Anthony
authors.initials: A
authors.lastname: Harrison
authors.forename: Ruth
authors.initials: R
authors.lastname: Thorlby
mesh_terms: D004739:England; D006801:Humans; D009937:Organizational Objectives; D009985:Orthopedics / Q000458:organization & administration*; D013222:State Medicine / Q000458:organization & administration; D014850:Waiting Lists