The effect of hospital choice and competition on inequalities in waiting times

We use a quasi difference-in-difference approach to examine whether the 2006 relaxation of constraints on patient choice of hospital in the English National Health Service (NHS) affected waiting times inequalities for three common elective treatments (coronary bypass, hip replacement and knee replacement) in hospitals which faced more potential competition (number of rivals) before the choice reform was introduced relative to those which faced less competition. After the 2006 choice reform hospitals which had more rivals before 2006 had longer waits for hip and knee replacement, with one additional rival increasing the median waiting time by 2.5% and 4.0%, and the 75th quantile waiting time by 4.2% and 7.1%. There was no effect on waiting times for coronary bypass patients up to the 75th quantile of the wait distribution. The choice reform and market structure had no effect on the standard deviation of waiting times within hospitals but did increase waiting time variation within small geographical areas. Older hip replacement patients had shorter waits pre-choice reform but the gradient disappeared after it and was not affected by market structure. Before the choice reform, more deprived patients had longer waits but post-reform there was no deprivation gradient in waiting times, and the reduction in the gradient was not affected by pre-reform market structure. Overall, the results suggest that the choice reform led to longer and more dispersed waiting times in more competitive areas but deprivation related inequity was smaller in the post-choice period.