As part of a team of 4, I co-authored a policy brief designed to tackle increased inpatient waiting times within the NHS in the UK. Three policy alternatives were proposed, including a feasibility analysis. The brief was pitched in the winter of 2021 to Dr. Dirk Ruwaard, Professor of Public Health and Health Care Innovation.

1. Group 2 Team 4:
Vedika Bajoria (i6285885)
Jean-Pierre Boijmans (i486884)
Katharina Braeger (i6298759)
Maxime Snippe (i6193087)
HPI4009 - Policy Analysis - Maastricht University
Increased hospital
waiting times lead to a
reduction in quality of
care in the UK

2. The problem
Worsening inpatient care quality due to 5,7 Mio patients waiting
2%
8%
14%
6%
4%
12%
10%
0%
2017 2020
2007
1997
2008-2009
economic downturn
Covid 19
pandemic
Health expenditure in the UK as % of GDP has
passed the 10% mark in 2019 [1;2]. This problem
analysis focuses on supply factors as they
ultimately reflect the changes in demand
(e.g. a population aging)
1 2 3
47%
24%
9%
7%
12%
Other providers
Retailers and other
providers of medical
goods
Ambulatory providers
Residential long-term
care facilities
Hospital providers
0
6
1
4
3
2
5
09 13
08 14 20
16 17
10 18
Aug
-07
19
11 12 15 Sep
-21
However, the number of patients waiting above target
times for hospital admission is increasing. In 09/21, 82%* of
patients referred to treatment (RTT) were waiting [4;5;6],
leading to cases with lower quality of care [7]
Waiting times has been a target of NHS improvement plans since the 2000’s. Despite increased attention,
they are still increasing and deteriorate inpatient care quality. Among others, diabetes and hip replacement
patients are impacted. In January 2021, an average of 58,000 patients waited 25 additional weeks for a hip
replacement, the equivalent of 29,000 QALYs across the English population.
Of this 10%+ health expenditure
about 47% is spent on hospitals
[3], a high share in an increasing
budget
Number
of
people
waiting
(million)
* This does not include patients in treatment, it only counts RTT patients. For 09/21, admitted (unadjusted) RTT patients account for 3,5%, non-admitted RTT patients for 14,6% and
incomplete RTT patients for 81,9% (i.e. the latter refers to patients waiting for treatment). See [19] for the full definition.

3. The root-causes and the problem owners
1) Staff vacancies, 2) underfunding & 3) inefficiencies
Hospitals report ⇡ budget deficits not only due to
underfunding (point 2) but also due to in-
efficiencies. It is due to lack of integration (over-
burdening of acute care) and use of ineffective care
(i.e. ⇡ end-stage diseases expenditures) [13,14].
1
182
94
89
85
73
69
69
67
61
60
Barts Health
Pennine Acute
Barking, Havering and Redbridge
Worcestershire Acute
King’s College hospital
Budget deficit 2018/2019 (in £ m)
Mid Essex
Morecambe Bay
Cambridge University
Royal Free
United Lincolnshire
2 3
100,000 staff vacancies throughout the NHS
-> hiring of agency staff or use of bank
staff*. The total number has been increasing
in recent years [8;9], representing 5% of
total NHS expenditures [9,10]
Government underfunds the NHS through the
national tariff fees to force providers to cut
costs. BUT the annual growth rate was ⇣ than
the inflation rate and actual provider unit
cash costs (i.e. operating expenses) [11,12].
The patients are ultimately paying for these problems & are also a problem owner in all problems. The problem
owner of root-causes 1 and 2 is the government, who will need to collaborate intensively with another problem
owner, the providers, to define solutions to reduce waiting times. The problem owner for root-cause 3 is the
government in the case of integration but the Clinical Commissioners & the NICE in the case of ineffective care.
*
* Bank staff works for an NHS staff bank which is an entity managed by a trust, or through a third-party organisation who contract healthcare professionals to take on temporary
shifts at trust hospitals. Agency staff fulfil a similar role, costs more, are not a part of the NHS but can fulfil positions difficult to contract through a NHS staff bank.
2.4 2.4 2.4
3.0
3.5 3.8
5,4
Agency staff
expenditure
(in £ bio)
Bank staff
expenditure
(in £ bio )
6,2
2017-18
5,9
2018-19 2019-20
0.90
0.92
0.94
0.96
0.98
1.00
2018-19
2015-16
2014-15
2013-14
2012-13
2010-11 2019-20
2009-10 2011-12 2017-18
2016-17
Index: 2009-10 = 1
Tariff unit cash prices
Provider unit cash costs
(i.e. operating expenses; actual and anticipated from 2015-16)
!

4. NHS RECRUITMENT CAMPAIGNS [15] £5.9 BILLION FUNDING [17]
Past policy efforts
Past efforts did not reduce the waiting times
NHS PLAN [10]
Staff vacancies, underfunding &
inefficiencies: general measures undertaken
were the investment in facilities & staff
recruitment, establishment of helpline
→ Only temporary achievements & increased
healthcare spending
Staff vacancies: Recruitment through
advertising → Small increase does not
meet rising demand
NHS LONG-TERM PLAN [16]
Staff vacancies: Training, education & continuous professional development (NHS
People Plan 2019 & 2020/21)→ Promising, depends on future decisions, no urgent actions
Underfunding: Funding increases annually by 3.4 % on average real-terms → Still less
than needed for rising demands
Inefficiencies: Digitalization, integrated care systems, prevention & health equalities →
Comprehensive & reasonable, implementation success questionable
Underfunding & inefficiencies: “one-stop-
shops”, investments in elective surgery,
technology & data → One-time funding,
success depends on sufficient staff
Past policy efforts yield results, but have failed to reduce waiting times. The success of these measures
depends on an adequate workforce, which is increasingly problematic to obtain.

5. Government values and objectives
Plans, principles & rights on access to care
Related to access to care
& quality of care:
‘’The NHS provides a
comprehensive service,
available to all’’
‘’The NHS aspires to the
highest standards of
excellence and
professionalism’’
PRINCIPLES NHS [21]
Related to access to care:
‘’Provide convenient, easy access
to services within the waiting
times set out in the Handbook to
the NHS Constitution’’
Related to quality of care:
“Identify and share best practice
in quality of care and
treatments’’
PLEDGES NHS [21]
Related to access to care:
Patients have the right to:
‘’start their consultant-led
treatment within a maximum
of 18 weeks from referral for
non-urgent conditions’’
PATIENT RIGHTS [22]
(Liberal) Conservatism [18]:
Since WWI, the Conservative Party &
the Labour Party have dominated
British political life. [6]
Johnson is the Prime Minister of the
UK & leader of the Conservative Party
since 2019. [6]
2019 plan on access to services [20]:
‘’Allocate additional funding for NHS,
which will go to frontline services 'to
reduce waiting times'.’’
IDEOLOGY GOVERNMENT
The government ambitions to allocate funding to maintain a high quality of care, including reasonable
waiting times. The ruling government ideology has not changed in the past 20 years. These values are
fundamental elements in analysing potential policy alternatives.

6. Feasibility (⇡easy) Feasibility (⇡easy)
Description of policy alternatives
Policy alternatives to tackle the problem
POLICY ALTERNATIVE 2:
COST-EFFECTIVENESS OF CARE
POLICY ALTERNATIVE 3:
PREVENTION AND SELF-MANAGEMENT
POLICY ALTERNATIVE 1:
IMPROVING WORKING CONDITIONS &
BENEFITS FOR THE STAFF IN NHS
1. Understaffing
2. Underfunding
3. Inefficiencies
Impact
on:
1. Understaffing
2. Underfunding
3. Inefficiencies
Impact
on:
1. Understaffing
2. Underfunding
3. Inefficiencies
Impact
on:
Focus on the supply side
1. Constant funding for NHS workforce expansion
2. Follow staff recruitment strategy from NHS
long-term plan [16] & focus on international
recruitment of nurses for urgent actions
3. Improving work-life balance for staff [22]
4. Improving working conditions & training offers
to support intellectual growth [23]
5. Implementing fair benefits & formalized
employment package [24,23]
→ Overall increase in staff levels by closing
employee gap, increased investment in staff &
efficiency by increasing workforce quality
Focus on demand side
1. Stronger focus on prevention & health
literacy programmes → Patient participation
for better health outcomes & reduction of
inefficiency [26].
2. Digitalization to support self-management
→ reduced costs, increased quality &
improved overall population health and
efficiency [23;27]
3. Increase of budget for prevention from
4,3% to 5,5% of total healthcare budget →
Increased funding [13,28,29,30]
Focus on the supply side
1. Revise the Health insurance package to
include effective treatment options
2. Currently 4% of care provided has proved
to be harmful an additional 6% are
ineffective, hence, excluding them could
cut cost and increase quality [25]
3. The effectiveness of 46% is unknown
requiring further research [25]
→ Overall, cost reduction to tackle
underfunding.

7. POLICY ALTERNATIVE 1:
IMPROVING WORKING CONDITIONS &
BENEFITS FOR THE STAFF IN NHS
POLICY ALTERNATIVE 2:
COST-EFFECTIVENESS OF CARE
POLICY ALTERNATIVE 3:
PREVENTION AND SELF MANAGEMENT
Expected future outcome
(impact on waiting times
& quality of care) Addresses root-cause #1 “vacancies” in the short
term, but requires support from additional measures
to stay effective in the long run.
Addresses root-cause #2, leading to short & long-term
effects on waiting times & quality through the
liberating of additional funds & effective treatments.
Has most difficulties in generating a short-term return,
but is essential in creating sustainable change for the
NHS, leading to a more effective HC system.
Legal feasibility (current
legislation barriers) Mainly a matter of funding and political will. Mainly a matter of cooperation between the
commisioners and the NICE, as well as political will to
change.
Requires a health definition change to one that
recognises the ability of patients to cope with malaise,
and the impact of the physical & social environment.
Ethical feasibility
(societal debate) The toughest here is to convince important non-
medical actors to prioritise it, given the relative direct
impact on waiting times this ought to be possible.
Many low-hanging fruits, not effective treatments BUT
there will be equally treatments which are effective
but not cost-effective, soliciting intense debate.
Intense debate from the medical community. But general
opinion is in favour of changes as more and more
evidence highlights the non-medical health impact.
Political feasibility
(governments’ values /
ideology match)
Given the additional investments required in the
healthcare budget to support the improvement of
working conditions and benefits for NHS staff this is
still a difficult measure to pass. The labour party is
clearly for, closely followed by the conservatives.
This measure fits close to the ideals and interests of
the government as it ambitions efficiency
improvements in resource allocation. It should hence
be the easiest to pass, looking at it from the angle of
political feasibility.
As it requires both a budget increase for public health
as well as a start of reforming the current health
system, this is the toughest alternative to pass to the
party electorate. The labour partiy is clearly for, the
conservatives less clear, the liberals oppose.
Conclusion on feasibility
• Alternative #1 has the highest feasibility. • Alternative #2 has the second highest feasibility. • Alternative #3 has the lowest feasibility.
Analysis of policy alternatives I: Alternative comparison
Policy alternative #1 out on top, followed by #2
Short-term impact
Long-term impact
Short-term impact
Long-term impact
Short-term impact
Long-term impact

8. Analysis of policy alternatives II: Stakeholders
Policy alternative #1 has the most friends
POLICY ALTERNATIVE 1:
IMPROVING WORKING CONDITIONS
& BENEFITS FOR THE STAFF IN NHS
POLICY ALTERNATIVE 2:
COST-EFFECTIVENESS OF CARE
POLICY ALTERNATIVE 3:
PREVENTION AND SELF-MANAGEMENT
Stakeholders NHS Government Patient NHS Government Patients Private HC* NHS Government Patients Industry
Interest
(friend/enemy) Friend Mostly
Friend Friend Friend &
Enemy Friend Friend &
Enemy Friend Mostly
Friend Friend Friend &
Enemy
Friend &
Enemy
Powerful** Yes Yes No No Yes Yes No Yes Yes Yes Yes
Reasoning Success
depends on
compliance &
acceptance of
staff
Benefit → Staff
recruitment &
retention [31]
Generally in
favour, except
for extension
of migration
policy [32]
Benefit →
Improved
quality of
care delivery
[16]
More efficient,
but some
treatments
might be
excluded from
reimburse-
ment [33]
Benefit →
Reduced costs
& increased
population
health [34]
Benefit from
effective care,
but no access
for treatments
that are
effective, but
costly [33]
Attraction of
patients by
insuring
treatments
that are non
cost-
effective [33]
Decreased
work pressure
in long-term
[34], but
resistance to
change
expected [16]
Benefit →
Reduced costs
in long-term &
increased
population
health [35]
Success
depends on
compliance &
acceptance
from patients
[36]
More sales for
sectors in
digital
technology,
less sales for
other
industries
(f.ex. tobacco)
Potential
conflicts
● NHS needs large investments from
government → Government may
want to restrict these investments
● The short-term solution of
international staff recruitment might
be welcomed by patients in need,
but resistance from other parties
[32]
● Sharpening the assessment of treatment based on
cost-effectiveness threshold and therefore
exclusion of non cost-effective care from care
package might increase resistance from patient
groups, but government favours increasing cost-
effectiveness of care [37]
● Share of NHS staff & patients vs. government: NHS
not willing to change way of working [16], NHS,
patients show lack of digital skills [30;38] &
patients with complex needs, lack of resources,
motivation or ability to adapt [37;39] vs.
government that is strongly in favour
● Fear of profit & image losses from industry vs. cost
reduction & long-term benefits for government
Conclusion on
feasibility
The stakeholders involved in this policy
alternative are in favour and there are
no big potential conflicts
Although there are strong forces in favour, there are
stakeholders partially against it, especially due to
ethical concerns resulting in potential conflicts
Overall, the stakeholders involved are in favour, but
there are several potential conflicts probably arising
by the NHS and patients
= powerful & in favour → Stakeholder should be
selected
= powerful & not entirely in favour
→ Stakeholder should be selected but take into
account and pay attention to potential conflicts
= not powerful → Stakeholder should be ignored
* HC = Healthcare
** Powerful is defined in terms of Yes and No

9. Choice of policy and instruments based on the analysis
Recommendation of policy alternative #1
1. Taxes → Generate funding to pay for benefit increase (e.g.
asset tax to let affluent elderly to make an extra (wealth -
dependent) contribution to the rising cost of healthcare or
annual health care funding growth increase from 3,4% to
4,3% and for social care from 1,7% to 9,0%) [40]
2. NHS pensions and tax scheme (conduct a review of the
NHS pensions and tax scheme to ensure that staff are
fairly rewarded for their work) [20]
3.Salary growth rate (deliver year-on-year above-inflation
pay rises for public sector workers) [20]
4.Yearly maintenance grant (introduce a yearly maintenance
grant of between £5,000 and £8,000 for student nurses
depending on region and discipline) [20]
5. Establishment of a staffing committee to establish and
promote training bursaries and CPD [20]
6.Easing of immigration policy to simplify & stimulate
international recruitment of nurses (e.g. Introduce a new
NHS visa for qualified health professionals with a job offer
from the NHS) [3,20]
Preferred Policy
Instruments
● Part of strategy such as staff recruitment
according to NHS long-term plan is long-term
[16]
● The success depends on the ability to
collaborate with the government such as with
the immigration department to adapt the
immigration policy for the medical staff [16]
● Continuous adaptation required regarding future
employee gap due to ongoing demographic
change such as the increasing demand and
older workforce
Limitations &
Unanticipated Outcomes
● Successful implementation of NHS long-term
plan - a promising opportunity to reduce
waiting times and hence increase quality of
care - depends on adequate staffing levels [16].
● The short-term impact is desirable given the
difficulty to pass more fundamental changes in
the current political climate. It also has the
broadest support from stakeholders.
● Mostly it is in line with government values &
objectives (e.g. comprehensive care available to
all at highest standards, allocate funding to
frontline services to reduce waiting times) [19],
[20], [21]
Why?

10. 3 key causes for this problem:
Problem 1 → 100,000 staff vacancies: Prevent adequate care, increasing waiting times.
Problem 2 → Government underfunding of NHS: national tariff fees lower than inflation rate & operating costs.
Problem 3 → Inefficient care: NHS provider deficits of ￡850 Mio in 2019.
There are 3 possible solutions to tackle this.
EXECUTIVE
SUMMARY
Imagine you suffer from heart disease, or cancer. You go to the hospital, but the doctor tells you that
you can’t get any treatment right now. You need to wait weeks, or even months, to receive the care you
need. This is an undesirable situation, isn’t it?
Yet this is the case for 5.7 million people in the UK. The increased waiting times lead to a reduction of
the quality of care. For instance, in January 2021 an average of 58,000 patients waited 25 additional
weeks for a hip replacement, the equivalent of 29,000 QALYs across the English population.
INTEREST
PROBLEM
Alternative 1 → Improvement of working conditions & benefits for NHS staff to yield immediate results &
enabling of successful implementation of NHS long-term plan.
Alternative 2 → Improvement of cost-effectiveness of care by revising the health insurance package &
only including cost-effective treatment options.
Alternative 3 → Prevention and self-management of the patient.
All part of the complete solution, but address different moments in the future → Important criterion.
Since Alternative 1 has the biggest short-term impact, it is important to start with this.
GOAL
Improvement of working conditions & benefits for NHS staff → Retention of current & recruitment of
new staff, offering opportunities to significantly reduce waiting times & improve the quality of care.
In this way, you as a patient receive the necessary care in time.
GAIN
1
2
3
4

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