Abstract
Objectives: The English National Health Service introduced a policy in 2002 whereby a financial penalty was levied when a patient did not receive their operation within 28 days of a last-minute cancellation of an elective surgical procedure. This study investigates the impact of the 2002 policy change, the global recession, and the Covid-19 pandemic on cancelled operations and breaches of the above 28-day standard. Our purpose is to use England as a case study to examine the effect of a policy based on financial incentives as constraints on supply, relative to demand, were ratcheted up under external events.
Methods: We conducted a retrospective observational study using publicly available data. We used an interrupted time series analysis to assess the effects of the 2002 policy change, the 2008 recession, and the Covid-19 pandemic on cancelled operations and on breaches of the 28-day cancelled operations standard. We also performed an analysis to examine the hypothesis that hospitals with an A&E department would be more predisposed to breach the 28-day standard than hospitals without an A&E department.
Results: Elective surgery admissions have nearly doubled over the past 30 years. Cancellations built up gradually in the years leading up to the 2002 policy change, reverting rapidly to low levels (under 1%) following the change. The 2008 recession and COVID-19 pandemic did not impact cancellation rates. Breaches of the 28-day standard rose before the 2002 policy change, again dropping rapidly afterward (-9.6%, 95% CI: -11.2 to -9.0). Breaches gradually increased after the recession and rose notably post-pandemic (13.0%, 95% CI: 4.9% to 21.0%), remaining stable thereafter. Hospitals with A&E departments experienced higher increases in breach rates, greater variation, and more pronounced seasonal effects.
Conclusion: The 2002 policy change effectively reduced breaches of the 28-day standard. The effect persisted through many years. However, this positive effect of the policy could not be maintained after COVID when breach rates reached high levels and showed wide variation, especially in hospitals that had an A&E department and hence could not protect elective beds. Our findings support a theory that targets are likely to be maximally effective in systems that have some spare capacity in human and physical resources and/or can control demand. Failure to recognise such constraints will lead to policy that is self-defeating and manifestly unjust.