The Cost Effectiveness of Elective Surgical Procedures with Longer NHS Waiting Lists: A Targeted Review.

Waiting times for elective surgeries in the English NHS are at record levels. The cost effectiveness of many surgical interventions exceeds that of many pharmaceuticals, which tend to be priced right to the NHS’s maximum willingness to pay (£20,000 to £30,000 per QALY gained). Investment in expanding surgery in preference to pharmaceuticals is likely to be a good use of NHS resources.

We conducted a targeted literature review (TLR) to identify evidence for the cost effectiveness of nine elective procedures where there are currently long waiting lists in NHS England: percutaneous coronary intervention (PCI), coronary artery bypass graft surgery (CABG), hysterectomy, cholecystectomy, knee replacement, groin hernia repair, hip replacement, prostatectomy and cataract surgery. These surgeries were selected based on a comprehensive review of data on demand for elective procedures derived from a previous OECD report [ 18 ], including consideration of real-world data from patients in the NHS, current waiting list data, and with input from stakeholders at the Department for Health and Social Care (DHSC) [ 13 , 19 ]. These surgeries were also discussed with representatives at NHS England who confirmed that they aligned with broader NHS England priorities. As we wished to include evidence for nine elective procedures, each of which may be associated with more than one patient population, we chose to use a TLR approach towards identifying the relevant evidence base. The TLR approach was conducted using the principles of a systematic literature review; that is, the methods for conducting the review were planned a priori in a review protocol, which was not amended following commencement of the review; the review followed the same systematic and sequential steps in the identification, selection and consideration of evidence; and the review findings are reported transparently for replicability purposes. There were two key differences in the methods used in the TLR compared with a systematic review: (i) the evidence search was targeted towards the sources that were considered most relevant for the review objectives, with supplementary searches used to identify any additional papers not indexed in those databases (see Search and Screening section); (ii) we used pre-defined prioritisation criteria to select those studies most relevant to the review question; and (iii) formal checklists were not used to quality appraise the included studies, but rather an informal approach to identifying limitations of the included studies, as defined by domains of the CHEERS checklist [ 20 ], was used and any issues were considered during the synthesis. Eligibility criteria for the TLR are shown in Table 1 . We included full economic evaluations of the selected elective procedures excluding cost-minimisation analyses. We took an inclusive approach to eligible study populations, in that any population was relevant for inclusion except where it was considered that the increased use of surgery would not be appropriate in current NHS practice (for example, we excluded evidence for the cost effectiveness of hysterectomy for menorrhagia, which is not typically performed within the NHS). The aim of the review was to determine the cost effectiveness of the elective procedures, and therefore we included comparisons between the surgical procedures and medical management, no treatment (including waiting list and active surveillance), and surgery at an alternative time (i.e. the same surgery performed earlier compared with later). We considered all comparisons would be useful to determine the cost effectiveness of the procedures, but that the latter comparison would be most useful for considering the cost effectiveness of reducing waiting lists, as it is the closest parallel to marginal cost effectiveness (i.e. the cost effectiveness of expanding a given service or treatment rather than replacing one with another). Comparisons between surgery and no treatment or medical management were considered more relevant to some conditions than others. Table 1 Inclusion/exclusion criteria Included Excluded Population Children or adults with any condition/disease severity referred by a clinician for a relevant surgery NA Intervention Agreed list of surgical interventions: Percutaneous coronary intervention (PCI) Coronary artery bypass graft surgery (CABG) Hysterectomy Cholecystectomy Knee replacement Groin hernia repair Hip replacement Prostatectomy Cataract surgery Surgeries not listed Comparator Management without surgery No treatment Waiting list Alternative surgical interventions Outcome Outcomes QALYs in each arm Life years gained in each arm Cost breakdown in each arm Incremental cost per QALY Summary of analysis of uncertainty (e.g. sensitivity analyses and/or credibility intervals) Eligibility for NICE severity modifier Other outcomes not specified Evaluation methods Discount rate Time horizon Analysis perspective, cost categories and cost items included Price year Source of health state utilities Subgroups Where reported, data will be extracted separately for marginal groups, such as those with low disease severity or particularly high-risk patients NA Setting Outpatient and inpatient settings. Evaluations from the UK, Europe, Canada and Australasia are relevant for inclusion, though will be included according to the prioritisation criteria NA Study design Full health economic evaluations reporting life years or QALYs gained. Types of analysis may include: Cost–utility analyses Cost-effectiveness analyses Cost–benefit analyses Cost–consequence analyses Economic evaluations alongside clinical trials Publications not reporting life years or QALYs gained Cost minimisation analyses Source type Full-text journal publications, HTA reports, monographs Conference abstracts, posters, research reports that have not been peer reviewed Search limits English language NA Prioritisation criteria Location : Evaluations based in the UK will be prioritised, followed by locations with healthcare systems most similar to the UK in Europe, Australasia, and North America Date : More recent studies will be prioritised for inclusion Quality : Evaluations reported consistently with best practice guidance (e.g. the CHEERS checklist) Outcomes : Papers that consider the impact of capacity on effectiveness Multiple indications : Indications that are consistent with NHS priorities and/or provide a representative overview of indications for that procedure (e.g. both acute and chronic) HTA health technology assessment, NA not applicable, QALY quality-adjusted life year Inclusion/exclusion criteria Agreed list of surgical interventions: Percutaneous coronary intervention (PCI) Coronary artery bypass graft surgery (CABG) Hysterectomy Cholecystectomy Knee replacement Groin hernia repair Hip replacement Prostatectomy Cataract surgery Management without surgery No treatment Waiting list Outcomes QALYs in each arm Life years gained in each arm Cost breakdown in each arm Incremental cost per QALY Summary of analysis of uncertainty (e.g. sensitivity analyses and/or credibility intervals) Eligibility for NICE severity modifier Evaluation methods Discount rate Time horizon Analysis perspective, cost categories and cost items included Price year Source of health state utilities Full health economic evaluations reporting life years or QALYs gained. Types of analysis may include: Cost–utility analyses Cost-effectiveness analyses Cost–benefit analyses Cost–consequence analyses Economic evaluations alongside clinical trials Publications not reporting life years or QALYs gained Cost minimisation analyses Location : Evaluations based in the UK will be prioritised, followed by locations with healthcare systems most similar to the UK in Europe, Australasia, and North America Date : More recent studies will be prioritised for inclusion Quality : Evaluations reported consistently with best practice guidance (e.g. the CHEERS checklist) Outcomes : Papers that consider the impact of capacity on effectiveness Multiple indications : Indications that are consistent with NHS priorities and/or provide a representative overview of indications for that procedure (e.g. both acute and chronic) HTA health technology assessment, NA not applicable, QALY quality-adjusted life year Searches were conducted on January 27, 2023 in MEDLINE (via Ovid), HTA Database (via inahta.org), Cost-Effectiveness Analysis (CEA) Registry (via tuftsmedicalcenter.org), and the NICE website clinical guidelines search tool [ 21 ]. Search strategies were pragmatic and balanced sensitivity with specificity. The MEDLINE search used relevant geographic filters (for the UK and OECD countries) and economic evaluation filters. No date restrictions were used. The MEDLINE search strategy is provided in the electronic supplementary material (ESM). In addition, we conducted rapid searches in Google Scholar (e.g. ‘Cholecystectomy UK NHS QALY ICER’) and checked the reference list of a recent similar review with overlapping procedures (Chen et al. [ 10 ]) to check for possible ‘missed’ studies. No new studies were found via these checks. A single reviewer screened identified studies with a 10% quality check by a second reviewer. Reviewers were encouraged to tag articles they were uncertain about for additional review and discussion within the team as required. Discrepancies were resolved through discussion with the team. Three stages of screening were used: at stage 1, title and abstracts of identified publications were assessed against review population, intervention, and study design criteria; at stage 2, full-text publications included at stage 1 were assessed against the full eligibility criteria. At stage 3, full-text publications included at stage 2 were prioritised for inclusion in the review according to the prioritisation criteria specified in Table 1 . The prioritisation criteria were chosen a priori to include those studies that were most relevant to current NHS practice and the aims of the review within the available timeline. Stage 1 and 2 screening was conducted in Rayyan [ 22 ]. The results of included studies were tabulated and narratively synthesised to identify key results and patterns in the evidence base, taking into consideration variation in evaluation methods, procedures and settings. To allow for comparisons between cost-effectiveness estimates that were calculated in different countries and years, all ICER estimates were updated to present day (2024) costs and into British pounds (GBP). The CCEMG-EPPI Centre Cost Converter (version 1.4) [ 23 ] was used to convert both the price year and currency. As this study was a literature-based review with no primary research that directly included participants, there was no patient or public involvement in the development of the study. However, the results of the study may be used to inform decision making in funding decisions across the NHS, and therefore may encourage further evidence-based funding decisions, and thus overall health gain.

After de-duplication, 4859 records identified from the searches were included for screening. A total of 335 records were included at stage 1 (title and abstract screening), 77 records were included at stage 2 (full-text screening), and 21 papers were included in the review at stage 3 (prioritisation). A PRISMA diagram showing the flow of publications through screening is shown in Fig. 1 . Fig. 1 PRISMA flowchart PRISMA flowchart Evidence was identified for most of the surgeries though no evidence was identified for groin hernia repair. Hip replacement was identified to be the type of surgery with the greatest number of included studies (6 studies). Only one included study evaluated hysterectomy. We included five studies that evaluated the cost effectiveness of PCI and CABG, although noted that the only available evidence for these surgeries were either relatively dated (publication years 2007–2011) or had a high risk of bias. Ten studies compared early versus later surgery, nine studies compared surgery versus either no intervention or waiting list, and five studies compared surgery with medical management. Studies that evaluated early versus delayed surgery varied in their approaches to delivering earlier surgery, whether this involved additional resources to reduce waiting lists (3 studies) or reconfiguration of waiting lists to prioritise surgery according to symptom severity or patient suitability for surgery (7 studies). Overall, the quality varied and, due to sparse evidence for some surgeries, lower quality/less generalisable evidence was included in this review. An overview of the included studies is summarised in Table 2 . Additional information on included study characteristics, including patient population, the time horizons of the models, and included costs are reported in the ESM, Table 3 . Table 2 Included study characteristics Study Country Surgery type Population Comparison type Comparison method Comparison details ICER (as reported) ICER (converted to 2024 GBP) NICE, 2017 [ 35 ] UK Cataract Bilateral LSA Early vs delayed surgery Severity threshold Delaying surgery until VA (visual acuity) reaches a certain threshold £1946 (2015) £2564 NICE, 2017 [ 35 ] UK Cataract Bilateral LSA vs no surgery Dominant Dominant Boyd et al., 2020 [ 36 ] New Zealand Cataract At risk of falls (aged 65–89 y) Early vs routine surgery Expedited surgery Expedited surgery NZ$10,600 (2011) £6789 Sutherland et al., 2020 [ 26 ] Canada Cholecystectomy Symptomatic gallstones vs baseline CAD$2018 (2016) £1485 Karimuddin et al., 2021 [ 27 ] Canada Cholecystectomy Symptomatic gallstones vs baseline CAD$2200 (2016) £1619 NICE 2014 [ 25 ] UK Cholecystectomy Gallstones/ gallstones and CBDS/CBDS vs conservative management Dominant Dominant NICE 2014 [ 25 ] UK Cholecystectomy Gallstones/ gallstones and CBDS/CBDS Early vs delayed surgery Severity threshold Delay surgery until acute cholecystitis occurs £201,896 (2012) SW quadrant £289,603 Brazzelli et al. 2014 [ 24 ] UK Cholecystectomy Symptomatic gallstones vs conservative management £13,205 (2012) £18,133 Griffin et al. 2007 [ 50 ] UK CABG Angina pectoris vs no surgery £22,000 (2004) £36,308 Forné et al. 2021 [ 51 ] Europe PCI Elderly patients with acute coronary syndromes Increased use vs current practice Severity threshold Expanded service provision – treating patients according to probability of receiving PCI €2262.8 – €6422.4 (2018) £4361 Bøhmer et al. 2011 [ 37 ] Norway PCI Acute myocardial infarction Early vs conservative approach Severity threshold Immediate angiography compared with community hospital admittance €69,750 (2008) £83,414 Fearon et al. 2013 [ 52 ] US PCI Stable coronary artery disease vs no surgery US$36,000 (2012) £33,701 Mújica-Mota et al., 2017 [ 31 ] Germany Hip replacement Severe hip OA Early vs delayed Severity threshold Surgery once patient has progressed to a functionally dependent state €476 – €1307 (2013) £1088 Mújica-Mota, 2013 [ 30 ] Italy Hip replacement Functionally independent adult with OA Early vs delayed Severity threshold Surgery only once patient has progressed to a functionally dependent state Dominated – €2337 (2010) £1007 Mújica-Mota, 2013 [ 30 ] Italy Hip replacement Functionally independent adult with OA Delayed vs medical management Severity threshold Progressed to a functionally dependant state compared with non-surgical interventions €466 – €3105 (2010) £377 Fordham et al. 2012 [ 29 ] UK Hip replacement Total hip replacement vs no surgery £7182 (2001)* £12,751 Tuominen et al. 2013 [ 28 ] Finland Hip replacement Primary joint replacement due to OA Early vs routine surgery Expedited surgery Short waiting time (3 months) compared with non-fixed waiting time €3000 (2006) £3746 Wilson et al. 2021 [ 48 ] New Zealand Hip replacement Primary THA vs baseline NZ$2700 (2018) £1514 Taipale et al., 2009 [ 53 ] Finland Hysterectomy Benign uterine disorder vs no surgery €14,135 (2009)* £16,867 Tuominen et al. 2013 [ 28 ] Finland Knee replacement Primary joint replacement due to OA Early vs routine surgery Expedited surgery Short waiting time (3 months) compared with non-fixed waiting time €9058 (2006) £10,760 Wilson et al. 2021 [ 48 ] New Zealand Knee replacement Primary THA vs no change from baseline (assumed conservative management) NZ$3500 (2018) £1963 Lao et al., 2017 [ 34 ] New Zealand Prostatectomy Low risk localised prostate cancer vs active surveillance Dominated – NZ$43,583 (2013) £16,855^ Degeling et al., 2021 [ 32 ] Australia Prostatectomy Low or favourable risk localised prostate cancer vs radiotherapy Dominated Dominated Sanghera et al., 2020 [ 33 ] UK Prostatectomy Low or favourable risk localised prostate cancer vs active surveillance Dominated Dominant Sanghera et al., 2020 [ 33 ] UK Prostatectomy Low or favourable risk localised prostate cancer vs radiotherapy £27,725 (2015) £36,533 CABG coronary artery bypass grafting, CBDS common bile duct stones, ICER incremental cost-effectiveness ratio, LSA laser eye surgery, OA osteoarthritis, PCI percutaneous coronary intervention, SW south-west, THA total hip arthroplasty * Not reported in paper, assumed year of publication ^Average across all age groups Included study characteristics CABG coronary artery bypass grafting, CBDS common bile duct stones, ICER incremental cost-effectiveness ratio, LSA laser eye surgery, OA osteoarthritis, PCI percutaneous coronary intervention, SW south-west, THA total hip arthroplasty * Not reported in paper, assumed year of publication ^Average across all age groups As seen in Fig. 2 , there was a range of ICERs across the elective surgeries, but most fell well below the willingness-to-pay threshold. For hysterectomy, a single study that focused on four indications (benign uterine or ovarian conditions, endometriosis, uterovaginal prolapse and menorrhagia) found it to be cost effective with an overall ICER across all four of £16,867 per QALY. Fig. 2 Mean (2024) ICERs across elective surgeries. CABG coronary artery bypass grafting, ICER incremental cost-effectiveness ratio, PCI percutaneous coronary intervention, RT referral to treatment, QALY quality-adjusted life year Mean (2024) ICERs across elective surgeries. CABG coronary artery bypass grafting, ICER incremental cost-effectiveness ratio, PCI percutaneous coronary intervention, RT referral to treatment, QALY quality-adjusted life year Cholecystectomy was evaluated in four studies. A UK HTA evaluation [ 24 ] found it to be cost effective compared with conservative management, yielding an ICER of £18,133 per QALY. However, the NICE guideline on diagnosis and management of gallstone disease [ 25 ] found it to dominate conservative management (lower cost and better outcomes). The same guideline reported that early versus delayed surgery yielded fewer QALYs but substantially reduced cost, resulting in an ICER of £289,603 per QALY (south-west quadrant ICER, implying early is cost effective vs delayed). A Canadian study [ 26 ] based on a retrospective analysis of elective cholecystectomy patients estimated an ICER of £1485 per QALY, compared with delayed surgery. A follow-up study disaggregated by length of waiting time found a 12-month delay increased the ICER by around 20% [ 27 ]. Knee replacement was assessed in two studies. One compared a capped waiting list (3 months) with a non-fixed waiting list strategy (mean 8.5 months) [ 28 ], showing early surgery led to increased cost but similar QALYs, nevertheless yielding an ICER of £10,760 per QALY, but with a 40% chance of being below £20,000. A New Zealand study using a 15-year horizon found that knee replacement cost £1963 for every extra QALY gained compared with conservative management. Six studies evaluated hip replacement, with four comparing immediate versus delayed surgery and two comparing surgery with medical management. A UK study [ 29 ] found hip replacement using the Exeter implant resulted in higher QALYs over 5 years with an ICER of £12,751, falling to £1514 over a 15-year time horizon. Italian [ 30 ] and German [ 31 ] studies (conducted by the same research team) used progression to a functionally dependant state as a severity threshold for surgery, showing early surgery to be more costly but resulting in more QALYs. The Italian study reported an ICER of £1007 per QALY compared with medical management and £377 compared with delayed surgery, with the German study (reported by the same authors) yielding similar results. Tuominen et al. [ 28 ] compared a short (3 months) with a non-fixed waiting time strategy (mean 7.8 months), finding the short waiting time yielded an ICER of £3746 per QALY compared with long. Three studies [ 32 – 34 ] evaluated prostatectomy against active surveillance in localised prostate cancer. In low-risk populations [ 32 ], surgery was more cost effective than active surveillance due to the risk of patients developing metastatic disease, and surgery also dominated radiotherapy. Studies reporting disaggregated results by age found a decline in cost effectiveness of surgery with increasing age [ 33 , 34 ]. Cataract surgery was reviewed in two studies from the UK [ 35 ] and New Zealand [ 36 ], evaluating the cost effectiveness of early, delayed or no surgery. The UK study (a NICE guideline) assumed bilateral surgery, whereas the New Zealand study assumed single-eye surgery. Immediate surgery was very cost effective with an ICER of £2564 per QALY for low-risk individuals versus delayed, and immediate surgery dominated no surgery. In the New Zealand setting, the ICER of expedited versus routine surgery in those at risk of falls was £6789 per QALY. For percutaneous coronary intervention (PCI) and coronary artery bypass graft surgery (CABG), four studies were reviewed. A US study [ 52 ] found PCI to be more costly and more effective than medical management in people with stable CAD, but yielded an ICER of £33,701 per QALY, and a Norwegian [ 37 ] study of immediate angiography and intervention versus admission to community hospital in acute myocardial infarction (AMI) yielded an ICER of £83,414 per QALY. These are in excess of NICE thresholds but were conducted in higher-cost countries than the UK. However, a UK study of CABG versus no surgery for angina estimated an ICER of £36,308 per QALY [ 50 ]. A study of expanding PCI to a lower severity threshold in patients with acute coronary syndromes was found to be cost effective with an ICER of £4361 per QALY [ 51 ].

This review presents an overview of the cost effectiveness of selected elective procedures for which there currently exist long waiting times in the English NHS. Overall, most of the surgeries considered yielded ICERs below the NICE threshold of £20,000 to £30,000 per QALY, in many cases substantially. Investment in increasing capacity in these could yield greater net health benefits for NHS patients as a whole compared with investment in interventions priced right at the threshold. Some of the included evidence was dated (particularly for PCI and CABG), and it was anticipated that the efficiency of procedures would improve over time as techniques develop. With respect to PCI, the highest ICER of £83,414 per QALY was produced from an analysis of PCI with only a 1-year time horizon, which would be unlikely to be sufficient to be able to capture all relevant costs and benefits, as the benefits are expected to outweigh the costs after a year. Additionally, the studies related to PCI are from higher cost settings than the UK, and therefore it is uncertain whether these are transferable to the UK. Not all patient populations on waiting lists for included procedures were represented in the evidence, and future research should examine whether cost effectiveness varies by subpopulation (e.g. severity) to match the characteristics of those on the waiting list.

This review identified evidence for the cost effectiveness of elective procedures currently having longer waiting lists in the NHS. The evidence review comprised 21 evaluations (7 UK-based), published between 2007 and 2021. The included studies suggested that, in the populations evaluated, cataract surgery, cholecystectomy and hip replacement surgeries were highly cost effective with ICERs <£11,000. Prostatectomy and knee replacement were cost effective procedures in younger populations (ICERs below £20,000 per QALY gained) and likely to be so in older populations (ICERs below £30,000). CABG yielded an ICER above £30,000 per QALY, although this is based on an old study, and immediate PCI does not appear to be cost effective compared with treatment as usual in acute myocardial infarction. Overall, most of the elective procedures were highly cost effective with ICERs substantially below the lower end of the NHS willingness-to-pay threshold for health technologies (£20,000–£30,000 per QALY). In some cases, surgical procedures were also cost effective below the estimated cost of a marginal QALY (£5000–£10,000) [ 38 ]. In the context of a healthcare system with finite resources and significant pressures on spending, this review suggests that addressing demand for these elective procedures may be a good use of NHS resources. Out of the reviewed papers, ten included comparisons between early and delayed surgery. Seven of these explored the impact of delaying the surgery until a certain severity threshold was reached; for example, Mújica-Mota et al. [ 30 , 31 ] looked at hip replacement patients who had immediate surgery compared with delaying until patients are functionally dependant. Three papers examined the impact of expedited surgery, specifically a policy focusing investment towards reducing waiting times for those that met eligibility criteria. The results showed that such investment is likely to be cost effective. However, studies were frequently unclear about how waiting list times for these surgeries were reduced for the purposes of the trial, and not all methods would have integrated the increased spending that would be required in the NHS to increase the capacity necessary. Additionally, results suggest that when comparing with no surgery, elective surgeries are in most cases very cost-effective interventions, albeit with some exceptions (Table 2 ). Overall, the amount, quality and generalisability of the evidence was highly varied. This review showed that treating patients sooner and expanding eligibility to less severe patients are both cost effective compared with delaying, or no treatment. Given current waiting lists, investment might better focus on those rather than broadening eligibility criteria. However, the optimum way to achieve this is unknown, and further investigation is needed. In March 2024, only 59.1% of patients met the 18-week waiting time target [ 3 ] and 8% of patients were waiting for longer than 45 weeks [ 39 ]. Given the large number of eligible patients waiting considerable time for elective procedures, targeted funding to reduce wait lists for the majority of surgeries in this review is expected to be cost effective. There is evidence that waiting times to surgery exacerbate the impact on patient quality of life; for example, Oudhoff et al. [ 40 ] assessed the impact of wait times on health, wellbeing and psychological outcomes in varicose veins, inguinal hernia and gallstone surgeries. The study found that for each surgery, the group in the waiting list had worse general health perceptions and raised levels of anxiety, and longer wait times were associated with a lower quality of life in inguinal hernia patients [ 40 ]. Another study examined the change in knee pain during the wait period before elective knee replacement surgery, finding a mean pre-surgery waiting period of 183 (121.9) days. Those waiting 9–12 months showed significant deterioration in SF-36 scores (−11.3%; −18.4 to 4.4), and WOMAC pain scores (−9.9%; −19.2 to −0.54) [ 41 ]. Therefore, the studies included in this review may underestimate the value of earlier surgeries, as they may not capture all outcomes associated with the timings around surgeries. The findings also have implications for thinking about the prioritisation of NHS spending across intervention type. NICE operates a willingness-to-pay threshold of £20,000–£30,000 per QALY for technologies such as drugs and some medical devices. Whilst NICE was established in 1999 and a WTP threshold was not stated explicitly until 2012, committee decisions have been made using the £20,000–£30,000 range since 2004 [ 42 ]. The establishment of this threshold was based on thresholds for historical treatments recommended for routine commissioning rather than having a strong theoretical or empirical basis [ 43 ]. Whilst the baseline threshold has not changed since its inception, NICE has made explicit increases such as higher thresholds for rare and/or severe diseases (through the highly specialised technologies [HST] programme), and implicit increases such as severity weightings and inclusion of QALYs for carers as well as patients in the benefit calculation for some appraisals. Conversely, there have been no corresponding downwards threshold adjustments for other treatments to compensate the impact of these. There have been calls to increase the threshold paid by the NHS, such as to account for price inflation and to accommodate relatively more expensive treatments, such as advanced medicinal therapeutic products [ 44 ]. However, previous research has suggested that it is already too high: estimates of the current average cost of a marginal QALY was between £5000 and £10,000, meaning that adopted technologies exceeding this result in overall efficiency loss for the NHS [ 38 ]. Even as early as 2007, there were arguments suggesting that the threshold was too generous and was diverting resources from other more cost-effective healthcare resources [ 45 ]. Thus, increasing the willingness-to-pay threshold would do more harm than good [ 46 ]. Claxton et al. [ 47 ] demonstrated why; if the NHS spends £10m per year on a technology with an ICER of £30,000 and if the prior threshold was £20,000 per QALY, the £10m disinvested from elsewhere in the NHS would result in a net health loss of 500 QALYs per year. This review suggests that several high-demand surgeries in England are consistent with the estimated marginal cost per QALY in the NHS of between £5000 and £10,000. Investment into new interventions or technologies that is greater than this threshold is more likely to reduce the efficiency of the NHS. This means that spending on health technologies with ICERs higher than this leads to significant QALYs lost to patients in the healthcare system as a whole. There is also the risk of a ‘creeping up’ effect with the continued reimbursement of expensive technologies, meaning that the average cost per QALY will continue to rise, and the efficiency of the NHS will decrease over time. Interventions submitted to the NICE processes tend to be priced to this threshold, therefore spending on long-term capital investment into elective surgeries to reduce waiting lists could lead to greater improvements in health gain than investments in such interventions, for the same cost. This review identified the cost effectiveness of elective procedures with long NHS waiting lists through a broad search and permissive inclusion criteria, focusing on NHS applicability. The findings provide an insight into a highly topical area for policy makers determining how finite healthcare resources can best be spent, particularly in the aftermath of the demands of the COVID-19 pandemic where waiting lists for interventions may be at peak levels in recent history. This review also evaluated expanding service provision to include less severe cases. Further research is needed to explore the specific causes of long waiting lists for each of the cost-effective procedures identified (for example, whether there is a shortage of key personnel, facilities, specialist training etc.) and the costs associated with addressing these causes in order to meaningfully reduce waiting times. Evaluations are needed to compare the value of increasing capacity for surgeries with long waiting lists, which may incur high immediate costs but the potential for broad value within the health service. Due to the breadth of procedures we sought to include in the review, we used a TLR approach to the identification and consideration of evidence. Supplementary searches were conducted to identify any studies missed by the main database search strategy; however, it is possible that a broader search (e.g. to include EMBASE and CINAHL) may have identified further records. Several studies excluded costs of infrastructure required to reduce waiting times, and therefore may overestimate cost effectiveness. However, many surgeries were highly cost effective with ICERs substantially below NICE’s conventional threshold, and a more comprehensive economic evaluation may still find them cost effective even with these additional costs. The studies varied widely in model structure, time horizon and settings. Specifically, capacity models, discrete event simulations (DES) or hybrid simulation approaches may be more appropriate to estimate costs and effects of capital investments, however only one study [ 32 ] used a DES model structure. Shorter time horizons may also be insufficient to capture all differences in cost and outcomes; one of the included studies [ 48 ] showed how hip arthroplasty was only cost effective when evaluated at a longer time horizon, at which point the potential benefits of treatment have been realised. Studies set in healthcare systems comparable with the NHS were prioritised for inclusion, but nevertheless eligibility criteria for surgery, techniques and peripheral care may limit the applicability of studies to the NHS. Although costs were converted, there may still be differences between countries in costs/resource use and utility values. Finally, this review did not identify sufficient evidence to determine the most effective way to prioritise patients who are waiting, or how to best reduce the waiting list times. Comparing the present study with that of Chen et al. [ 10 ], a similar study based in Ireland, both studies found concurrent results. Chen additionally stated that higher average cost effectiveness could be achieved in Ireland from the adherence to the current threshold, as there are many approved technologies that cost more than €45,000 per QALY. However, the paper faced similar limitations in the generalisability of the results, but perhaps to more of an extent considering there was only one Irish-specific study included, and over half of the included papers were UK-based. Kamaruzman et al. [ 49 ] conducted a similar UK-based study but focused only on evaluating the cost effectiveness of surgical interventions for the management of osteoarthritis. The review included 23 studies and found overall that total knee arthroplasty (TKA) and total hip arthroplasty (THA) were cost effective. The results are in line with the current study, but the focus was shifted to comparing different methods of surgery, without so much focus on waiting lists or early versus delayed surgery. However, this study also found a mixed quality of evidence, and the included papers spanned nine countries, so had similar concerns over the generalisability of the results.

The National Health Service (NHS) is a publicly funded healthcare system that aims to provide the majority of care free at the point of use. UK citizens are able to access the majority of healthcare services for free, but high demand for services limits access, and rationing of healthcare occurs in the form of waiting lists (rather than by price). A fluctuating demand along with a constrained capacity means that individuals admitted to NHS services are unlikely to be treated immediately, with more urgent cases taking priority [ 1 ]. Waiting lists for elective surgeries are currently at an all-time high, in part due to the impact of the COVID-19 pandemic [ 2 ]. During the pandemic there were many patients (over 10 million), who required elective treatments but did not access care, meaning that increased levels of uncertainty on demand will emerge, as well as a potentially higher demand on elective resources than the current figures state [ 2 ]. With strict prioritisation criteria, there are many patients remaining on waiting lists for treatments for longer than the government target of 18 weeks [ 3 ]. As of March 2024, there were 7,603,812 patients waiting for elective surgery from the NHS in England [ 4 ]. Waiting lists have also been found to be particularly pronounced in more deprived areas, thus exacerbating health inequalities [ 5 ]. As the NHS has a fixed annual budget, within-year investments are funded by disinvestments from other existing treatments (generally manifested as delays or deferments). However, these delays generate opportunity costs, as they forgo the potential health gains that could have been achieved by timely, cost-effective treatments. Time costs, such as delays caused by long waiting lists, may therefore be treated as monetary costs added to the numerator of a cost-effectiveness ratio, or time costs may be subtracted directly from quality-adjusted life years (QALYs) in the denominator [ 6 ]. Time delays caused by inefficiencies here can represent a tangible loss in either economic terms or the health outcomes. Under this framework, failing to allocate resources to the most cost-effective interventions not only results in lost efficiency, but increases overall costs by prolonging wait times and reducing potential health gains. Investing NHS resources into interventions that are more cost effective than those currently provided will result in a net gain to the health of NHS patients from the available budget, while investing in less cost-effective interventions will lead to a net loss to NHS patients as a whole. The ‘Long Term Plan’ for NHS England highlighted that it would allocate sufficient phased funds to increase elective surgeries and cut waiting times [ 7 ]. However, an even larger impact may be seen by shifting the focus of overall investments into the most cost-effective areas of the NHS. The high-profile processes of the National Institute for Health and Care Excellence (NICE) for pharmaceuticals and medical devices places a large focus on this area in the minds of the NHS and the public. While NICE has not explicitly stated a specific incremental cost-effectiveness ratio (ICER) threshold above which interventions should not be recommended, those with an ICER below £20,000 per QALY are generally considered cost effective. For ICERs between £20,000 and £30,000, committees are expected to account for factors such as uncertainty, limitations in capturing health gains and the innovative nature of the technology [ 8 ]. Pharmaceuticals and medical devices tend to be priced to the maximum of this threshold, and there is evidence to suggest that the use of an explicit threshold pushes the ICERs of these products up towards that threshold [ 9 ], perhaps making them less cost effective than other areas; reallocating resources into more efficient areas is likely to result in higher overall health gain for the same resource inputs. To note, this threshold has rarely been used to assess surgical interventions as the main programme under which NICE considers these types of procedures (Interventional Procedures Guidance) does not consider economics [ 8 ]. A study conducted in Ireland on the cost effectiveness of elective surgeries [ 9 , 10 ] found that of the 20 surgeries with the longest waiting lists, 14 had ICERs lower than €20,000 per QALY, and 10 fell below €10,000/QALY, well under the €45,000/QALY threshold used in Ireland [ 11 , 12 ]. Recent analysis also suggests that reducing waiting lists for elective surgeries has benefits for patient outcomes [ 13 ]. Additional investment in expanding capacity in these surgeries in preference to other areas may deliver benefits to the many patients waiting for surgery while also resulting in an increase of efficiency across the whole of the NHS to the ultimate benefit of other NHS patients [ 10 , 14 – 16 ]. The objective of this study was to review evidence for the cost effectiveness of elective surgeries (defined as non-emergency surgeries [ 17 ]) with longer NHS waiting lists in the UK. This is to inform debate on appropriate cost-effective thresholds across NHS functions, and the prioritisation of NHS spending in the context of long waiting lists for surgeries.

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