Objectives To assess the extent and pattern of implementation of guidance issued by the National Institute for Clinical Excellence (NICE). Design Interrupted time series analysis, review of case notes, survey, and interviews. Setting Acute and primary care trusts in England and Wales. Participants All primary care prescribing, hospital pharmacies; a random sample of 20 acute trusts, 17 mental health trusts, and 21 primary care trusts; and senior clinicians and managers from five acute trusts. Main outcome measuresRates of prescribing and use of procedures and medical devices relative to evidence based guidance. Results 6308 usable patient audit forms were returned. Implementation of NICE guidance varied by trust and by topic. Prescribing of some taxanes for cancer (P < 0.002) and orlistat for obesity (P < 0.001) significantly increased in line with guidance. Prescribing of drugs for Alzheimer's disease and prophylactic extraction of wisdom teeth showed trends consistent with, but not obviously a consequence of, the guidance. Prescribing practice often did not accord with the details of the guidance. No change was apparent in the use of hearing aids, hip prostheses, implantable cardioverter defibrillators, laparoscopic hernia repair, and laparoscopic colorectal cancer surgery after NICE guidance had been issued. Conclusions Implementation of NICE guidance has been variable. Guidance seems more likely to be adopted when there is strong professional support, a stable and convincing evidence base, and no increased or unfunded costs, in organisations that have established good systems for tracking guidance implementation and where the professionals involved are not isolated. Guidance needs to be clear and reflect the clinical context.

Long waiting times for inpatient treatment in the UK National Health Service have been a source of popular and political concern, and therefore a target for policy initiatives. In the London Patient Choice Project, patients at risk of breaching inpatient waiting time targets were offered the choice of an alternative hospital with a guaranteed shorter wait. This paper develops a simple theoretical model of the effect of greater patient choice on waiting times. It then uses a difference in difference econometric methodology to estimate the impact of the London choice project on ophthalmology waiting times. In line with the model predictions, the project led to shorter average waiting times in the London region and a convergence in waiting times amongst London hospitals.

National income accounting practice is to weight health service activities by their cost so that they can be aggregated into an output index. Quality changes are ignored. We propose an 'ideal' value weighted output index in which the value attached to each output reflects its contribution to health outcomes and other characteristics valued by patients. Calculation of the index for the health system as a whole is currently infeasible because of a lack of data, especially on health outcomes. We demonstrate alternative ways of combining health outcome data with existing information on post-treatment survival, life expectancy and waiting times to construct quality adjusted cost weighted and health outcome weighted indices for a small set of hospital activities for which there are health outcome data.

In a number of countries where health care is publicly funded, policies to introduce greater patient choice are being implemented. In most cases patient choice is seen as an instrument to reduce waiting times for elective (non-emergency) hospital services. An important issue is whether facilitating greater patient choice will increase the demand for health care and thereby undermine the achievement of reduced waiting times. A large scale pilot of choice in the London metropolitan area permits a test of the hypothesis that choice will affect demand. This paper estimates a model of the demand for elective surgery using a panel of 150 English acute hospitals over the period 1995 to 2004 for three surgical specialties. It examines whether demand shifted following the introduction of the London Patient Choice Project in 2002. The results suggest that the choice project only shifted NHS inpatient demand in orthopaedics and that this shift was inwards.

This paper considers methods to measure output and productivity in the delivery of health services, with an application to NHS hospital sector. It first develops a theoretical framework for measuring quality adjusted outputs and then considers how this might be implemented given available data. Measures of input use are discussed and productivity growth estimates are presented for the period 1998/9-2003/4. The paper concludes that available data are unlikely fully to capture quality improvements.