HEALTH ECONOMICS LETTER CANCELLED PROCEDURES: INEQUALITY, INEQUITY AND THE NATIONAL HEALTH SERVICE REFORMS GRAHAM COOKSON a, * , SIMON JONES b and BRYAN MCINTOSH c a King’s College London, London, UK b University of Surrey, Surrey, UK c Richmond University, London, UK SUMMARY Using data for every elective procedure in 2007 in the English National Health Service, we found evidence of socioeconomic inequality in the probability of having a procedure cancelled after admission while controlling for a range of patient and provider characteristics. Whether this disparity is inequitable is inconclusive. Copyright © 2012 John Wiley & Sons, Ltd. Received 19 July 2011; Revised 31 May 2012; Accepted 8 June 2012 KEY WORDS: cancelled procedures; equity; equality; NHS reforms 1. INTRODUCTION Most developed countries endorse the concept of healthcare equity: treatment should be allocated on the basis of medical need and not income, race or location (Wagstaff and van Doorslaer, 2000). The National Health Service (NHS) reforms of the past decade, which were designed to improve the efficiency of healthcare delivery through a realignment of provider incentives (Cutler, 2002), have raised concerns that the cost of greater efficiency may be equity of access (Appleby et al., 2003; Barr et al., 2008; Cooper et al., 2009; Cookson and Laudicella, 2011). One argument is that fixed price reimbursements provide an incentive for providers to game the system by selecting in favour of low-cost patients and against high-cost patients (Cookson and Laudicella, 2011). If patients from lower socioeconomic groups stay longer and cost more, this incentive could precipitate inequality of access and without an underlying medical justification inequity of access. Another argument is that patients of higher socioeconomic status are better able to use their ‘voice’ to negotiate for better services or better access and that they are more able to capitalise on the patient choice agenda (Cooper et al., 2009). Despite these concerns, the emerging literature does not find evidence of this tradeoff between efficiency and equity. For example, Cookson and Laudicella (2011) found no relationship between length of stay and area deprivation for hip replacement patients, which undermines the argument that hospitals have an incentive to select against patients from low socioeconomic backgrounds because they stay longer after surgery. Similarly, Cooper et al. (2009) found no evidence that patients of lower socioeconomic status were required to wait longer for a range of common elective surgical procedures after the introduction of waiting time targets. *Correspondence to: Department of Management, King’s College London, Franklin-Wilkins Building, Stamford Street, London, SE1 9NH, UK. E-mail: graham.cookson@kcl.ac.uk Copyright © 2012 John Wiley & Sons, Ltd. HEALTH ECONOMICS Health Econ. 22: 870–876 (2013) Published online 4 July 2012 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/hec.2860