The 1991 reforms to Britain's health service established a quasi-market where the purchasing function was performed by health authorities and those general practices that joined the fund-holding scheme. Whilst the literature lacked any direct comparison of the performance of these agencies as purchasers, there was much controversy about the equity implications of the system. Most notably this focused upon alleged differences in the waiting times for hospital services of patients registered with fund-holding and non fund-holding practices. However, such allegations were based on anecdotal evidence and open to contradiction. The thesis moves this debate beyond a reliance on anecdotal evidence and for one service, elective surgery, redresses the lack of evaluation in the relative merits of fund-holders and health authorities as purchasers. The waiting times of fund-holding and non fund-holding patients for operations covered by the fund-holding scheme were compared at four public providers over a four-year period. Fund-holding patients from the elective waiting list generally had significantly shorter waits than their non fund-holding counterparts. Because such trends became evident after practices joined the scheme, shorter waits were linked to fund-holding status. Another important aim was to ascertain why this tendency occurred. A series of hypotheses were tested, including the generosity of fund-holders' budgets, contrasts in the surgical case mix of each population, plus differences in the way fund-holders and health authorities perform their purchasing roles. An aspect of this last hypothesis was confirmed. Hospitals admitted fund-holding patients sooner to dissuade fund-holding practices from referring elsewhere. This connects to the income hospitals receive from fund-holders being more closely attributable to actual patient throughput than was the case with their income from health authorities. In discussing the policy implications of the study, the thesis then addresses how public sector quasi-markets can work in the contexts of both equity and efficiency.

The cumulative likelihood of admission estimated for any given 'time-since-enrolment' depends on how we define membership of the population 'at-risk' and on how we handle right and left censored waiting times. As a result, published statistics will be biased because they assume that the waiting list is both stationary and closed and exclude all those not yet or never to be admitted. The cumulative likelihood of admission within three months was estimated using the Government Statistical Service method and compared with estimates which relaxed the assumption of stationarity and reflected variation in the numbers recruited to, and admitted from, the waiting list each quarter. The difference between the two estimates ranged from +5.5 to -9.1 percentage points among 11 Orthopaedic waiting lists in South Thames Region. In the absence of information on 'times-to-admission', exact 'times-since-enrolment' were extracted from Hospital Episode Statistics and assumed to be similarly distributed. In the absence of information on 'times-to-competing-event', the number of competing events falling in each waiting time category was estimated by differencing. A period lifetable was constructed using these approximations, census counts, counts of the number of new recruits and estimates of the number 'reset-to-zero' each quarter. The results support the view that the method used by the Government Statistical Service overestimates the cumulative likelihood of elective admission among those listed. The Government Statistical Service calculates the cumulative likelihood of admission within three months (range: 0.62-0.27) conditional on the fact of admission. Multiplying by the unconditional likelihood of being admitted (range: 0.93-0.31) estimates the cumulative likelihood of admission within three months among those listed (range: 0.55-0.12) and gives a rather different ranking of waiting list performance among 34 Orthopaedic waiting lists in South Thames Region.