Background
In March 2010, the NHS Constitution was updated to include a new right for patients to start consultant-led treatment for non-urgent conditions within a maximum of 18 weeks of a GP referral. In 2012, it became a statutory requirement that at least 92% of patients should have a referral-to-treatment time of less than 18 weeks. In 2013/14, NHS England set an operational standard to ensure that no-one waits more than 52 weeks for treatment.
In March 2020, after the onset of the Covid-19 pandemic, non-urgent elective activity was postponed to free up inpatient and critical care capacity. In July 2020, national guidance was published outlining targets to return to near-normal levels of elective activity by autumn, but as Covid-19 cases rose over winter 2020/21, activity was disrupted again.
The elective recovery plan was published in February 2022 and set targets to reduce long waits for elective treatment – namely, to eliminate waits of over 104 weeks by July 2022, waits of over 78 weeks by April 2023, 65 week waits by March 2024, and 52 week waits by March 2025. The longest waits were set to be eliminated first, followed by those that have been waiting for a shorter time. £14 billion of capital and resource funding was allocated to support the recovery of elective and cancer services for 2022/23 to 2023/24.
Waiting list for elective treatment
In mid-2007, 4.2 million people were waiting for elective care, which reduced drastically to 2.3 million by the winter of 2009. After this, there were clear seasonal trends with the list growing over the summer and shrinking in the winter, but there has concurrently been a large increase in the number of people on the waiting list for elective treatment. In February 2020, just before the Covid-19 pandemic, there were over 4.4 million people on the reported waiting list, and together with the estimate for missing data the total number of people waiting for treatment exceeded 4.5 million.
In March 2020, the number of people on the waiting list began to fall. Although elective activity fell during the first wave of the pandemic, there was a larger drop in GP referrals, resulting in an overall reduction in the waiting list. The total waiting list reached a low of 3.9 million in May 2020 (reported waiting list plus the estimate for missing data).
Since then, the waiting list for elective care has increased rapidly, at a faster rate than prior to the pandemic. Since May 2023, over 7.5 million people have been on the waiting list, with the highest ever number of 7.75 million people recorded in August 2023. Whilst the industrial action by junior doctors, consultants, nurses and other NHS staff throughout 2023 and 2024 impacted the waiting list, the extent of the continued long waits comes from a multitude of factors such as funding and bed capacity.
Waiting a long time for treatment can have detrimental effects on patients. It can result in worse prognosis, a need for more complex surgery, increased medication, and a slower process of recovery. Targets have been set in place to increase elective activity by 2024/25 which will address the elective care backlog and reduce the length of waits.
Long waits for elective treatment
The number of patients still waiting over 52 weeks for elective treatment after referral fell dramatically between 2007 and 2009 from 578,682 in August 2007 to 82,232 in January 2008. There was a small peak in the summer of 2011 to around 20,000 patients, which corresponds to the relaxation of the central performance management of the targets in June 2010. After this, the number of people waiting over 52 weeks for treatment dropped to a low of 214 patients in November 2013. Between 2013 and 2020, there was a gradual increase in the number of patients waiting over 52 weeks, to 1,613 patients in February 2020.
Between March 2020 and March 2021, the number waiting over 52 weeks increased sharply, from 3,097 to 436,127. By August 2021, it decreased to 292,138 before steadily climbing back up during 2022. In January 2024, 321,394 people had been waiting over 52 weeks – 196 times more than the number in January 2020. NHS planning guidance has set a target to eliminate 52-week waits by March 2025.
The number of patients waiting over 52 weeks grew tremendously following the onset of the Covid-19 pandemic (as referenced above). Studying the trajectory of even longer waits (65 weeks and 78 weeks) provides a more nuanced picture of the elective care backlog and demonstrates how waiting time patterns differ based on the wait duration in question. The number of patients waiting over 52 weeks for elective treatment fell sharply between April 2021 and June 2021. However, during this period, the number of patients waiting over 65 weeks and 78 weeks increased. Since June 2021, the number of patients waiting over 52 weeks has increased gradually, reaching 410,983 in October 2022. Between October 2022 and January 2024, it decreased slightly to 321,394.
While the number of patients waiting over 52 weeks showed an overall increase from June 2021 onwards, patients waiting over 65 weeks decreased. Between June 2021 and January 2024, patients waiting over 65 weeks dropped from 233,051 to 92,213. The goal of eliminating the over 65-week wait, which was originally meant to be achieved by March 2024, has now been moved to September 2024, according to the 2024/25 planning guidance.
A similar trend was observed for patients waiting over 78 weeks. Barring an increase from June 2021 to September 2021, the number of patients waiting over 78 weeks decreased sharply to 10,718 in March 2023. The target to eliminate 78-week waits by April 2023 has not been met despite the recent fall in numbers as 11,477 patients remained on the waiting list at that time. This number slightly increased to 14,013 in January 2024. Considerably more improvement in reduction of long waits is needed for targets to be reached.
Waiting times for elective treatment
The proportion of patients who were either admitted for treatment, still waiting for treatment or a decision had been made that they did not require elective treatment within 18 weeks of a GP referral increased considerably between August 2007 and August 2008. During this time, performance targets were introduced for 90% of admitted patients and 95% of non-admitted patients to start treatment within 18 weeks of referral. For patients still waiting for treatment (the waiting list), the target was set at 92%. In June 2015, the admitted and non-admitted targets were abolished and the target for patients still waiting became the sole measure of treatment waiting time performance.
Since its introduction, performance against the 92% waiting list target has decreased. The target was first breached in December 2015, when 91.8% of patients waited less than 18 weeks, and has continued to decline. Performance fluctuated at the start of the Covid-19 pandemic, reaching a low of 47% in July 2020, then increasing to 68% in November 2020. In January 2024, only 57% of patients had been waiting less than 18 weeks to start elective treatment – similar to the previous year.
The percentage of admitted patients who waited less than 18 weeks from referral has fluctuated greatly since the Covid-19 outbreak, reaching a high of 90% in April 2020 and low of 54% in August 2020. Waiting times for admitted patients have since stabilised but continue to worsen – in January 2024, 60% of patients were admitted for treatment within 18 weeks of referral.
Waiting times for elective treatment vary considerably by specialty. In January 2024, no specialty met the target of 92% of patients waiting less than 18 weeks. The specialties with the lowest proportion of patients waiting less than 18 weeks in January 2024 were plastic surgery (51.5%), oral surgery (49.5%) and ear, nose and throat (48.3%). These specialities were in similar positions the previous year, having seeing only a very small improvement. Conversely, the specialties with the highest proportion of patients waiting less than 18 weeks for the same month were elderly medicine (77.4%), other (unspecified) services (69.7%) and mental health (68%). In parallel to the bottom three, these specialities also had the highest proportions of patients waiting less than 18 weeks in January of 2023, and their numbers have slightly decreased (data not shown).
About this data
Once there has been a decision from a consultant that a patient needs treatment and they have been referred to a hospital, they are on the waiting list and the clock starts on their referral-to-treatment waiting time. There are three different treatment pathways that are measured each month:
- Admitted referral-to-treatment pathways are waiting times for patients whose treatment started during the month and involved admission to hospital.
- Non-admitted referral-to-treatment pathways are waiting times for patients whose wait ended during the month for reasons other than an inpatient or day case admission to hospital for treatment.
- Incomplete referral-to-treatment pathways are waiting times for patients still waiting to start treatment at the end of the month.
Since October 2015, no adjustments have been made to admitted referral-to-treatment pathways for clock pauses, where a patient declined reasonable offers of admission and chose to wait longer.
For further guidance on referral-to-treatment waiting times, please see the NHS England website.