In the initial response to the pandemic in the spring of 2020, the NHS paused non-urgent elective (planned) treatment to free up hospital capacity for the influx of Covid-19 hospitalisations. The impact this had on an already strained system is still being felt two years later. With the overall waiting list already having almost doubled between 2010 and 2020, from 2.3 million to 4.4 million, by March 2022 the elective care waiting list ballooned to 6.3 million – a yawning gap between demand and provision that is estimated to rise further.
While this backlog is a national issue, its severity is not felt equally across the country. There are 42 Integrated Care Systems (ICSs) in England working across hospitals and GPs, social care and local authorities to transform elective care and increase activity, but some of them face much greater challenges than others in reducing the backlog.
In this QualityWatch blog, we dive deeper into the current state of elective care and explore variations across ICSs.
How has the elective waiting list changed since the start of the Covid-19 pandemic?
The elective care waiting list across England grew by 40% from 4.4 million to 6.2 million between February 2020 and February 2022. All ICSs saw an increase in their elective care waiting lists in the same time period. In February 2022, the population-standardised elective care waiting list across ICSs ranged from 739 per 10,000 population in Frimley to 1,413 per 10,000 population in Birmingham and Solihull. That the largest waiting list is almost double the size of the smallest highlights the scale of variation.
Some ICSs have seen little increase in their waiting list: Gloucestershire’s waiting list increased by only 7%, from 843 per 10,000 population to 900 per 10,000 population. In contrast, Cambridge and Peterborough, who had the smallest waiting list relative to its population in February 2020, saw its waiting list almost triple, from 331 per 10,000 population to 951 per 10,000 population.
Patients have a right, as stated in the NHS Constitution, to start receiving elective care within 18 weeks of a referral. Yet nationally, the proportion of patients on the elective care waiting list who have already waited over 18 weeks increased from 17% (744,997) to 37% (2,311,758) between February 2020 and February 2022 respectively.
Although no ICS met the 18-week target in February 2022, patients are more likely to be seen sooner in some areas of the country than others. In South West London, one in four (24%) patients had to wait more than 18 weeks, whereas in Leicester, Leicestershire and Rutland this was as high as one in two (50%).
Resurgence of long waits
Since the start of the pandemic, there has been an unwelcome rise in patients waiting over a year for elective care. Nationally, one in 20 patients (299,478) had been waiting over a year in February 2022 – 186 times more patients than in February 2020. It had been over 14 years since the NHS had this high a number of patients waiting over a year for elective treatment.
While there is a worrying increase in patients waiting over a year for elective treatment, some are waiting even longer. Of the patients waiting over a year in February 2022, almost one in four (23%) had been waiting over 18 months and 8% had been waiting over two years.
So how do these long waits vary across England? Quite notably. Just nine ICSs account for 52% of patients waiting over a year. In contrast, nine ICSs had fewer than 25 patients per 10,000 population waiting longer than a year.
What does this mean for the elective care recovery?
Long waiting times for elective treatment was one of the biggest factors for the drop in patient satisfaction with the NHS in 2021. With elective care waiting lists expected to grow before they get smaller, how the NHS recovers from the backlog of treatment will remain a key issue.
New guidance to tackle the elective care backlog sets targets to eliminate long waits through increased elective activity, investment in the workforce and transformation of elective care at ICS level.
While additional funding has been allocated to ICSs for elective recovery, budgets are still tight, and putting in place additional capacity is a challenge if the right equipment, facilities and trained staff are not available. How and when ICSs can increase activity and reduce waiting times is unclear.
What is clear is the unjustifiable variation in access to elective care, where some of the poorest areas have the largest waiting lists. As well as variation across the country, ICSs also need to consider inequalities when managing their own backlog. Long waits for elective treatment can impact patients’ quality of life and financial security, further compounding inequalities.
The task of elective care recovery looks very different in each ICS, and some will manage better than others. Hopefully, best practice and innovative approaches can be shared across the NHS.
About this data
The measure for the elective care waiting list per 10,000 population is constructed by dividing the number of referrals waiting for elective care at the end of the month by the population of an ICS.
Figures presented in this data blog are constructed using the Office for National Statistics mid-2020 clinical commissioning group (CCG) population estimates and NHS England’s consultant-led referral to treatment waiting time data. More information about these data sources is below.
Population size data for each integrated care system uses the Office for National Statistics’ mid-2020 CCG population estimates. This dataset lists each CCG, their respective sustainability and transformation partnership (STP) and a population estimate for the CCG, using the 2011 census data. STPs are now known as integrated care systems. Population estimates at this level are published to encourage further analysis. However, they cannot be guaranteed to be exact.
The same population estimates are used for the February 2020 and February 2022 consultant-led referral to treatment (RTT) waiting times data. The population estimates lose accuracy over time, consequently, the population estimates are less accurate for February 2022 than February 2020.
Elective care data
This blog uses data from the Incomplete Commissioner dataset, which is published each month as part of NHS England’s consultant-led referral to treatment (RTT) waiting times statistical publication. The elective care waiting list is defined as the number of patients waiting to start treatment at the end of the given month, referred to as incomplete pathways in this publication. Some consultant-led elective treatment is commissioned directly by NHS England instead of a specific ICS. Data for elective care commissioned by NHS England has not been included in the charts in this data blog; however, NHS England commissioned elective treatment is included in national figures.
For more information, please see the consultant-led referral to treatment waiting times rules and guidance and NHS England website.