Still waiting: Is it just England that still has a backlog problem?

The NHS wasn’t the only health system that experienced severe disruption of care during the pandemic, but how quickly have waiting times in England recovered in comparison to other nations? Sarah Reed and Theo Georghiou look at how waiting times have changed in England and in other countries since the peak of the Covid-19 crisis.

Long read

Published: 11/07/2024

Waiting times for NHS care were understandably a major campaign issue before last week’s election, with the new government inheriting an elective treatment waiting list of around 7.5 million in England. This is a 66% increase since the start of the pandemic, although the decade leading up to the pandemic saw persistently increasing numbers of patients waiting. While recent waiting list numbers for elective care have been marginally better than at their peak in the autumn of 2023, progress has stagnated and long waits remain endemic in the NHS.

We know that the NHS is far from the only health system that experienced severe disruptions to care during the pandemic and saw waiting times increase as a result. But in other countries, have these long waits been a passing blip, or part of an ongoing problem as they have been in England? 

In 2022, we looked at how other health systems were starting to recover from the pandemic, and how the size and scale of care backlogs varied across countries. In this long read, we review the most recent data available to understand how waiting times have changed in England and in other countries since the peak of the crisis. We discuss the main patterns that emerge and the questions they raise for how England compares.  

A note on methods and country selection:

The many methodological differences in how and what health systems measure to record waiting times can account for some of the dissimilarities we see in waiting times across systems. We make note of key definitional differences throughout our analysis that may limit comparability. 

We primarily focus our analysis on how median waiting times changed over seven years, spanning pre- and post-Covid periods (2017 to 2023). 

The median waiting time is defined as the number of days which divides the waiting population in half: 50% waited fewer days than the median, 50% waited more. 

In our analysis, we focus less on the absolute waiting times for different countries (to better account for definitional differences), but rather how median waiting times have changed in each country post-2020 versus pre-2020.

We limited our analysis to other high-income countries with comparable health systems and recent data included in OECD health statistics. Some countries have been excluded – ie Denmark – due to modifications in how waiting times have been calculated pre- and post- 2020 that make it difficult to understand trends. 

We use OECD health statistics for each country except England, which have been calculated using NHS England Hospital Episode Statistics (HES). This is because the UK has not submitted waiting times data to OECD health statistics since 2020, although we were able to closely reproduce OECD figures for England pre-2020. OECD health statistics only cover up to 2022, but for England we have calculated an additional year (2023). England data derived from HES data include NHS patients treated in both NHS and private hospitals.

The OECD and HES-derived waits are waiting times from specialist assessment to treatment. As such they only tell us about the waits for individuals who have received treatment in each year.  


For some major surgeries, median waiting times are further from their pre-Covid baseline in England than in most other countries

England’s relative performance and pace of elective recovery varies depending on the procedure in question.

Looking at two major surgeries – hip replacements and knee replacements – median waiting times in England rose more substantially relative to other countries, and remained stubbornly high into 2023. 

Median waiting times for hip replacements (see chart below) jumped from around 87 days before 2020 to 180 days in 2020. For the three subsequent years, median waits remained around 128 days, nearly 50% longer than the median 87 days before 2020. England was among other poorer performers including Australia, Canada and New Zealand. 

In Canada, median waiting times for hip replacements deteriorated by a similar degree, and in 2022 also stood over 50% higher than their pre-Covid levels. Australia looks similar according to their latest data (only available to 2021), but an important contextual point here is that Australian data only includes public hospitals when most elective surgeries are performed privately, so median waiting times for the general population may differ. 

New Zealand shows a different trend, where waiting times slowly increased in the years leading up to the pandemic, but did not increase significantly until 2022. This likely reflects contextual differences in how New Zealand experienced the pandemic, with Covid-19 cases peaking later than in other countries included in our analysis. 

Other countries we looked at appeared to perform better, with little change in post-2020 median waits compared to pre-2020 (Spain and Finland), or even lower median waits (in the case of Italy). In Norway and Sweden, median waits have also increased compared to pre-pandemic levels, but to a lesser degree than England.

It is also worth noting that even where England is a worse performer in terms of the relative change in median waiting times pre- and post-2020, in absolute terms median waits appear lower in England than in several countries. This includes some health systems where median waiting times increased more modestly compared to pre-2020 averages, such as Portugal. (Though again, the many definitional differences in how countries calculate waiting times makes us less interested in how they compare in absolute terms versus the overall trend in each country over time.)      

The picture was broadly similar to the above for knee replacements (see chart below). England was again in the poorer performing pack of countries (alongside Canada, Sweden and New Zealand). Median waits rose from around 91 days before 2020 to 209 days in 2020, and in the three years since remained around 142 days. 

Post-2020 median waits for knee replacements in Spain, Italy, Portugal and Finland appeared to be similar to, or shorter, than their pre-2020 values.   


But for cataract surgeries, median waiting times in England have improved quicker than nearly everywhere else 

Looking at waiting times for cataract surgeries, we see a vastly different picture than we did for orthopaedic surgeries. Median waits in England appear to have been better insulated from the effects of Covid-19 compared to many other countries, and have steadily improved over time. Before 2020, median waits were around 63 days. This dropped in 2020 to 58 days, and in the three subsequent years fell even more substantially to an average of 42 days (36 days in the latest year of 2023).  

Finland, Italy and Portugal were other countries whose median waiting times improved on pre-2020 levels. Meanwhile, waits in New Zealand and (especially) Australia rose.  


So what does this all tell us? 

How do we make sense of this seemingly contradictory view of England’s performance, and the variation we see across systems? 

Looking first at major surgeries, that waiting times surged to the extent they did in 2020 and appear to have been slower to recover raise important questions. We know that many other health systems had similar policies to cancel or defer elective procedures at the start of the pandemic as England, but it may be that some other countries were better able to restart routine health services and catch up in between waves of the pandemic – either because of more resilient services, fewer Covid-19 hospitalisations, or both. 

Hip and knee replacements are intensive procedures that typically require inpatient stays and extensive rehabilitation, unlike cataract surgeries that often can be performed with a day admission using only local anaesthetic and are therefore far easier to scale. Even though private hospitals have been turned to as a means of addressing waits for both specialties (in 2021/2022, private hospitals performed 50.5% of hip and knee replacements in England and 45.6% of cataract surgeries), it has been far more difficult to return orthopaedic volumes to pre-pandemic levels given finite numbers of staff across both NHS and private services to meet demand. In contrast, volumes of cataract operations in England are now much higher than they were pre-Covid.

This may be reflective of the structural vulnerabilities that the NHS had going into the pandemic, and which have made recovery a challenge. England has fewer hospital beds, lower numbers of key staff and lower levels of capital investment than many other high-income countries. Bringing down waiting times for major surgery also requires all parts of the system to work together, including post-operative rehabilitation and community support where we know that the NHS has struggled relative to other countries. Growing waits were a problem well before the pandemic started. 

And while waiting times will be influenced by many variables and contextual differences across health systems, countries that had more headroom to balance Covid-19 and non-Covid-19 services throughout the pandemic – and had kept up with routine pressures before it – are likely to have been better placed to return waiting times to some level of pre-pandemic normalcy. But we should also be careful not to overinterpret England’s relative performance. Countries where waiting times have been more stable in the aftermath of the pandemic may obscure other access issues. For example, in Italy, Portugal and Spain – where waiting times have appeared to stabilise or improve – there have been concerns that this is due to fewer referrals being received from primary care or patients having difficulty accessing appointments. 

There is no question that increasing waiting times are a shared challenge across health systems, even if the degree of that challenge differs. And until we have data from more recent years from more countries, we cannot fully understand whether increased waiting times in other systems will be a passing issue or the start of an entrenched problem as we see here in the NHS. But regardless of England’s position internationally, improving waiting times for major and complex procedures is a major challenge for the new government. That some other systems have been able to restore waiting times more quickly raises important questions about why – and what it might take to improve. 

Hospital Episode Statistics data (2017/18 to 2023/24) Copyright © (2024), NHS England. Re-used with the permission of NHS England. All rights reserved.

Data note

English median waits were calculated separately for each financial year, using Hospital Episode Statistics Admitted Patient Care (HES APC) datasets. “2017” is 2017/18, and so on. Note that 2023 (2023/24) values are calculated using provisional data. 

Activity was included where the following were recorded against an episode of care: 

  • episode order is 1 (admission episode) 
  • patient classification is 1 or 2 (ordinary or day case admissions)
  • admission method is 11 or 12 (waiting list or booked only, and not “13 = planned”) 
  • administrative category is 01 (NHS patients)
  • specific operation (and diagnostic) fields recorded – see below.

The variable ‘elecdur’ was used to give the number of days waiting. This is a derived field which is the difference between the date on which it was decided to admit the patient and the admission date. Activity included in the three analysis groups was determined via primary operation codes, and additionally - in the case of cataracts - diagnostic codes. 

Hips: Primary operation code starts with any of W37, W38, W39, W46, W47, W48, W93, W94, W95 

Knees: Primary operation code starts with any of W40, W41, W42, O18 


Where both exist: 

Primary operation code starts with any of C71, C72, C73, C74, C75, C776, and Diagnosis code (any position) starts with any of E46, H26, H25, E039, E103, E113, E123, E133, E143, E200, E201, E208, E209, E349, E639, E889, G711, H280, H281, H282, Q120.