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, 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.
In March 2021, NHS England’s 2021/22 priorities and operational planning guidance was published. It set thresholds for the recovery of elective activity, increasing from 70% of the value of 2019/20 activity in April to 85% from July to September 2021. In July, the threshold was increased to 95% of the value of 2019/20 activity. Local systems that achieve activity levels above the thresholds are eligible to access additional funding through the Elective Recovery Fund.
A review of NHS access standards began in 2019. The interim report proposed an average wait target for people on the waiting list as a potential alternative to the current 18-week threshold target. Twelve hospital trusts began testing the use of an average (mean) wait measure in early August 2019, but publication of the review’s recommendations has been delayed due to the Covid-19 pandemic. Performance of the field test sites continues to be included in the national time series, so the most recent referral-to-treatment data is unaffected by the field testing.
For further information, read the latest Nuffield Trust blog on what the proposed changes to treatment waiting time targets could mean for hospitals and patients.
The proportion of patients starting consultant-led non-emergency treatment within 18 weeks of a GP referral was consistently high following the introduction of the various referral-to-treatment waiting time targets. The targets were that 90% of admitted patients and 95% of non-admitted patients should 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.
The 92% target for patients still waiting was breached for the first time in December 2015. Since then performance has worsened, and the target has not been met in five years. In March 2020, performance fell sharply during the Covid-19 pandemic, reaching a low of 47% in July 2020. Performance has since improved slightly, but remains lower than before the pandemic. In July 2021, only 68% of patients had been waiting less than 18 weeks to start elective treatment.
The percentage of admitted patients starting treatment within 18 weeks of referral increased to 90% in April 2020, from 69% in February 2020. This corresponds to a considerable fall in the number of patients starting treatment, with almost seven times fewer admitted patients starting treatment in April 2020 than in February 2020. Waiting times for admitted patients have since worsened – in July 2021, 64% of admitted patients started treatment within 18 weeks of referral.
Waiting times for elective treatment vary considerably by specialty. In July 2021, no specialty met the target for 92% of patients to start treatment within 18 weeks of referrals. The specialties with the lowest proportion of patients waiting less than 18 weeks in July 2021 were ear, nose and throat (59%), oral surgery (59%) and trauma and orthopaedics (61%). This compared to 91% of patients in elderly medicine. The percentage of patients waiting less than 52 weeks to start treatment follows a similar pattern, ranging from 99.7% for elderly medicine to 89% for plastic surgery.
In mid-2007, the waiting list for elective care contained 4.2 million people, but this was reduced drastically to 2.3 million by the winter of 2009. After this, there have been clear seasonal trends with the list growing over the summer and shrinking in the winter. Beyond these seasonal changes, there has 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. In July 2021, there were over 5.6 million people on the waiting list, the highest number since records began. The waiting list may continue to rise while elective activity levels remain lower than before the onset of the pandemic.
The number of patients still waiting for elective treatment over 52 weeks after referral fell dramatically between 2007 and 2009. There was a 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.
In March 2020, the number waiting over 52 weeks began to increase dramatically, reaching a high of 436,127 in March 2021. By July 2021, it had decreased slightly to 293,102, but this was still 284 times higher than in July 2019.
The median referral-to-treatment waiting times fluctuate from month to month, but overall there has been an increase in median waits for all pathways. Between February 2011 and February 2020, waits for patients still waiting increased by 2 weeks, waits for admitted patients increased by 1.8 weeks and waits for non-admitted patients increased by 2.9 weeks.
After non-urgent elective activity was postponed during the Covid-19 pandemic, the median waiting time for patients still waiting increased sharply to a high of 20 weeks in July 2020. As activity began to resume, the median waiting time fell but remained higher than before the pandemic. In July 2021, the median waiting time for patients still waiting was 11 weeks. The median waiting time in July 2021 was 4.5 weeks longer for admitted patients than non-admitted patients.
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.