National Audit Office report on NHS backlogs and waiting times in England

Recovering elective and cancer care performance to the standards required will be a huge and lengthy challenge for the NHS, and there is a real risk that the waiting list for patients seeking elective care will be longer in 2025 than it is today, according to analysis from the National Audit Office (NAO).

The government is providing the NHS in England with an additional £8 billion between 2022-23 and 2024-25 to support the recovery of elective care. With the extra funding, it expects the NHS to increase elective care activity by 2024-25 by 10% more than its pre-pandemic plans.

Before the COVID-19 pandemic, the NHS was doing more work year-on-year, but demand for its services was increasing even faster.¹ Between 2010 and 2019, NHS resources changed unevenly: the number of consultants grew at over 3% a year, but there was almost no change in nurse numbers, and there was an annual 1.1% reduction in the number of general and acute care (non-critical care) beds available for overnight use. To keep pace with the demand for its services, the NHS would have needed either more beds and more staff or a different way of working, or a combination of the two.

Performance against NHS waiting times standards had generally been deteriorating prior to the COVID-19 pandemic.²The main standard for elective care is that 92% of patients on the waiting list should start their treatment within 18 weeks of being referred to a consultant.³ In February 2020 - the last month before the impact of the pandemic was felt - 17% of elective care patients had been waiting for longer than 18 weeks. There are nine waiting time standards for cancer care, including a standard that 85% of patients should wait no more than 62 days to start treatment after an urgent referral by a GP. Between August 2018 and February 2020, 22% of people had to wait for more than 62 days.

Since the start of the COVID-19 pandemic, the NHS has had to redirect much of its resources to treat COVID-19 patients and to implement infection, prevention and control measures. In January 2021, an average of 24,100 general and acute care beds were being used by COVID-19 patients (31% of all those occupied).4 Between January and September 2021, an average of 35% of unoccupied general and acute care beds had to be set aside for COVID-19 patients.

COVID-19 disruption was inevitably going to cause a sharp increase in waiting times and backlogs in a healthcare system that had been operating at very close to its maximum capacity. By September 2021, there were 5.83 million patients on the waiting list for elective care, of whom 1.95 million patients had been waiting for more than 18 weeks, including 301,000 waiting for more than a year. By June 2021, NHS cancer services activity had recovered to pre-pandemic levels. However, since the start of the pandemic (up to September 2021), patients with an urgent GP referral for cancer were more likely to be delayed - 26% had to wait more than 62 days for treatment to start.

Millions of people have also avoided seeking or been unable to obtain referrals for healthcare during the COVID-19 pandemic. The NAO estimates that there were between 240,000 and 740,000 "missing" urgent GP referrals for suspected cancer during the pandemic. In addition, the NAO estimates that up to September 2021 between 35,000 and 60,000 fewer people started treatment for cancer than would have been expected. Over the same period - March 2020 to September 2021 - the NAO estimates there were between 7.6 million and 9.1 million fewer referrals for elective care.  The NAO recognises that there is inherent uncertainty about these estimates.

It is also uncertain how many of the "missing" cases will return to the NHS to seek treatment and over what time period, though clearly many will. The NHS will need to increase its activity to meet this surge in demand. Even if it can adapt, the scale of the challenge it faces is daunting. If 50% of "missing" referrals for elective care return to the NHS and its activity grows only in line with pre-pandemic plans, the elective care waiting list will reach 12 million by March 2025. If 50% of "missing" referrals return and the NHS can increase activity by 10% more than was planned, the waiting list in March 2025 will still be 7 million.

Addressing backlogs and reducing waiting times will be a multi-faceted challenge for the NHS. Announcements about additional funding in September and October 2021 answer some questions but important uncertainties about the road to recovery remain. To increase the numbers of hospital beds, nurses and doctors beyond the levels already planned could take years because of the time required for capital projects and for training. The ongoing COVID-19 pandemic could also continue to affect bed and staff availability in unexpected ways and at short notice.

 Today's NAO report highlights how tackling the difficulties ahead will require: 

• extra beds and operating theatre capacity beyond the levels that were planned before the COVID-19 pandemic;
• managing the ongoing pressure on the NHS workforce, including long-standing staff shortages; and 
• ensuring that existing health inequalities are not perpetuated or exacerbated.⁵ 

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Notes for Editors

1. Between 2016 and 2019, there was an average annual growth in elective care referrals of over 2%. Between 2010 and 2019, there was an annual average growth in urgent cancer referrals from GPs of over 10%. This increase partly reflects greater incidence of cancer in England, but much of the growth is the result of the NHS deliberately encouraging more people to come forward for screening or to have suspicious symptoms investigated.
2. The NAO report NHS waiting times for elective and cancer treatment (2019) found that rising demand for healthcare, particularly cancer care, had combined with a period of increased financial constraint to cause more patients to have to wait longer.
3. In broad terms, ‘elective care' means any non-emergency care planned by consultants, for instance hip and knee replacements or cataract or tonsil removal.
4. General and acute care beds are under the control of consultants and activity covering over 90% of medical specialties is classed as general and acute. The other categories of speciality not included are maternity, mental health and learning disabilities. Critical care beds are counted separately. 
5. NHS England & NHS Improvement has been developing recovery plans and detailed expectations for 2022-23 and beyond. The NAO intends to follow today's report with a second one, examining the plans to improve this situation and evaluating the NHS's early progress.