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

According to the National Audit Office (NAO), the plan to reduce long waits for NHS elective and cancer care services by 2025 is at serious risk. The funding government allocated for recovering services has not kept pace with inflation, and the NHS faces significant workforce and productivity issues.

In December 2021, the NAO reported that at the start of the COVID-19 pandemic the NHS had not met its standard for elective care¹ for four years nor its full set of eight standards for cancer services for six years.² The waiting list for elective care then grew from 4.4 million in February 2020 to 5.8 million by September 2021. In February 2022, NHS England (NHSE) published a plan to recover elective and cancer care (the recovery plan) over the three years up to March 2025. The Department for Health and Social Care (DHSC) funds the recovery plan and is responsible for holding NHSE to account.

NHSE intends that, by March 2025, elective care waits of more than one year should be eliminated, and that, by March 2023, the number of patients waiting more than 62 days from an urgent referral for cancer care should return to pre-pandemic levels. However, even if the objectives of the recovery plan are met,³ many patients will still be waiting longer than standards state - elective care patients should start their treatment within 18 weeks, and cancer patients within 62 days of an urgent referral by their GP.⁴

NHSE is aiming to increase elective care activity sharply to reach 129% of 2019-20 levels in 2024-25. This would be an historic achievement - it previously took 5 years (2013-14 to 2018-19) to increase elective activity by 18%. Even if NHSE meets this aim, it is unclear whether increasing elective activity to 129% would be sufficient to meet the other commitments in the recovery plan.

During 2022-23 so far, overall elective care activity has remained below the planned trajectory for reaching 129% of 2019-20 levels by 2024-25. By July 2022, the NHS came close to ending elective care waits of more than two years, but thewaiting list has continued to increase - reaching 7.0 million patients in August 2022. This includes 387,000 patients who have already waited longer than a year for treatment, compared with just 1,600 in February 2020. 26 of the 42 NHS Integrated Care Systems⁵ have signalled in their plans that they will not reach their 2022-23 target of delivering 104% of 2019-20 levels of elective care activity.

NHSE's programme to recover elective care partly relies on initiatives which have potential but for which there is so far limited evidence of effectiveness. It wants GPs to handle many elective cases usually referred to hospital doctors. This might add to GPs' workload in the context of a 4% decrease in the fully-qualified permanent GP workforce between 2017 and 2022. Surgical hubs and community diagnostic centres can contribute to recovery, but their impact will need to be closely monitored - capacity could be reduced if their host hospital or other NHS and social care services in their local area come under pressure.

Urgent referrals for suspected cancer have increased compared with 2019-20, but the NHS is not treating all cancer patients in a timely way. Between April and August 2022, GPs urgently referred 15% more people with suspected cancer than in the same period in 2019. The welcome increase in patients coming forward has, however, highlighted the inadequacy of current diagnostic and treatment capacity. In 2022-23 up to the end of August, only 62% of patients started cancer treatment within 62 days, compared with 78% of patients in the equivalent period in 2019-20.

Inflation has eroded the value of both the £14 billion specifically allocated to the recovery plan and the wider planned increases in NHSE's budget. In the October 2021 Budget, NHSE was allocated an additional £8 billion of resource and £5.9 billion of capital funding for the recovery plan for the period 2022-23 to 2024-25. At that time, the total NHSE funding settlement provided for average annual real terms growth of 3.8% in resource funding up to 2024-25. But the NAO estimates that, as at September 2022, this settlement represented an average annual growth in funding of just 3.3% in real terms because of higher forecast inflation.

NHSE estimates that in 2021 productivity in the NHS was 16% lower than before the COVID-19 pandemic. Some of this results directly from the pandemic, such as increased sickness absence and infection prevention and control measures. An internal NHSE review identified a range of other causes including reduced willingness to work paid or unpaid overtime. NHSE believes reduced productivity has continued in 2022-23.

There are many challenges threatening to push the recovery plan further off track, including high numbers of unfilled posts and low morale among the NHS workforce. The NAO recommends that DHSC and NHSE review the progress of the recovery plan in early 2023-24, and decide whether targets and funding allocations need to be adjusted. Before April 2023, DHSC and NHSE should clearly and fully define metrics for increasing activity and reducing long waits. In 2024-25, they should publish a strategy for returning elective and cancer care services to a state where legal standards are met.

Gareth Davies, the head of the NAO, said:

"There are significant risks to the delivery of the plan to reduce long waits for elective and cancer care services by 2025. The NHS faces workforce shortages and inflationary pressures, and it will need to be agile in responding as the results of different initiatives in the recovery programme emerge.

"DHSC has an essential role to play, holding the NHS to account for its delivery of the recovery plan and providing more challenge and support when it is needed."

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Notes for Editors

1. In broad terms, ‘elective care' means any non-emergency care planned by consultants, for instance hip and knee replacements or cataract or tonsil removal.

2. This is the NAO's second report on NHS backlogs since the start of the pandemic.  The first report, NHS backlogs and waiting times in England, was published in December 2021. It looked in detail at the backlogs and waiting times and why they had built up. 
3. The recovery plan's 2025 targets for elective and cancer care are supported by the following interim targets:

• Elective care waits of more than 104 weeks should have been eliminated from July 2022.
• Elective care waits of more than 78 weeks should be eliminated from April 2023.
• Elective care waits of more than 65 weeks should be eliminated from March 2024.
• Elective care waits of more than 52 weeks should be eliminated from March 2025.
• The weekly backlog of cancer patients waiting more than 62 days from urgent referral should be reduced to 14,266 by March 2023.
• 75% of urgent GP referrals for suspected cancer should be diagnosed or ruled out within 28 days from March 2024.

4. The main standard for elective care is that 92% of patients on the waiting list should wait no more than 18 weeks to start treatment. There are nine long-standing waiting time standards for cancer care, eight of which have had operational targets attached to them, including a standard that 85% of patients should wait no more than 62 days to start treatment after an urgent referral by a GP. One additional cancer waiting time standard was introduced from April 2021.
5. Integrated Care Systems replaced Clinical Commissioning Groups, see the NAO's report Introducing Integrated Care Systems: joining up local services to improve health outcomes.