Tackling the NHS waiting list backlog will mean taking tough – and unpopular – decisions
3 min read
A National Audit Office (NAO) report published in December 2021 found nearly six million people in England on waiting lists for elective care. Of these, 300,000 of them had been waiting for more than a year; and about a quarter of patients with an urgent GP referral for cancer were waiting two months or more to start treatment.
Millions of people have avoided seeking treatment or have been unable to obtain referrals for health care during the pandemic.
The NAO estimates that between March 2020 and September 2021 there were between 7.6 million and 9.1 million fewer referrals for elective care. It is unclear if or when these “missing” people will seek NHS treatment. If half the “missing” referrals for elective care do return and NHS activity growth is the same as planned before the pandemic, then the NAO estimates that elective care waiting lists will reach 12 million by March 2025 – more than 20 per cent of the population.
These are staggering figures and show what a mountain the NHS now has to climb. So far, the government has said it will provide the NHS in England with an extra £8bn over three financial years, starting in April 2022. It expects the NHS to increase its elective care activity by the end of this period by 10 per cent more than pre-pandemic plans. Even so, the NAO thinks that if half the “missing” people return to the NHS there will still be seven million people left on the waiting list in 2025. It remains unclear how much extra funding for the NHS will actually find its way to reducing waiting times and backlogs.
Millions of people have avoided seeking treatment or have been unable to obtain referrals for health care during the pandemic
Extra funding is not the only issue. The NHS is the largest employer in the country, with about 1.3 million staff. Historically it has relied on recruiting many doctors, nurses and other staff from overseas. Brexit and tighter immigration controls have reduced the flow from these sources, both in the NHS and social care. The shortage of funding and staff in social care continues to reduce NHS ability to discharge patients who don’t need a hospital bed. There are now serious staff shortages in both the NHS and social care and no credible workforce plans for delivering the extra million staff said to be needed in the two sectors by 2031.
The NHS is essentially a monopoly provider of clinical services with considerable geographical disparities in performance, as regulators have revealed. While it often responds well to a crisis, it can drift when the crisis ends. Even with substantially increased investment it can be difficult to secure improved NHS performance, as the Blair government found in the noughties. Some new tools were needed in the ministerial toolbox to improve patient access to treatment.
These tools were targets, more competition and greater patient choice. There were new, clear national targets for GP access, A&E waits, providing cancer treatment and a maximum 18-week wait for all specialist treatment. There was a No 10 delivery unit monitoring public service performance targets. Private sector diagnostic and treatment capacity for elective surgery was increased for NHS patients by about 10 to 12 per cent, but at the same price as NHS services. NHS foundation trusts could compete for patients. Patients had more choice of hospital where they could have elective surgery.
This approach was not always popular with NHS staff who preferred the extra investment to the higher patient expectations. But patient outcomes and public satisfaction increased. As with many public services, when the going gets tough, governments have to choose who they wish to be popular with – the recipients or providers of those services.
Lord Warner is a Crossbench peer and former health minister
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