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Almost £17bn needed to clear backlog and treat expected rise in patients needing NHS hospital care Further support and investment in staff and infrastructure also essential to address ‘huge challenge’ facing the NHS, warns Health Foundation

6 September 2021

About 6 mins to read

New analysis from the Health Foundation’s REAL Centre sets out the scale of the challenge facing government if it wants to clear the backlog in NHS care over the course of this parliament and return hospital waiting times to 18 weeks.  

The REAL Centre estimates it will cost up to £16.8bn over the remainder of this parliament (up to 2024/25) to enable the NHS to clear the backlog of people waiting for routine elective care, return to 18 weeks, and treat millions of ‘missing’ patients who were expected to receive care during the pandemic but did not. In all, this would allow an additional 2.2million extra patients to be seen a year.

The overall funding the NHS may need could yet be significantly higher than this as the REAL Centre’s modelling does not include the ongoing impact of COVID-19 on NHS productivity, and the additional investment that may be needed in primary and community services to support the recovery. They also warn that while major workforce shortages persist the NHS’ ability to clear the backlog, even with new funding, will be hampered.

The findings come ahead of the first day of oral evidence at the Health and Social Care Committee’s inquiry into clearing the NHS backlog. Anita Charlesworth, Director of Research and REAL Centre at the Health Foundation, will appear at the evidence session to explain the figures.

There is already a record waiting list of 5.5 million people waiting for routine hospital treatment, of which 1.7 million have been waiting more than 18 weeks. The new analysis highlights two options facing the government – to clear the backlog over the course of this Parliament, which will present significant challenges in terms of boosting staffing levels and capacity, or address the waiting list over a longer 8 year period. The findings published today are part of an in-depth analysis of the wider funding needed across the NHS and social care.

During the pandemic, millions of patients who were expected to be referred for treatment were not. The number of ‘missing patients’ is now approaching an estimated 8 million – this is in addition to the 5.5 million on the current waiting list. As services resume, some of the missing patients are expected to present to the NHS needing care, although precise numbers are uncertain. If 75% of the missing patients return and activity continues as usual, the waiting list could grow to 12.5 million. 

Ensuring 92% of patients are treated for routine hospital care within 18 weeks (the NHS constitutional standard) by the end of 2024/25 would require £4.2bn a year in additional funding between 2021/22 and 2024/25. However, the analysts highlight that even with this funding, there may not be capacity - in terms of staff, beds and equipment - to treat an additional 2.2 million patients annually for the next 4 years. 

Total NHS funding and the impact of COVID-19 

The cost of clearing the backlog forms a significant part of the money needed to enable the NHS to recover from the pandemic. A total NHS funding increase of between £4.0bn and £7.1bn in 2022/23 alone, with further funding in subsequent years, would be needed to meet growing demands for care, return to pre-pandemic standards, tackle the growing backlog, meet rising demand for mental health and primary care services and cover ongoing costs of the vaccination programme. Our lower funding estimate would mean clearing the elective backlog more slowly over the next decade, whereas the higher figure would achieve this by 2024/25. 

Importantly, these figures do not include the direct costs of COVID-19, such as caring for hospitalised patients, nor the indirect costs associated with reduced productivity as a result of things like social distancing and enhanced infection prevention and control measures. This is because the ongoing impact of COVID-19 on the NHS remains too uncertain to model conclusively. However, for every 1% reduction in productivity, an additional £1.5bn per year in additional funding will be needed to meet the same care demands. 

With COVID-19 moving from a pandemic to an endemic disease the report assumes that there will be ongoing costs from the vaccine programme, as well as significant impacts on the way NHS care is delivered. Our analysis suggests that if this led to a fall in productivity of 2–4% it would cost approximately an additional £3bn to £6bn (per year) to maintain the same level of care, and that would leave the NHS facing funding pressures of between £7bn and £13bn in 2022/23. 

To enable the NHS to recover from the impact of the pandemic, additional investment is also needed in capital infrastructure, public health and social care.  

NHS workforce and infrastructure 

Increased demand for services and the need to tackle the backlog indicate that the NHS workforce would need to grow by more than a third over the coming decade, on top of the recruitment needed to reduce current shortages. This would see the total NHS workforce grow by up to 277,500 full-time equivalent staff by 2024/25.  The growth would be higher if the NHS sought to reduce bed occupancy to provide more resilience to health shocks.   

The REAL Centre estimates that the capital budget will need to rise from £6.4bn in 2018/19 to £10.3bn in 2024/25 to enable investment in equipment and bed capacity. 

Social care 

A substantial increase in adult social care funding would be required to expand access to care, pay more for care to sustain the provider sector and pay higher wages. We estimate additional funding of between £3.7bn and £7.9bn in 2022/23 needed to allow for these improvements, over and above a budget of around £20bn. The higher end of the funding estimate would allow for more ambitious improvements. These increases are comparable to, or exceed the funding needs of the NHS and reflect to some extent the lack of funding for adult social care over the last decade, compared to the NHS.  

Anita Charlesworth, the Health Foundation’s Director of Research and REAL Centre said: 

‘COVID-19 will cast a long shadow over the NHS for many years to come, even with a successful vaccination programme. The government will need to provide at least £13.3bn to stop the long waiting list for NHS treatment growing even further over this parliament. Meeting the 18 week waiting times standard will require almost £17bn of dedicated funding up to 2024/25. This is a huge challenge and it’s not just about money; it will require many more doctors and nurses to provide the care.    

‘Long waits are not the only challenge facing the NHS. As the risks from COVID-19 continue the NHS needs to adapt to ensure it has enough capacity to treat outbreaks alongside the normal demands on the system. Enhanced infection control means the NHS can’t provide as much care as normal with the people and buildings it has. If heightened infection control measures are here to stay, the NHS will also need extra funding to fill the gap. Managing the costs of COVID-19 could be as much as tackling the waiting list backlog. The government must resist the temptation to pick and mix funding for COVID-19 and for the backlog – patients need both.’

Media contact

Creina Lilburne
07941 156827 / 020 7664 4647


A detailed report from the REAL Centre will be published later in September and will explore the short and long-term funding needs of the NHS and social care and some of the major policy decisions faced by government over the next decade. Early findings, summarising the short-term funding requirements, are available for download below.

Download the analysis

Further reading

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