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‘Hidden backlog’ looms as NHS referrals for routine hospital care drop by a third Radical action needed to address growing NHS waits

11 November 2020

About 1 mins to read

New analysis by the Health Foundation shows there were 4.7 million fewer people referred for routine hospital care – for things like hip, knee and cataract surgery – between January and August 2020 compared to the same period in 2019, representing a potential hidden backlog of unmet care needs.

The report authors say that the drop in demand for routine, consultant-led treatment, which under the NHS Constitution should have a maximum waiting time of 18 weeks, is unlikely to be because need has simply disappeared. Rather, they say it is likely to be due to huge pent-up demand for treatment caused by the pandemic.

During the first 8 months of 2020, 4.7 million fewer patients in England were referred for consultant-led, routine hospital care as compared to 2019, a reduction of a third (34%). The report authors say this reduction is due to a number of factors, including GPs not being able to refer patients to services that were suspended and patients being more reluctant to seek care during the pandemic.

NHS and health policymakers will need to plan for this ‘hidden backlog’ of unmet need, alongside ensuring treatment for the 4.2 million people currently waiting for routine elective care1. Of those waiting for elective care, 2.3 million (46.4%) have already waited longer than the 18 week standard.

Detailed results from the report show:

  • The regions that have seen the sharpest decline in the number of people referred for routine elective care during the first 8 months of the year are London (37% reduction as compared to 2019), North West (35% reduction) and South East (35% reduction). The South West saw the smallest reduction in the number of people referred for elective care compared to 2019 (29%). The North East and Yorkshire saw a 34% reduction and Midlands and East of England both had a 33% reduction.    
  • Those regions that experienced the lowest rates of COVID-19 during the first wave, namely the South West and East of England, are also those that have made the most progress in reopening elective care services. While there are currently only limited signs that more treatment is being postponed in the regions hardest hit by COVID-19, this may change in the future.
  • Referrals to clinical areas have declined as follows:
    • oral surgery (43% lower than in 2019, representing 177,591 fewer people)
    • trauma and orthopaedics (42% lower, representing 622,593 fewer people). This includes surgery for hip and knee replacements
    • ophthalmology (41% lower, representing 531,660 fewer people). This includes cataract operations
    • thoracic medicine (29%, or 98,546 fewer people) cardiothoracic surgery (29%, or 7,889 fewer people)
    • neurosurgery (29% lower, or 23,872 fewer people); urology (28% lower, representing 186,119 fewer people).

The research highlights the scale of the challenge facing the NHS as it looks to resume services following the disruption caused by the first wave of COVID-19. The number of patients in hospital with COVID-19 is growing as we head into winter, a time when the NHS always experiences greater pressures from flu and other seasonal illnesses. If the virus is not controlled and emergency pressures surge, even more routine treatment will need to be postponed which will only add to the challenge of recovering from the pandemic.

The Health Foundation’s Senior Policy Fellow Tim Gardner, one of the report authors, said:

'While the NHS is rightly focused on the urgent task of fighting COVID-19, there is meanwhile a rising tide of unmet need which will have a significant impact on people’s health if a sustainable solution is not found. 

'The NHS made significant progress towards fully reopening services after the first peak of the pandemic, but there is still a potentially huge hidden backlog, as the health service is undertaking far fewer routine procedures compared to last year. While the NHS is working hard to address the backlog, radical interventions will nonetheless be needed to avoid prolonged delays for those currently waiting for things like hip, knee and cataract surgery, as well as those not yet on any waiting list.

'There is no silver bullet – addressing these issues will take time, money and determination. A range of options should be explored – including making greater use of the independent sector, greater use of remote consultations, and creating dedicated diagnostic hubs and elective care centres. If no action is taken, long waits could become the norm for millions of people.'


1. ‘Elective care’ is the term used to describe routine, non-urgent, consultant-led treatment for things like hip, knee and cataract operations and hernia repairs. This treatment usually takes place in a hospital following referral from a GP or other medical practitioner. Under the NHS Constitution, elective care should take place within 18 weeks of a referral.

Media contact

Creina Lilburne
020 7664 4647

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