At the end of April 2020, the NHS in England was asked to begin a cautious programme to begin resuming the routine services suspended in response to COVID-19. Over a 6-week period, NHS hospitals in England went from treating no patients with COVID-19 to looking after a daily peak of 19,000 inpatients (confirmed as having the virus) in mid-April. NHS services were transformed to free up beds and manage the spread of the infection: patients were discharged, planned treatment postponed and services shifted online.

Today the number of patients in hospital with COVID-19 is falling, but many of those discharged will need aftercare and ongoing support for example from mental health, primary and community health services.

Reconfiguring NHS services was essential to meet the anticipated surge in demand for COVID-19 patients in March and April 2020, but there were wider consequences for the health and care system. All non-urgent planned acute care was postponed and – following a 57% fall in A&E visits in April 2020 compared to the same month in 2019 – there were concerns about people not getting the urgent care and treatment they need, including for serious health conditions such as cancer.

Restarting planned treatment is important but will be complex. Patients will need reassurance about the risk of catching COVID-19 in hospital settings, while the virus must now be a factor in clinical judgements about the balance of risk for different care options.

The NHS expects some rebound in emergency demand, but the timing and extent is uncertain. April 2020 saw just over half the number of emergency admissions than the same month in 2019; returning to normal could see emergency patients potentially reoccupying tens of thousands of hospital beds. The imperative to keep patients with COVID-19 separate will prevent the NHS from returning to pre-pandemic levels of bed occupancy, which reached 92% by the end of 2019. There will need to be longer term changes in how planned care is delivered and the independent hospital sector could play an important role, after it was virtually block-booked early in the pandemic to provide additional capacity.

Returning to ‘normal’ levels of activity is expected to take some time and, even before COVID-19, there were substantial challenges with waiting times. As the NHS looks to start to recover services, this analysis looks at the context in which planned treatment will recommence. Specifically, it looks at what would have been needed – if the NHS were operating within a ‘business as usual model’ – to return to delivering the standard of 92% of patients being treated within 18 weeks, given the waiting lists and waiting times backlog that had built up by January 2020.

Waiting lists are as old as the NHS, but targets for waiting times are a more recent phenomenon dating back to the Patient’s Charter introduced in 1992. Improvements in performance allowed maximum waiting times to be repeatedly revised down – to 3 months for a first outpatient appointment and 6 months for inpatient treatment in 2000 – as part of a new ‘war on waiting’.

But this did not always reflect the reality of how long people waited. A typical pathway involves three stages:

1. time from GP referral to first outpatient appointment
2. time to arrive at a diagnosis and decide on treatment options, and
3. time from that decision to the start of treatment.

The 3 and 6 month targets could be met but, with no comparable measure of time spent in the second stage, some patients still experienced long delays.

The 18-week standard

Introducing the 18-week standard in 2004 fundamentally changed how the NHS measures and manages waiting times. Under the 18-week standard, the clock starts with a GP referral and only stops when the patient starts treatment or is discharged. This demanded a different mindset to the previous ‘stage of treatment’ targets. Hospitals had to instead look at the whole pathway – managing capacity and tracking patients through outpatients, diagnostics and inpatient services – and align clinical pathways with administrative systems to achieve the standard.

The 2000s were the era of ‘targets and terror’, but delivery took more than performance management. Delivery of waiting times was also hardwired into system reforms to enable patient choice and competition. The system of Payment by results rewarded trusts for expanding elective activity, and being on track to hit 18 weeks was a prerequisite for applying for coveted foundation trust status. Nationally procured contracts with the independent sector created additional elective capacity, as well as another incentive for trusts to raise their game and avoid losing lucrative extra income. This was all in the context of substantial growth in funding and staff numbers.

The 18-week standard was met in 2008 and performance broadly sustained through the transition to the coalition government. The original standards were based on completed pathways, which created a perverse incentive to treat patients who had not yet reached 18 weeks, over those who had already waited longer, to make reported performance look better. To address this, the coalition added an additional standard for 2012/13 that at least 92% of patients still waiting to start treatment should have waited 18 weeks or less. A few years later, the ‘completed pathway’ standards were dropped entirely and the ‘incomplete pathway’ standard became the NHS’s single measure of elective waiting times.

The standard was last met in February 2016, when the number of patients who had waited more than 18 weeks was 269,589. By January 2020, the number waiting more than 18 weeks increased nearly threefold to 730,267 in 4 years, while the waiting list has grown from 3.35 million to 4.42 million – and probably more, with several trusts not currently reporting data. Fundamentally, NHS activity to complete pathways and remove patients from waiting lists has not kept pace with the growth in demand.

Waiting times have increased in all regions and specialties. Figure 1 shows the percentage of patients on the waiting list for over 18 weeks by region in January 2020 – this is compared to the 8% (100%–92%) target.

In 2017, waiting times specialist Rob Findlay published estimates of the cost of meeting the standard to start elective treatment. At that point, 92% of patients were being seen within 20.3 weeks rather than 18, and the waiting list was 3.83 million. Findlay estimated that the NHS needed to treat an additional 170,000 people per year to keep up with demand and see 92% of new patients within 18 weeks. In addition, he concluded that there was a backlog of a further 600,000 patients who would also need to be treated to recover the standard overall.

Since then, waiting times have deteriorated. In the winter of 2017, 8% of patients were waiting over 21 weeks for their referral; this rose to 25 weeks by the end of January 2020, with 4.42 million people on the waiting list. The number of people being added to the waiting list each year is growing by 3.1% and the NHS is not keeping up with the growth in demand. Findlay recently pointed out that ‘4 years of waiting list growth would need to be undone to achieve the NHS Constitution standard again’. Using the same methodology, Health Foundation analysis estimates that to keep up with this growing demand and meet the 18-week standard for new patients, the number of additional patients the NHS needs to treat each year has increased to 210,000.

Since 2017 the backlog of patients has also grown. By 2023/24 the NHS must see and treat an additional 1.3 million people over the next 4 years, to address patients already on the list and eliminate this backlog. This is more than double Findlay’s 2017 estimate of the backlog.

If the aim is to meet the 18-week standard by the end of this parliament (which this analysis takes as by the end of financial year 2023/24) this would mean the NHS needs to treat over 500,000 more patients in each of the next 4 years.

Figure 3 compares the actual number of people on the waiting list with the size of the waiting list, which would be consistent with 92% of people starting treatment within 18 weeks. It then projects forward current trends.

We estimate the total direct cost of treating 92% of patients within 18 weeks to be £5.2bn–6.8bn, including elimination of the backlog by the end of March 2024. The total direct cost will depend on how efficiently the NHS deals with waiting lists. All financial figures are in 2019/20 terms.

Our base scenario consists of an additional £380m per year for 4 years to keep pace with demand (200,000 additional patients a year being treated), plus £3.6bn to clear the backlog (1.3 million patients). If this were spread evenly over the next 4 years, it equates to a total annual cost of £1.3bn.

The government has set out funding plans for NHS England up to 2023/24, showing that spending will increase by £20.8bn in real terms by 2023/24. Alongside the additional funding, in the NHS Long term plan the health service set out a strategy for how to spend the money and improve services. Part of the additional £20.8bn real-terms funding increase between 2018/19 and 2023/24 is earmarked for reducing waiting times. Figure 4 is our estimate of the planned allocation of NHS funding growth.

Figure 4

Our estimates depend on the NHS’ ability to efficiently deal with waiting lists. Shifting from 18 months to 18 weeks required funding, but it also involved significant attention to how patients flow through the health care system from referral, to assessment for diagnostic tests, and onto treatment. Managing the process efficiently and effectively is critical to reducing waiting times.

Financial penalties for not meeting the 18-week standard were introduced in 2012, which led to more effective prioritisation of cases and management of patient flow. This can be quantified through the index of waiting list management, a measure of how effectively hospitals are allocating their resources and how quickly the NHS can treat a given list of patients. This index improved from 2011 to meet the current standard, but has deteriorated since the beginning of 2016. A key assumption in the base scenario of our analysis and costing of recovering the 18-week standard is that this index will not continue to get worse.

However, the additional measures that will now be needed to deliver planned care – as well as the risk of having to up- and downscale activity to manage local outbreaks of COVID-19 – will present substantial challenges to efficiently managing waiting lists. This analysis therefore presents the activity and cost implications of meeting the 18-week waiting time standard if the index returns to 2011 levels. In this high-cost scenario the backlog is estimated to be higher in March 2020 at 1.6 million instead of 1.3 million. It is also highly possible that the cost of the recurring additional activity is higher than the estimated average; here the recurring costs have been inflated to match the backlog clearance (£2,800). This results in a higher cost of recovering the 18-week standard of £6.8bn.

Is there a realistic prospect of delivery?

Our estimates are the direct costs of treating these additional patients. As such, they do not reflect the full scale of the challenge. Realistically, whether this can be done will depend on whether a system already at capacity is able to go over and above current plans.

The numbers above would require almost 2.2 million more outpatient appointments and elective admissions in 2023/24. This may also have capital funding implications in order to provide enough beds and physical facilities. Staffing shortfalls, bottlenecks in diagnostic services and high levels of bed occupancy will continue to constrain hospital capacity, with scope for elective activity to be crowded out by increasing demand for emergency care. This is before the impact of COVID-19 on both demand and capacity is taken into account.