Government’s plan for 18-week NHS waiting times: is it realistic?

At the end of 2024, the Prime Minister launched the government’s Plan for Change. This included a central pledge to ‘end hospital backlogs’ and meet the NHS standard for elective treatment – that 92% of patients in England should wait no longer than 18 weeks from referral to treatment.

In January 2025, the government published a new elective care reform plan that commits to achieving this by March 2029. The plan sets out a variety of initiatives to make this happen: greater use of the private sector, performance incentives, fewer follow-up appointments, and reductions in unnecessary referrals. It also confirms the government’s commitment to provide an extra 40,000 extra appointments a week within the first year of the parliament.

But how realistic is restoring the 18-week standard for elective care? And what increase in treatments would be needed to achieve it?

Where are we now?

Under the NHS Constitution, patients have a right to treatment within 18 weeks. To achieve this, the NHS performance standard is that 92% of patients on the waiting list should wait no longer than 18 weeks (this allows for some patients choosing to wait longer or where delaying treatment is clinically appropriate).

The standard has not been met since 2015/16. Currently, only 59% of patients have been waiting 18 weeks or less, and more than 234,000 patients have been waiting for more than a year. There is a huge gap between the performance standard and the service patients are experiencing.

To meet the government’s pledge, the percentage of patients waiting 18 weeks or less will need to increase from 59% in October 2024 to 92% by July 2029. Waiting times (how long patients wait for treatment) are closely related to the size of the waiting list (how many patients are waiting for treatment). To substantially reduce waiting times, the rate at which patients are removed from the waiting list needs to significantly exceed the number of new referrals on to it. Patients can be removed from the waiting list – so-called ‘completed pathways’ – either by starting treatment or for other reasons (such as a decision by a doctor or patient not to proceed with treatment). In our calculations we refer to all removals from the waiting list as ‘treatments’ for simplicity.

Referrals onto the waiting list grew by 1.5% in the year to October 2024, compared with the preceding year. Assuming this growth rate continues over the next 5 years, we would expect the number of new referrals to increase from 20.8 million in the year to July 2024 to 22.4 million in the year to July 2029 (see the chart below).

To meet the 92% referral-to-treatment standard within this period, we estimate that treatments would need to rise from 20.8 million in the year to July 2024 to 23.5 million in the year to July 2029. This corresponds to 500,000 extra treatments in the first year, rising to 2.6 million extra treatments in the final year, an annual increase of 2.4%. This would see the waiting list decrease from 7.6 million in July 2024 to 4.4 million in July 2029. Details of our calculations are shown in Methods and approach below.

How far will the commitment to provide an extra 40,000 appointments a week go towards meeting the 18-week standard by July 2029?

The elective care reform plan confirms the government’s pledge, included in its election manifesto, to provide an additional 40,000 appointments a week – 2 million in total – within the first year of the parliament.

One appointment alone does not necessarily represent a completed pathway. Indeed, there are currently an average of three to five appointments per completed pathway. Therefore, an additional 2 million appointments is equivalent to around 400,000–700,000 additional treatments. This range covers the 500,000 additional treatments needed in the first year. However, a similar increase in appointments would be needed every year to reach the additional 2.6 million treatments needed to meet the government’s pledge by 2029.

How achievable is a 2.4% increase in treatments?

The table below shows historical growth rates for referrals and treatments:

In the most recent year (to October 2024), treatments grew by 4.8% compared with the previous year. While this increase was significant, it was artificially high due to the impact of unprecedented industrial action and continuing recovery from the pandemic, which led to a low level of activity the previous year. This rate of increase is unlikely to be sustained.

Our estimate that a 2.4% annual growth in treatments will be needed to achieve the 18-week standard by July 2029, is similar to the growth in treatments of 2.3% before the pandemic (between October 2015 and February 2020). This was achieved during a time of relatively low funding growth for the NHS, a growing waiting list and rising waiting times. In this context, an annual growth rate of 2.4% over the next 4–5 years looks achievable.

However, in the pre-pandemic period, referrals grew at 2.0% per year, higher than the 1.5% we have assumed in our estimates. A lower rate of growth in referrals seems unlikely given increasing population needs for health care and would risk increasing unmet need for treatment. The continuation of a 1.5% growth in referrals therefore represents a ‘best case’ scenario: if referrals grew instead at 2.0% over the next 5 years, treatments would need to increase at 2.9% per year to achieve the 18-week standard by July 2029.

The level of activity needed to meet the pledge is sensitive to changes in the number of referrals and treatments, so it will be important to closely monitor and understand what is driving trends over the period.

Our analysis estimates that an extra 2.6 million more treatments a year will be needed in 2029 to meet the 18-week standard. The elective reform plan commits the government to funding the activity needed to achieve the standard, including an additional 40,000 appointments a week within the first year of the parliament. It also sets an interim target to increase the percentage of patients waiting less than 18 weeks for elective treatment to 65% by March 2026 (from 59% currently), which translates into an expectation that every trust will deliver a minimum 5 percentage point improvement. It states that the improvements required in subsequent years will be confirmed in NHS planning guidance.

This leaves a significant gap between the additional appointments committed to in the first year of the parliament and the increases that will be needed in subsequent years. To address this, the plan sets out a wide range of reforms. While these reforms will help, it is unclear how they will impact on progress towards meeting the 18-week standard. Increasing use of GP advice and guidance may help to mitigate referral growth, enabling faster progress to be made. However, improvement efforts can lead to unintended consequences: for example, improved access to scans through community diagnostic centres could create demand for scans that may add limited value or detect issues that are currently missed, resulting in extra referrals. Overall, progress will depend on how fast both referrals and treatments increase.

Experience from the 2000s tells us that, with focus and resource, the 18-week standard can be met. However, the last Labour government achieved this in more promising economic circumstances, over a longer period of time and with more significant increases in investment than are likely to be available this time. Given this, improving elective care productivity is vital. It is also essential that the priority given to elective care does not distract from addressing pressing needs in other areas of care, including urgent and emergency care and primary care. This underlines the scale of the challenge ahead.