Briefing

How can the next government improve hospital waits in England?

Published June 2024

Time to read

About 19 mins

Authors

Francesca Cavallaro
Kathryn Marszalek
Lucinda Allen
Josh Keith
Charles Tallack
Tim Gardner

Topics

Key points

NHS waiting times are a key election issue, with both major political parties committing to tackle the backlog in care. But with the elective care waiting list standing at 7.6 million, the challenge ahead is huge.
NHS standards for elective care waiting times have not been met since February 2016, while standards for ambulance and A&E waiting times have not been met since 2020/21 and 2015 respectively. A number of targets for recovering elective care and urgent and emergency services have also been missed.
The human toll is significant with millions of people waiting in pain or discomfort for hospital treatment and lives being lost due to the strain on urgent and emergency services. The public understands the severity of the challenges facing the NHS – satisfaction with the service is at a record low and the NHS tops the list of the public’s concerns going into the general election.
Progress on waiting times for elective and emergency care has been limited by a combination of factors, including a fall in the total number of admissions – with fewer people able to access inpatient hospital care, longer hospital stays for emergency admissions and worsening delays in discharging patients.
There is significant variation in waiting times between different parts of the country and growing evidence of inequalities in access to hospital treatment. The fall in hospital admissions has been much more pronounced in more deprived areas, with 59,000 fewer admissions (7.6%) in the most deprived tenth of areas, compared with 24,000 fewer (4.6%) in the least deprived.
The situation facing the NHS is arguably worse than at any other time in its history. There are no quick fixes, but the health service can recover with a long-term plan that combines the right mix of policy change, radical innovation and improvement, and long-term investment.
The next government will need to take urgent action to make better use of existing hospital capacity and invest in expanding capacity for the longer term. Making sure people get the care they need will also require wider investment and reform of health and care services, and cross-government action to improve the nation's health.

Introduction

Tackling NHS waiting times has been a central issue in the general election. The NHS is consistently among the top of the public’s concerns and will be a key factor in shaping how people vote. Waiting times for elective and emergency care have also regularly been included by the public among their top priorities for the NHS. Both major political parties have committed to cutting waiting lists for routine hospital treatment and reducing how long patients wait for NHS care.

The scale of the challenge is considerable. On an average day in May 2024, 4,680 patients in England spent over 12 hours waiting in A&E departments including over 1,372 who needed to be admitted to a hospital bed. Despite some recent signs of progress, the waiting list for elective care remained at a near-record high of 7.6 million in April 2024, including over 302,000 waits of more than a year. This is estimated to represent 6.3 million individual patients waiting for appointments, tests or treatment, often in avoidable discomfort and pain or anxiously awaiting a diagnosis. But this is only the tip of the iceberg: those whose ongoing or follow-up care is delayed are not routinely counted on elective waiting lists and waiting times for mental health and community health services are also mostly counted separately.

The NHS was badly affected by the pandemic from 2020 and by the unprecedented industrial action that began in 2022, but hospital waiting times were deteriorating long before the initial outbreak of COVID-19. Despite increased funding and staffing, only limited progress has been made towards goals in the national recovery plans for elective and emergency care and waiting times are nowhere near the standards set out in the NHS constitution.

Here, we look at recent trends in waits for elective care (routine, non-urgent, hospital treatment) and urgent and emergency care (ambulance response times and waiting times in A&E departments). We also examine some of the main factors that affect how long people wait for these services and how these may be affected by lack of access to other health and care services. We conclude by identifying priorities for the next government.

What is happening to elective care in England?

National targets for elective care

The NHS Constitution gives patients the right to begin non-urgent, consultant-led treatment within 18 weeks of a referral, unless there is a clinical reason not to or the patient chooses to wait longer. Since 2012, the national standard has been that at least 92% of people referred for care should be on the waiting list for no longer than 18 weeks before starting treatment.

The NHS consistently met the 18-week standard from 2008 to 2015. But since February 2016, the standard has not been met due to growing demand, funding constraints and staff shortages. At the same time, the size of the waiting list has steadily increased, growing from 2.4 million in February 2012 to almost 4.6 million on the eve of the COVID-19 pandemic in February 2020. The need to postpone large volumes of routine care to free up space for patients acutely unwell with COVID-19 saw the waiting list increase rapidly to 6.2 million by the time remaining pandemic restrictions ended in February 2022.

That month, the Department of Health and Social Care and NHS England published an elective care recovery plan to address the backlog. The plan focused on reducing very long waits for elective care by giving GPs better access to specialist advice, establishing networks of community diagnostic centres and elective hubs, and expanding use of the independent sector; all of which contribute to increasing the system’s capacity to treat people. Waits of more than 2 years were expected to be mostly eliminated by July 2022, with those longer than 1 year eliminated by March 2025. While no specific targets for reducing the size of the waiting list were included, the plan suggested the waiting list would have peaked by around March 2024.

Progress on elective care waits

Progress against the elective care recovery plan has been mixed (Figure 1). NHS England’s ambition to eliminate almost all waits of more than 2 years by July 2022 was achieved. Since then, the waiting list has increased further, with efforts to address the backlog hampered by the significant financial and operational pressures facing the NHS and, since November 2022, by industrial action. Neither of the interim milestones to eliminate waits over 18 months and 15 months have been achieved. With more than 302,000 having waited over 1 year as of April 2024, the NHS appears some way from achieving the ambition of eliminating almost all waits of more than 1 year by March 2025. The median waiting time has increased marginally from 13.2 weeks in February 2022 to 13.9 weeks in April 2024.

Figure 1

In January 2023, when the waiting list was at 7.2 million, Rishi Sunak pledged that ‘NHS waiting lists will fall and people will get the care they need more quickly.’ The pledge did not define how far the waiting list was expected to fall or a timescale for achieving this, leaving considerable room for interpretation about how it will be met. The waiting list fell to 7.6 million in April 2024, down from the peak of 7.8 million in September 2023. This is still, however, higher than at the time of the Prime Minister’s pledge. While the government has blamed the relative lack of progress on industrial action, Health Foundation analysis suggests this accounts for less than 3% of the overall waiting list and is only responsible for half of the growth in the waiting list between March and October 2023.

The waiting list counts ‘incomplete pathways’ of care. Some patients may be on more than one incomplete pathway at the same time as they wait for care for different conditions. This means the waiting list represents how many different cases are yet to start consultant-led treatment or to be discharged, rather than the total number of patients.

Since October 2023, the number of completed pathways has continued to grow, as a result of increases in activity, and is now consistently exceeding pre-pandemic levels. Despite progress made in increasing activity, the more recent fall in the waiting list has in effect resulted from lower than expected numbers of referrals, which have dropped to pre-2020 levels. It is unclear what has driven this reduction in referrals or whether this is a temporary change or the start of a longer-term trend. However, it may represent people going without care, which potentially stores up problems for the future.

The size of the waiting list and waiting times vary across England. When looking at the size of the waiting list across the localities within integrated care boards, there is a more than three-fold difference (Figure 2). In Southend, there are approximately 19,700 incomplete pathways per 100,000 population; while in Berkshire West there are only 7,200 incomplete pathways per 100,000. Differences in the total size of the waiting list are mirrored in differences in waiting times, although they are less pronounced. Brighton and Hove has the highest median waiting time at 21.6 weeks. In comparison, the median waiting time in South Tyneside is less than half that at 9.2 weeks. Depending on where someone lives, people will have vastly different experiences in accessing the care that they need.

Figure 2

What is happening to urgent and emergency care in England?

National targets for urgent and emergency care

The NHS constitution sets a number of national standards for urgent and emergency care, including ambulance response times and waiting times in A&E departments. For Category 1 ambulance calls, which involve life-threatening injuries and illnesses that need immediate intervention, such as cardiac arrest, an appropriate emergency response is expected to arrive in an average of 7 minutes. For Category 2 calls, which are for emergencies requiring rapid assessment and urgent intervention, such as heart attack, stroke, sepsis, or major burns, the response is expected to arrive in an average of 18 minutes.

Prior to the pandemic, the NHS struggled to reliably achieve the constitution standards for responding to Category 1 ambulance calls, but was consistently meeting the Category 2 standard. After the initial waves of COVID-19, response times increased rapidly, primarily because longer handover times at hospital emergency departments reduced the availability of ambulances available to respond to calls. Following a peak in December 2022, responses to 999 calls have improved but the standards have not been achieved since April 2021 for Category 1 calls and July 2020 for Category 2. The average response time in May this year for Category 1 and Category 2 calls was 8 minutes and 16 seconds, and 32 minutes and 44 seconds respectively.

At least 95% of patients attending A&E departments are expected to be admitted, discharged, or transferred within 4 hours of arrival. The NHS consistently met the national standard for A&E waiting times from 2010 to 2014, but this was last achieved in July 2015. Performance steadily deteriorated before the pandemic, falling to 82.8% in February 2020 and a record low of 65.2% in December 2022 following the second wave of COVID-19.

In January 2023, the Department of Health and Social Care and NHS England published an urgent and emergency care recovery plan. The plan acknowledged high levels of hospital bed occupancy as an important factor in A&E waiting times, which in turn has a direct impact on ambulance handover delays at A&E departments and ambulance response times. It set out a range of measures to increase ambulance and hospital capacity and improve patient flow to use existing capacity to deliver more timely care, as well as expanding community-based services and alternatives to inpatient care. The plan set two specific recovery ambitions:

Responses to Category 2 ambulance calls to arrive within an average of 30 minutes across 2023/24.
For at least 76% of patients to be admitted, transferred, or discharged within 4 hours by March 2024.

Progress on urgent and emergency waits

Some progress has been made in reducing ambulance response times. But the ambition for responses to Category 2 calls to arrive within an average of 30 minutes during 2023/24 was narrowly missed. Patients are still facing long delays in ambulances before being handed over to the care of A&E departments. Figure 3 shows one-quarter of handovers are still taking over 30 minutes, and improvements have been limited in reducing handovers of more than 60 minutes in the past few years, despite major efforts. Further progress is constrained by capacity in A&E departments: if the department is full, ambulances will not be able to hand patients over.

Figure 3

There has also been some limited progress in reducing waiting times in A&E departments (Figure 4). In 2023/24, 72.1% of patients were admitted, discharged, or transferred within 4 hours – an improvement from 70.8% the previous year. The recovery plan ambition to reach 76% by March 2024 was not achieved, despite the introduction of two capital funding incentive schemes for £150m and £50m for trusts with best and most improved performance.

The number of patients who spent over 12 hours in A&E waiting to be admitted for a hospital bed, however, increased from 410,092 in 2022/23 to 439,411 in 2023/24. This represents a major increase in admission delays since the pandemic, often reflecting a lack of available hospital beds. These admission delays peaked at around 10% of all patients with emergency admissions in winter 2022/23 and 2023/24. Long waits before admission have been linked with excess deaths. More recent published data on long waits in A&E departments suggest a similar proportion of all patients attending A&E now spend over 12 hours in departments. These delays disproportionately affect some groups of patients, such as those experiencing a mental health crisis.

The lack of suitable alternative services – including difficulties in accessing primary care – may be contributing to high demand for ambulances and A&E departments. However, bottlenecks in the wider health and care system appear to be a bigger factor in causing delays – primarily due to the limited number of inpatient hospital beds, and the lack of sufficient capacity and suitable facilities to treat the growing number of patients with complex needs.

Figure 4

Four reasons more progress has not been made

How long patients wait for elective and emergency care depends on the demand for health care relative to how much activity hospitals are able to deliver. The major fall in waiting times in the 2000s highlights the important role that capacity and productivity can play in meaningfully improving access to treatment. Below we explore some of the factors hampering progress on reducing hospital wait times.

1. Underinvestment

A decade of low spending growth prior to the pandemic and relieving short-term pressures at the expense of long-term investment have left chronic staffing gaps and inadequate buildings, equipment and IT. Although numbers of front-line staff in hospitals, particularly doctors, have grown over recent years, the level of activity has struggled to reach pre-pandemic levels – raising concerns about productivity. Since 2015, a larger proportion of the NHS budget has been spent on hospital care, leaving a declining share for prevention, primary care and community-based health services – which help to keep people healthy and play an important role in supporting hospital discharges. Successive governments have also failed to reform adult social care, despite acknowledging that pressures on social care services have knock-on consequences for the NHS.

2. Falling admissions

The total number of inpatient admissions in England, a crucial measure of hospital activity, has not recovered to pre-COVID-19 levels. Prior to the pandemic, admissions consistently increased year-on-year, before falling in 2020 as hospitals were forced to postpone large volumes of routine care to prioritise urgent treatment for surges in patients acutely unwell with COVID-19. Although there has been progress in returning admissions to pre-pandemic levels, there were still 377,000 fewer hospital admissions (a 5.5% decrease) in 2023 than at the peak in 2019 (Figure 5). This means that fewer people are able to access inpatient hospital care compared with before the pandemic, contributing to longer waiting times for those needing elective and emergency care.

Figure 5 also shows that the fall in hospital admissions has not been evenly distributed across England. The reduction in admissions in 2023 relative to 2019 has been much more pronounced among people living in more deprived areas, with 59,000 fewer admissions (7.6%) in the most deprived tenth of areas, compared with 24,000 fewer (4.6%) in the least deprived. This pattern is mainly driven by the trend in emergency admissions, showing that recovery in access to inpatient hospital care has been more limited in the most deprived areas. These disparities are often compounded by wider inequalities in access to health services. For example, GP practices in more deprived parts of England have fewer doctors and less funding after accounting for differences in health needs. In contrast, patients living in more affluent areas are more likely to benefit from NHS-funded elective care delivered by the independent sector.

3. Increased lengths of stay in hospital

The main driver of decreases in both emergency and elective admissions appears to be increasing lengths of hospital stays following emergency admission. Over the two decades before the pandemic, the number of NHS patients admitted to hospital increased year-on-year – with reductions in lengths of stay allowing more patients to be treated despite reductions in the number of hospital beds. However, between 2019 and 2023, the mean length of stay increased by 1.1 days for emergency admissions (Figure 5). In response to high levels of bed occupancy, hospitals increased admissions thresholds, leading to a decrease in the total number of emergency admissions that hospitals could accommodate (156,000 fewer in 2023 than 2019, or a 3% fall). The decrease mainly affected emergency admissions lasting less than 14 days, of which there were 212,000 fewer in 2023 than 2019, suggesting some patients with less serious conditions were not admitted but would have been before the pandemic. Some of these patients may have received ambulatory care, for example in Same Day Emergency Care units, but others may not have received any care.

Longer emergency hospital stays also had a knock-on effect on elective admissions, which have decreased by 222,000 (a 17% fall) since 2019, despite still having shorter stays than before the pandemic (0.2 days shorter on average, compared with more than a 1 day increase for emergency admissions). This suggests that hospitals had no choice but to prioritise long-stay emergency admissions, at the expense of poorer access to elective admissions and short-stay emergency admissions.

Figure 5

4. Worsening delays in discharging patients

Delays for patients who no longer require hospital care and are medically fit for discharge have also worsened since the pandemic. While data do not show definitive causes, it is likely that difficulties discharging patients is one important driver of increasing lengths of stay for emergency admissions, alongside COVID-19 infections and inefficiencies in care. The number of patients meeting the criteria for discharge but remaining in hospital has increased since COVID-19, hitting a peak around 14,000 (around 13% of all hospital beds) in early 2023 (Figure 6). It then decreased to 12,000 over the summer as pressures on discharges eased, before returning to a high of 13,800 in January 2024. Patients who stay longer than needed in hospital are at greater risk of hospital-acquired infections and losing mobility and independence, and are therefore more likely to require increased support at home or in a residential care setting. This has important cost implications for the health and care system. These delays also have knock-on effects on flow through hospitals by reducing the number of available hospital beds, leading to delays in admitting patients from A&E and ambulances handing over patients.

Figure 6

A lack of capacity in social care is part of the problem, leading to delays in putting in place support at home and finding care home places. However, delayed discharges also reflect wider pressures on the health and care system including limited capacity in community care and high levels of adult bed occupancy – well above levels recommended by NHS England (92%) and the Royal Colleges of Emergency Medicine and Surgery (85%). While some progress has been made in increasing hospital capacity, further expansion may be needed to improve access in line with the population’s growing health needs. A 2022 analysis by the Health Foundation’s REAL Centre estimates an additional 23,000–39,000 beds will be needed by 2030/31 simply to deliver 2018/19 rates of care. The urgent and emergency care plan also included measures to help care for patients outside of hospitals, for example through virtual wards (hospital at home services) and Same Day Emergency Care units, although a credible plan to improve community care is still needed. The government has tried to improve social care capacity to improve discharge delays through repeated short-term funding schemes, with limited success: long-term funding reform for social care is sorely needed.

Priorities for the next government

The challenges facing the health service are arguably worse than at any other time in its history. The sight of ambulances stuck in queues outside hospitals, overcrowded A&E departments and patients on trolleys in corridors have all become worryingly common. As have accounts of people spending months anxiously awaiting a diagnosis, living with avoidable pain or discomfort, or left unable to work or enjoy an active life for want of a routine operation. These delays grew sharply in the wake of the pandemic, but performance was declining long before 2020.

There are no quick fixes, but the health service can recover with a combination of policy change, radical innovation and improvement, and long-term investment. Existing plans can provide a starting point. The urgent and emergency care recovery plan, based on a rounded understanding of the causes of delays, identifies a range of measures that could, if properly implemented, support improved performance. The elective care recovery plan emphasises the need for a major increase in hospital activity to address the backlog of people waiting for routine diagnosis and treatment. And the NHS Long Term Workforce Plan is a major milestone that, for the first time in two decades, sets out staffing needs based on plausible projections of future demand for care and supply of staff. But even taken together, these plans do not comprise a coherent strategy for delivering on the ambitious promises made in party manifestos.

The next government will need to take urgent action to make better use of existing hospital capacity and invest in expanding capacity for the longer term. But making sure people get the care they need and building a stronger, more resilient and sustainable health service for the future, will also require wider investment and reform of health and care services, and cross-government action to improve the nation's health. This means five broad areas for action need to be addressed:

Act now to make better use of existing hospital capacity: Focus on addressing bottlenecks and improving how patients flow into, through and out of hospital. Give NHS staff more freedom and support to innovate and continuously improve services, with clear accountability for performance and quality of care, backed by national action to help spread good practice. Take stronger action on pay, conditions and workplace cultures to boost efforts to improve staff retention. Support the operational management, analytical capability and cross-system working needed to treat people more quickly. Strengthen the support to meet existing commitments on interventions including Same Day Emergency Care, community diagnostic centres, elective hubs and virtual wards – including robust evaluation to inform policy decisions about what role these interventions should play in future.
Invest in expanding hospital capacity for the long term: Commit to stable, long-term investment needed to meet people’s needs in the future, tackle underlying cost pressures and strengthen the resilience of the NHS. Support a renewed drive to increase productivity, including with a once-in-a-generation capital settlement to modernise crumbling buildings, replace outdated equipment and invest in the new technology and digital infrastructure needed across the NHS – as well as the training and support to use that technology well. Build on the NHS Long Term Workforce Plan through a long-term commitment to funding the promise to train more staff. Focus investment in areas where there is the greatest mismatch between capacity and need, given our analysis shows that people’s experiences accessing care are vastly different depending on where they live.
Improve NHS performance by looking beyond the hospital sector: Reorient the NHS towards prevention, including better support for the growing numbers living with major illness to mitigate the need for people to go to hospital. The public wants primary care and community health services to be a higher priority for NHS resources than hospital services and supports a steady rebalancing of funding over time. Produce the long overdue refresh of the NHS Long Term Plan and retain its core principles – expanding primary and community care, more action on prevention and health inequalities and better access to high-quality care – but reflect the impact of COVID-19 and the new pressures that have emerged since.
Properly fund adult social care to benefit the NHS: Implement long-overdue reforms to social care funding to protect people against care costs. Improve access to publicly funded care and tackle unmet need. Develop a fully funded long-term workforce strategy to improve pay and conditions and expand the care workforce. Improve support for unpaid carers.
Put health – not just the health service – at the heart of government policy: Set an ambitious goal to improve the nation’s health and reduce inequalities, and drive cross-government action on the building blocks of health. Prioritise population-level action, including bolder use of tax and regulation on tobacco, unhealthy food and alcohol as the leading causes of preventable ill health. Enable local and combined authorities to fulfil their key roles in supporting the health of local communities, and focus on tackling barriers to work due to ill health and working with employers to keep people in-work and in good health in the first place.

Acknowledgments

We are grateful to the following Data Analytics team members for analysing data and producing charts for this long read: Anne Alarilla, Melissa Co, Caroline Fraser, Tatjana Marks, Sam Philmore, and Tom Prendergast, as well as Kaat De Corte, Jay Hughes, Sarah Opie-Martin, Fred Taylor and Freya Tracey for quality assuring the data analysis. We also thank Sarah Hardy for reviewing an earlier draft.

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