More money, more choice, more of the private sector: can the next government repeat the feat of the 2000s and cut waiting times?

So, can this feat be repeated? Both main parties have put ‘fixing’ the NHS at the centre of their policy priorities and many of their proposed solutions were also used in the 2000s. In this long read we explore what worked then, what is proposed now, and what might be missing from the current proposals.

What is proposed now?

The current government has continued to increase the use of independent sector providers (ISPs) to expand NHS capacity. In some specialties, such as ophthalmology and orthopaedics, use of ISPs is already widespread (providing 39% and 31% of inpatient care respectively). ISPs are seen – by the government, by Labour and by NHS England – as central to dealing with the backlog of care exacerbated by the pandemic. NHS-run surgical hubs (ringfenced resources to provide high-volume, low-complexity surgery to help tackle backlogs) have also proliferated. They mirror some of the approaches of ISPs, but in NHS-run hospitals. Both main parties seem committed to expanding the use of the private sector to increase NHS capacity.

What happened then?

The 2000s saw a major expansion in private provision of NHS-funded elective treatment. Purpose-built and privately owned independent sector treatment centres (ISTCs) were introduced from 2003, with the aim of increasing capacity and using the prospect of competition to motivate NHS hospitals to make progress on their waiting lists.

This was the first formal entry of private providers into the NHS, and it was highly controversial. In 2009, NHS England gave patients the legal right to choose where to be treated, with private hospitals paid the same pre-determined amount as NHS hospitals. By 2012/13, private hospitals and ISTCs together delivered 21% of publicly funded procedures, from a base of 0% in 2002/03.

Will it work?

Evidence about the historic impact of ISPs is relatively weak – and conclusions are often influenced by political ideology as much as robust data. But what evidence there is suggests that ISPs’ ability to increase capacity was limited. Care was often just displaced from NHS hospitals to private hospitals, rather than increasing the overall volume of care.

Instead, the main benefit of ISPs was encouraging patient choice and competition – acting, like targets, as a motivator for change among NHS providers. They feared they might lose patients to private sector competitors, with one hospital boss (when asked why his hospital’s activity and productivity had gone up) saying, ‘Well, we don’t want one of those bloody ISTCs on our doorstep.’

Evidence from recent growth in ISP provision is similarly inconclusive. While overall activity levels have increased, the recent reductions in the size of the waiting list have been driven by fewer referrals than expected, rather than more treatment actually being delivered. As before, there is little evidence that ISPs are adding genuinely extra capacity.

It’s also important to note that even if ISPs are effective at reducing waiting times and increasing capacity, it appears they might do so at the expense of more deprived areas. Independent sector providers are not evenly spread across the country, and people living in less deprived areas are much more likely to have their care delivered by an ISP than those in the most deprived areas (25% in the least deprived, 11% in the most deprived). The trend towards more independent sector provision may simply be shifting timely care to wealthier areas. The implications of this for health inequalities are unclear, but it’s possible that patients living in more deprived areas could be disadvantaged.

What is proposed now?

Both Labour and the Conservatives have suggested that a renewed focus on patient choice will empower patients, organise the waiting list more efficiently and ultimately reduce waiting times. The government says that patients will be able – using the NHS app or website – to choose from up to five health care providers, filtered by distance, waiting times and quality of care. Labour has proposed organising waiting lists on a regional basis, sharing lists across integrated care systems and giving patients more choice over where they are seen.

What happened then?

From 2006, patients could choose from four or five providers, and free choice has been in place since 2009, offering patients on long waiting lists the chance to be treated more quickly at alternative hospitals. In the 2000s, Labour’s focus was on making this choice equitable: rather than only wealthy patients being able to ‘choose’ to go private for faster care, all patients would now have the option to choose the fastest care, but funded by the NHS. Labour also expanded the role of the Healthcare Commission (now the Care Quality Commission) to support patient choice by publishing care quality ratings for all health care services.

The impact on waiting times was limited. One major analysis found that more choice was associated with lower waiting times, but that the effect was small – the waiting was reduced by at most a few days (a 1–2% reduction overall).

Will it work?

The ‘new’ patient choice policy announced by both main parties is not new – it restates existing rights under the NHS constitution. But this renewed emphasis may make more patients aware of their right to seek treatment elsewhere, and equip them with better data to inform their decisions. Both of these are clearly needed, as evaluations of the original policy found that only half of patients were ever offered a choice, and of those that chose, only 30% chose their non-local provider. Patients were not aware, not interested, or preferred to let their GPs choose. When offered a choice, patients were more likely to rely heavily on their own experiences, those of friends and family, or the advice of their GP – not the kind of information provided on the NHS app or website.

As with the increased use of ISPs, this is not a policy that actually increases overall capacity within the NHS: it simply shifts care from one provider to another. The hope is that this reduces the waiting time for a small number of patients, encourages competition and improves efficiency, but the total impact on the waiting list is likely to be small.

What is proposed now?

Neither the Conservatives nor Labour has unveiled spending plans for the next parliament, but each have made some specific commitments on NHS funding. Through the 2024 Spring Budget, the government announced an increase of £2.5bn to NHS England’s planned budget for 2024/25 – a 0.2% increase in real terms from 2023/24 – as well as £3.4bn in capital funding between 2025/26 and 2027/28. Labour has also committed to increases in funding, through closing tax loopholes.

To be effective, this spending must specifically target the areas that are holding back increases in NHS activity. These limiting factors are generally agreed to be capital investment and workforce. The NHS Long Term Workforce plan models current shortfalls at 150,000 full-time equivalent (FTE) (being filled by temporary staff), with shortages projected to rise to 260,000–360,000 FTEs by 2036/37 without major reform. Both capital investment and workforce are areas of policy focus for both main parties.

What happened then?

The post-1997 years were characterised by unprecedented investment in the health service (prompting Brown’s famous ‘you stole my f**king budget’ comment), rising from £92bn annually in 2000 to £168bn in 2010, in today’s prices. Much of this money was spent on capital investment, hospitals, GP premises and infrastructure (such as IT systems). It also bought more staff.

Between 1999 and 2004 the NHS Plan aimed to expand the NHS workforce as follows:

• 7,500 consultants (achieved 7,329)
• 2,000 GPs (achieved 4,098)
• 20,000 nurses (achieved 67,878).

Such targets were not just achieved but exceeded. Contributing to this success were pay increases (between 6% and 10% annually between 2000/01 and 2005/06), return-to-work schemes (recruiting between 3,000 and 4,500 nurses annually) and increases in training places of 34% (nursing) and 59% (medicine).

Will it work?

Overall, the NHS funding injections pledged during this general election campaign are nowhere near the levels invested in the early 2000s. Partly, this reflects the UK’s different fiscal position now. Back in 1997, UK economic performance had broadly increased under the previous Conservative government, and Labour initially stuck to a 2-year moratorium on spending increases. 

On workforce, there are more similarities: since 2010 there has been some success in increasing the NHS workforce. Commitments made at the last election to recruit 50,000 more nurses are on track to be met by 2024. But despite this recruitment the shortfall of nurses persists with more than 30,000 vacancies. A further increase in the nursing workforce is likely needed – and has been committed to by the new NHS Long Term Workforce Plan. Progress on GP recruitment is also a big issue with the number of fully-qualified permanent GPs lower now than in 2015. Given the challenges of international recruitment following Brexit, widespread strike action over stagnant wages and continuing concerns over workforce retention, it might prove very challenging to increase the NHS workforce further.

New Labour’s ‘war on waiting’ combined record investment, payment and provider reform, workforce recruitment, and the opening up of the NHS to private sector ‘competition’, with – crucially and famously – a highly centralised performance management approach (known as the ‘targets and terror’ regime).

It’s this last feature, the sustained commitment to meeting highly ambitious targets, that is most obviously missing from current plans. Those targets required major service transformation and, importantly, time to achieve. Such a relentless, consistent, long-term focus has been missing in recent years. 

By the early 2000s, New Labour recognised that investment alone would not be enough to shift waiting times – a more fundamental culture and motivational change was required. The government set targets (which became increasingly rigorous) and paired these with very senior performance management, including real consequences for underperformance. The poorest providers were named and shamed, ‘failing’ chief execs were sacked, and success was rewarded with coveted foundation trust status. Alan Milburn (Health Secretary) noted, ‘It was [a] relentless focus. The prime minister holding me to account, the delivery unit holding the department to account, me holding the department to account and the department holding chief executives to account – with the NHS knowing that this was the absolute top priority, because people were suffering and dying.’

The relentless approach was not without its critics – it was often associated with bullying and widespread gaming – but the (considerable) literature has tended to emphasise the centrality of this approach to driving change. For example, Scotland and Wales received similar increases in investment to England, but without the performance management (or competition), and did not improve waiting times as quickly as England. 

It is perfectly possible for the next government to recreate this approach. Much of the architecture (for example, the Prime Minister’s Delivery Unit – now renamed the Implementation Unit), still exists, and the availability of data to identify and drive performance is arguably better than ever before.

The challenge will be identifying the ‘right’ targets to drive change. Current targets have not been met for many years, and are possibly too distant to act as a motivator, and we know from previous experience that systems can learn to game metrics. Fresh targets, and more balanced performance management approaches, will be needed.

The Labour government’s approach between 1997 and 2010 undoubtedly transformed NHS waiting times. By 2008, waiting times had been falling for a decade, and targets were consistently met. Three of the main levers they used to achieve this – more money, more patient choice, and increased private sector provision – are once again being discussed as solutions to the current waiting times challenge. But there is limited evidence that they alone will be effective. Increased patient choice and private sector provision do not create additional capacity – they simply shift care from one part of the system to another, and in ways that raise concerns about the potential impact on inequalities.

Delivering a sustained decrease in waiting times will only be possible through some combination of three things. First, a reduction in referrals (perhaps due to demographic changes, or improvements in preventative care), second, an overall increase in capacity, and third, greater productivity. The latter two should be the focus of the next government’s work.

To increase capacity, capital investment and addressing workforce challenges will be crucial. To increase productivity, policymakers could take lessons from the fourth pillar of New Labour’s approach: a greater, sustained focus on achieving targets, supported by effective performance management, to drive improvements. This, paired with emerging innovations such as surgical hubs, might truly allow a repeat of the successes of the 2000s, and ultimately help deliver more care to more people more quickly.