The elective care waiting list: insights from linked data

The UK’s health and care system is under immense pressure, with the management of waiting lists for planned hospital care among the biggest challenges facing the NHS and the government. 

Elective care covers a broad range of planned, non-emergency, consultant-led services – from diagnostic tests and scans to outpatient appointments and surgery. In England, the elective care waiting list has tripled in size over the past decade, growing steadily since 2013 and increasing sharply during the COVID-19 pandemic (Figure 1, first panel). The waiting list currently stands at 7.4 million, with over 200,000 waits of over a year for treatment. Similarly, Scotland has seen the total size of its waiting list triple between 2013 and 2024. Behind the numbers are patients waiting in pain, unable to get on with their lives, and with conditions that are potentially getting worse over time.

Progress has been made on reducing the number of people waiting for a long time. And in January 2025, the government published a new elective care reform plan, setting out a wide range of measures to tackle excessive waiting times. These included a pledge that by March 2029, 92% of patients in England should start hospital treatment within 18 weeks of referral – a standard last met in September 2015 (Figure 1, second panel). The plan also sets out measures designed to tackle health inequalities and reduce disparities in those waiting for care.

Why delays to treatment matter 

Reports from Independent Age, National Voices and the Patients Association have highlighted how patients experience the impact of these ongoing delays. Themes include patients living with the consequences of debilitating conditions for longer; the risk of their condition worsening, requiring more complex, difficult and expensive treatment; the efficacy of the treatment being reduced due to delays; and in the most extreme examples, conditions becoming permanent and untreatable. Recent analysis of NHS Resolution data by the Sunday Times suggests that since 2010, there have been almost 40,000 compensation claims for injury and deaths caused by delays in care, costing the NHS more than £8.3bn. 

Waiting for treatment can impact other aspects of people's lives, for example making it harder to maintain independence or continue to work or attend school. Delays affect some groups of people more than others. People living in disadvantaged areas already experience poorer health outcomes and analysis highlights the disparity in waiting times around the country and a correlation with deprivation. On average, a person living in one of the most deprived areas is 1.8 times more likely to wait over a year than someone living in one of the least deprived areas.

Through our engagement with patients and the public, we heard from people on the waiting list about the challenges of physical pain while waiting for a procedure. A hip replacement patient from North West London described how pain while waiting ‘eats away at you… and uncertainty adds to your hyperawareness of being in pain.’ A patient on the waiting list in Grampian was conscious of how the additional support needed while waiting could take its toll on the wider NHS system, expressing concern at how this ‘puts additional strain on GPs who are already struggling to keep up with the demand and can’t afford to follow up on patients.’

How waiting lists are currently managed

The NHS Constitution states that people should be treated ‘at the right time and according to their clinical priority’ and that patients with urgent conditions should receive treatment more quickly. Currently, most hospitals manage patient waiting lists within each health care specialty, with initial prioritisation provided by GPs, and refined as needed by consultants and sector administrators within a specialty.

In 2021, NHS England set out five priority areas, one being to ‘restore elective care inclusively’. This meant examining waiting lists to identify inequalities relating to the level of area deprivation and by ethnic background, and prioritising service delivery by taking this into account. This was an important change to how NHS organisations were asked to manage waiting lists, embedding work to tackle health inequalities. The recent 10 Year Health Plan and elective reform plan have reaffirmed commitments to tackling inequalities in elective care, albeit in a broad fashion, with a greater focus on area-level support.

The growing complexity of patient needs and health care demand underscores the need for advanced methods for waiting list management. Traditional prioritisation by clinical urgency or first-come-first-served principles may not fully address complexities in patients’ needs nor optimise health care efficiency. For example, patients awaiting different types of elective care may vary in terms of their risk of deterioration or the benefits they are likely to obtain from more rapid access to treatment. These considerations have made their way into prioritisation policy, with some areas incorporating complex risk stratification based on a wide variety of indicators into the management of local elective waiting lists. Other areas have established ‘waiting well’ schemes to aid managing patients’ physical and mental wellbeing while they wait for their procedure. 

Analytical approach

The NDL uses a federated analytics approach meaning that analysis is performed locally, eliminating the need for patient data to leave secure local systems. This approach enables new insights from rich linked datasets that are not available at the national level. It also means the NDL can benefit from local data expertise and the understanding of local context that analysts, clinicians and patients bring.

For this topic we developed a central analysis plan using standardised definitions wherever possible. We also allowed for additional, customised analysis in order to meet local needs and maximise the value of locally held data. Analyses in sections 4 and 5 were performed by the NDL teams based in Cheshire and Merseyside, North West London and West Yorkshire; analyses in section 6 were produced by all four teams. 

NDL teams identified the following research questions for this analysis through engagement with local patients and their families, commissioners, local authorities and service providers:

• How long are people waiting for elective care and does this differ between population groups?
• Why do people ultimately leave the waiting list and does this differ between population groups?
• How much health care do people use before, during and after waiting for elective care, and does this differ between population groups?

When considering all complete pathways referred to the waiting list in our study period, substantial variation in wait lengths could be observed between NDL locations (Figure 2). 

Waiting times also markedly varied between age groups and health profiles. Older people had markedly shorter wait times than younger people: people aged 85 years and older had median wait times that were between 23 and 35 days shorter than those aged 18 to 24 years, depending on location. Similar patterns were observed in relation to levels of frailty and diagnosed long-term conditions. This appears to reflect the prioritisation of individuals with higher and more complex health needs, in line with advice to provide care ‘according to clinical priority’ in the NHS Constitution.

Overall patterns of health care use

For most people in our study, use of urgent and emergency health care was relatively rare in the 3 months prior to joining the elective care waiting list, during the waiting period and in the 3 months after leaving. In Grampian, for instance, less than 10% of people attended A&E or had an emergency inpatient admission in any of the observed time periods, and less than 5% had contacts with a minor injury unit.  

In contrast, contacts with primary care were much more frequent. Those waiting for elective care in NDL areas had between 17 and 26 GP appointments per week per 100 people depending on location. This is a higher rate of GP appointments than the UK median (16 appointments per week per 100 people). Overall, the weekly cost of primary care was more than double that of A&E attendances, despite individual GP appointments being substantially cheaper – the average 100 people on the waiting list in NDL locations had costs of £547 per week in GP appointments, compared with £251 in A&E attendances. 

Prescriptions were also extremely common among the cohort in all time periods, particularly for pain relief, antibiotics and antidepressants. In Grampian, over 95% of people in our study had a prescription for medication in at least one of the observed periods. 

Notes:

1. Health care use is represented in this table as the amount of health care (in this case A&E attendances or GP appointments) that the average 100 individuals in our samples use in a single week. Costs reported here similarly represent the average cost incurred per 100 individuals per week via each listed point of health care delivery.     
2. In NDL Grampian, the ‘while waiting period’ begins once a patient has been referred to inpatient surgery by a consultant, reflecting the Treatment Time Guarantee. In English NDL labs, the waiting period begins with referral to a consultant from general practice or elsewhere, reflecting the RTT waiting time standard. Patients who died before completion of the 3-month post-treatment period were excluded.  

Generally, use of health care was higher in the months before and after waiting than during the waiting period itself. A&E attendances and emergency admissions in almost all cases were highest in the 3 months before waiting and lowest while waiting. In the period following treatment, rates of A&E attendances were typically higher than during the waiting period, but lower than the period prior to joining the waiting list (Table 1). GP appointments and prescriptions followed a similar pattern in almost all NDL locations, aside from North West London where GP appointments were lowest in the post-treatment period. 

Higher than usual health care use in the months after receiving an elective procedure relative to the waiting period is also reflected in national-level statistics. Supplementary analysis of patients receiving hip replacement, cardiothoracic surgery and gall bladder removal procedures in the Hospital Episode Statistics dataset (HES) showed that rates of emergency inpatient admissions spiked following receipt of these procedures compared with the immediate months before. Rates of emergency admissions remained elevated among older patients for at least 9 months (see the technical appendix). 

Health care use by specialty

For most specialties, the highest rates of health care use occurred before the waiting period – but this pattern did not hold for GP appointments across all specialties. In North West London and West Yorkshire, patients waiting for cardiology, general internal medicine and ophthalmology had the highest rates of primary care use during the waiting period. Meanwhile, those waiting for elderly medicine, dermatology, gastroenterology, neurology, and paediatrics showed notable declines in GP use after treatment, with drops of more than 5% compared with during the waiting period. In contrast, patients waiting for cardiothoracic surgery – though a relatively small elective care group – saw a sharp increase in GP appointments after treatment, with rises of 25% to 97% across all NDL sites.

Overall levels of health care use also differed substantially between specialties. People waiting for elderly medicine services had the highest rate of GP appointments across all time periods and locations, between 34 and 47 appointments per 100 people each week depending on location. Patients who waited for general internal medicine, respiratory medicine, cardiology, rheumatology and cardiothoracic surgery services also had particularly high primary care use – among cardiothoracic surgery patients’ this was largely concentrated in the period following elective treatment. Rates of A&E attendances were highest among neurosurgery, cardiology, neurology and elderly medicine patients.

Health care use by patient characteristics and wait times

NDL North West London and NDL West Yorkshire analysed how health care use varied with total wait time. The group of people who waited for 18 weeks or less for elective care had the highest rates of health care use across all points of delivery, likely due to the age and health profile of that group (see section 4) – older people and people with long-term conditions used health care at a far higher rate than younger patients or people without long-term conditions. However, patterns of health care use over time varied between waiting time groups. 

For people waiting 18 weeks or less, emergency care use was lowest in the period after leaving the waiting list, dropping considerably in the 3 months after treatment compared with their level of use during the waiting period. In contrast, emergency care use increased following treatment for people who waited for longer than 18 weeks compared with their use while waiting – and this increase grew with longer waits (Figure 5). Similar patterns were seen for primary care among people who waited for more than 36 weeks. For those waiting longer, relatively greater increases in their care use following treatment may indicate additional aftercare needs or decreased effectiveness of treatment following a longer wait.

Targeting support at high-need patients and underserved groups

Levels of health care use before, during and after waiting varied considerably between population groups and elective care specialties. 

Patients on more than one waiting list in West Yorkshire had notably longer wait times than people waiting for a single service, and may benefit from additional resource to support to coordinate their care between specialties. People living in more deprived areas often had longer wait times than people from more affluent areas and people of ethnic minority backgrounds were seen to have longer wait times than white patients and greater barriers to attending appointments. People from more deprived areas were also more likely to have adverse health events while waiting, particularly those resulting in contacts with emergency care services.

Older people, people with long-term conditions or high levels of frailty and those waiting for general internal medicine, respiratory medicine, cardiology, rheumatology, and cardiothoracic surgery services used the greatest amounts of health care during and around waits for elective care. These groups of patients would benefit from additional support before, during and after waiting, such as being prioritised for continuity of care in these periods. Local waiting well initiatives can also play a key role in providing assistance to people with high health care needs, helping people during their wait to prepare adequately for their surgery.

These results highlight several key areas of focus for restoring elective care inclusively. Wider determinants of health, including local area deprivation and ethnic background, have already been incorporated into priority decision making in some integrated care systems. Our analysis suggests considering these factors as part of clinical decision making may be necessary for a truly inclusive recovery of elective care. This would need to address inequalities in wait times and protect groups at greater risk of adverse health outcomes during and around the waiting period.

Support beyond the waiting period

The patterns of health care use we observed – where use was often highest before joining the waiting list and remained high for some time after patients had their procedure – suggests that additional support is necessary beyond the waiting period itself. High levels of health care use before formally joining the waiting list possibly indicates a need for patients to make substantial use of primary care in search of an onward referral. As such, we suggest closer examinations of this pre-referral window should be a priority for future waiting list research.   

For some patient groups, health care use also markedly increased after treatment. People waiting for cardiothoracic surgery in NDL locations, for instance, saw primary care use increase by between 25% and 97%, and A&E attendance increase between 20% and 124% following their procedure. Patients who waited for longer periods also had greater proportional increases in emergency and primary care use following treatment compared with those waiting for shorter periods. For such patients, waiting well programmes have a crucial role to play in aiding fitness for surgery and raising awareness of potential complications. 

Increased care needs following treatment for some groups may also have wider implications for planning elective recovery, with high levels of aftercare placing additional strains on the health system as delivery is scaled up. Supporting national-level evidence on patients waiting for cardiothoracic surgery, hip replacement and gall bladder removal procedures found that emergency inpatient admissions spiked in the month following treatment, before slowly receding over the next 9 months. These patterns must be factored into local recovery plans and any related demand modelling, and should be a focus of future analyses.

Impact on primary care

Our results indicate that GP appointments and issued prescriptions were by far the most common health care events for patients waiting for care. People on the waiting list in NDL areas used primary care at a higher rate than the general population – however, this may be a reflection of the older age profile of people waiting for elective care. Despite much lower unit costs, the average cost per week of primary care for patients on the waiting list in NDL areas also substantially outstripped the weekly cost of A&E attendances. 

These patterns highlight the pressure facing primary care in a context where access is already under immense strain due to an aging population, increasingly complex population health needs and a sizeable shortfall in the number of GPs relative to demand. Pressure on GPs is likely to further increase in the coming years as care is shifted out of hospitals into the community.

Over-burdened primary care capacity can have a knock-on effect on A&E and urgent care use if GPs are increasingly less available to address routine health concerns. Opportunity costs from missed chances for early detection and the treatment of health issues before they become more severe, complex and costly are an additional pressure incurred by general practice. 

Data considerations

Reducing the elective care waiting list is a major national priority for the government. Despite this, we found that data relating to the waiting list often has substantial limitations and quality issues, meaning that some key knowledge gaps remain. 

Higher standards of reporting are required for waiting list data, particularly for the harmonisation of recording practices between providers. In a context where artificial intelligence is increasingly promoted as a key tool in waiting list reduction and in management of the NHS more generally, accurate, consistent data reporting is imperative.