NAO urges realism on elective recovery

The government has earmarked an extra £8bn to tackle waiting lists between 2022/23 and 2024/25. It expects that by the end of this three-year period, elective activity will be 10% higher than the 3.2% increase outlined in the NHS long-term plan.

However, an NAO report, NHS backlogs and waiting times in England, said that to tackle the rise in elective waits, the NHS needed more hospital beds and operating theatre capacity than planned before the pandemic. It must also manage pressures on the NHS workforce, including long-term staff shortages, and ensure existing health inequalities are not perpetuated or exacerbated.

Outlining the current scale of the problem, the NAO said performance against elective targets had been deteriorating prior to Covid, even though the NHS had been doing more work each year. In February 2020, the last month before the impact of the pandemic was felt, the 18-week standard was not met. Under the standard, no more than 8% of patients should wait more than 18 weeks, but in February 2020 it was 17% (3.7 million people).

Covid impact

Covid has led to resources being diverted away from elective care, while infection control measures have reduced elective capacity. It was inevitable the disruption caused by Covid would lead to a sharp increase in waiting times, the NAO said. In February 2020, 4.4 million people were on the waiting list – by September 2021 more than 5.8 million were waiting for treatment – 1.95 million for more than 18 weeks.

In addition, some people were unable to get referrals for elective care or did not present – the NAO estimates there were between 7.6 million and 9.1 million fewer elective care referrals between March 2020 and September 2021. It was uncertain how many of these missing cases will join the waiting lists, and over what time frame, but the NAO believes many will. It said the NHS must gear up activity to meet this demand, but even if can adapt to this surge, it insisted the challenge was daunting.

If half of the missing referrals turn to the NHS for care, and elective waiting lists grow at pre-pandemic levels, the waiting list will rise to 12 million by March 2025, it said. And, in this scenario, even if the NHS increases elective activity by 10% – as the government expects – there will be 7 million people on waiting lists, it added.

Increasing the numbers of hospital beds, nurses and doctors beyond the levels already planned could take years because of the time required for capital projects and for training. The ongoing pandemic could also continue to affect bed and staff availability in unexpected ways and at short notice, the report said.

‘The NAO’s report has delivered a cold dose of reality about the scale of the challenge facing the NHS in the years ahead,’ said Ruth Thorlby (pictured), assistant director of policy at the Health Foundation. ‘Even before the new Covid variant emerged, the NAO warns that the record-breaking waiting lists could grow even bigger before they improve. Any more disruption risks making the mountain to climb that much higher.’

The government’s NHS recovery plan must be realistic about the complexity of bringing waiting lists down and how long it could take to do so, she added. A balance must be struck between meeting increased demand for care, looking after patients’ wellbeing, and supporting ‘an under-resourced and overstretched workforce exhausted from the pandemic’. 

The recovery plan must support innovation and improvement, be developed with the NHS, and should not be punitive or driven by targets. She added that the plan must address the wider system. ‘Any plan must include ways to boost services in primary care and in the community, to help prevent people from becoming acutely ill and relieve pressure on hospitals. Social care especially needs urgent funding, both to enable people to leave hospital promptly and keep people well at home.'