NHS Faces 'Huge Challenge' to Tackle Waiting Lists Says Government Watchdog

Peter Russell

December 01, 2021

The health service faces a "huge and multi-faceted challenge" to meet standards of elective and cancer care that the NHS has committed itself to, according to the National Audit Office (NAO).

Under two possible scenarios, waiting lists in England could be longer in 2025 than they are now, an analysis by the Government's spending watchdog warned.

Lengthening Waiting Lists

The main standard for elective care is legally binding. It states that 92% of patients on the waiting list should start their treatment within 18 weeks of being referred to a consultant.

The number of patients waiting for elective treatment before the impact of COVID-19 was felt, was 4.43 million. Of those, 745,000 (17%) had been waiting for longer than 18 weeks, the report found.

During the pandemic, as NHS staff and hospital beds were committed to caring for COVID patients, the waiting list for elective care fell for 3 months in 2020 because the number of new referrals of patients to consultants "plummeted".

However, the backlog then grew rapidly to 5.83 million by September 2021, with 301,000 patients stuck on the waiting list for more than 52 weeks.

During the pandemic, NHS performance against elective care standards dropped to its lowest recorded level, the NAO found.

Cancer Care

COVID pressures on the health service quickly resulted in a significant drop in the number of patients completing cancer treatment.

In March 2020, NHS England & Improvement (NHSE&I) asked NHS commissioners and providers to maintain cancer services. However, this proved to be impossible as pandemic pressures engulfed the NHS.

Dame Cally Palmer, NHS England's national cancer director, told an inquiry by the Commons Health Select Committee last year that there had been "a reduction of 62% on the pre-pandemic levels" for urgent cancer referrals in the week commencing April 20, 2020.

By June 2021, NHS cancer services activity had recovered to pre‑pandemic levels. However, in September 2021 only 68% of patients requiring treatment within 62 days of urgent referral by their GP were receiving that treatment on time, the report found. That breached one of the time standards for cancer care that 85% of patients should have to wait no more than 62 days.

Missing Patients

Millions of people have avoided seeking, or been unable to obtain, healthcare during the pandemic. The NAO analysis estimates that there were between 240,000 and 740,000 'missing' urgent GP referrals for suspected cancer during the pandemic up to September 2021.

During the same period, there were between 7.6 million and 9.1 million fewer referrals for elective care, although the NAO acknowledges there are uncertainties over these figures.

It is also unclear how many of the missing patients will return for NHS treatment.

However, "under two plausible scenarios", the report says that if 50% of missing referrals return to the NHS – and activity grows only in line with pre-pandemic plans – waiting lists would reach 12 million by March 2025. If 50% of missing referrals return and the NHS can increase activity by 10% more than was planned, the waiting list would stand at 7 million by the same time.

The report acknowledges that NHSE&I has put initiatives in place to address NHS backlogs. These include £2 billion in 2021-22 to allow higher rates of funding for local NHS providers, and £700 million in the same financial year for investment in reforms to support recovery.

Also,  £350 million is being made available this year to boost diagnostic capacity, with £2.3 billion more between 2022-23 and 2024-25.

Additionally, an agreement will enable NHS commissioners and providers to purchase elective services from more than 80 independent sector providers.

Challenges Ahead

The challenge ahead for the NHS to meet elective and cancer care standards will require it to address pre-existing and more recent problems, the report says. These include:

  • Proving extra beds and operating theatre capacity beyond what was planned before the pandemic

  • Longstanding staff shortages

  • The ongoing pandemic, which may continue to affect bed and staff availability in unexpected ways, and at short notice

  • Existing health inequalities in which some patients might have to wait longer than others

  • The ongoing pressure on the NHS workforce

  • Delays in discharging patients because of pressure in the social care system

  • The effectiveness of programmes that prevent serious ill health that could reduce future demand for care

'Ongoing Uncertainty'

Commenting on the NAO report, NHS Providers said it underlined the difficulty in predicting how long a full recovery would take.

Its deputy chief executive, Saffron Cordery, said Trusts and frontline staff were faced with "ongoing uncertainty over how many people will continue to come forward for care, the number of hospital admissions due to COVID-19 hospitalisations in the future, particularly given the threat of Omicron, and how quickly we can stabilise the urgent and emergency care pathway".

The Royal College of GPs (RCGP) said the NAO had highlighted the need for carefully considered solutions to tackle the backlog and reduce waiting times for patients.

Dr Gary Howsam, RCGP vice chair, said: "It must be remembered that NHS pressures are not confined to secondary care and it's crucial that any efforts to alleviate the backlog in hospitals also account for the increased pressure the backlog is placing on general practice."

He said that in the light of falling GP numbers, the Government must "make good on its promise of an additional 6000 GPs and 26,000 other members of the practice team by 2024".

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