Written evidence submitted by NHS Confederation


About us

The NHS Confederation is the membership organisation that brings together, supports and speaks for the whole healthcare system in England, Wales and Northern Ireland. The members we represent employ 1.5 million staff, care for more than 1 million patients a day and control £150 billion of public expenditure. We promote collaboration and partnership working as the key to improving population health, delivering high-quality care, and reducing health inequalities.



In October, the elective and diagnostic waiting list rose to over 7 million for the first time. This is 60 per cent higher than prior to the pandemic in February 2020 (4.4 million), and 17 per cent higher than at the end of 2021 (6.1 million).The numbers show a rise of over 160,000 month-on-month, with the total number on the waiting list 58 per cent higher than the number of people waiting for treatment on the cusp of the pandemic (4.42 million).


These long waits are costing the economy, with many people waiting unable to work. But, most importantly, patients are suffering pain, disability, disease progression and are dying on waiting lists. Following a Freedom of Information request by the Labour Party it is estimated 117,000 patients died on NHS waiting lists in 2021.


In a bid to combat the growing waiting list, NHS England set a target for 2022/23 of delivering activity levels of 110 per cent compared to the pre-pandemic baseline. This, instead of a target to reduce the waiting list to a certain number, is because we cannot be sure how much waiting lists could grow by. They have, however, set targets for certain patient groups, such as 104-week waiters (most of whom were seen before the end of July 2022), eliminating 78-week waiters by April 2023 and waits over a year by March 2025 as per the plan for tackling the COVID-19 backlog of elective care. Though, as the recent National Audit Office (NAO) report stressed, even if the targets in the recovery plan are achieved many patients will still be waiting longer than NHS standards say they should.


National Recovery Plan Design

  1. Among its many lessons, COVID-19 has highlighted the benefits of providers working together to drive a more integrated approach to health and care which ultimately delivers improved outcomes. The importance of shared purpose, clinical leadership, trusting relationships and shared risk cannot be overstated- these things are key tenets of what we mean by integration in the health service.


  1. There are many good examples of integration done well. For example Greater Manchester Trusts set aside money to combat the elective backlog collaboratively, through setting up surgical hubs, amongst other measures. They expect this to continue to grow in value as we persist in tackling backlogs.





  1. Swift and effective integration requires strong collaboration across the system. As part of this, primary care voice and leadership need to be represented. Primary care can offer key insights on referrals and prevention strategy which would prevent duplication of efforts and ensure that efforts are within the capacity of the whole system.


  1. The single biggest barrier to stopping this plan from being achieved is workforce issues. The often-reported figure of 132,000 vacancies is a concern, but it’s also about having the right people. Numbers of nurses and doctors have been on an upward trajectory, bolstered by international recruitment. Yet our members report concerns around retention and gaps in certain roles affecting the speed of the elective recovery. We welcome the Chancellor’s announcement that Government will be bringing forward a workforce plan to assess how many doctors and nurses will be needed in 5, 10, and 15 years' time, but we hope to see him deliver funding to match these projections.


  1. Part of the workforce issue can be addressed by reviewing NHS pensions. For members of the NHS Pension Scheme, the value of pension savings is based on the growth in the member’s pension over the tax year. Pension growth is calculated by subtracting the value of the member’s pension at the start of the year from the value of the member’s pension at the end of the tax year. If the member’s pension growth exceeds the annual allowance, excess benefits may be subject to a tax charge. Our members tell us this can disincentivise staff from taking on extra work which would help to tackle the backlog.


  1. The plans expansion of surgical hubs and community diagnostic centres is particularly welcome – this will give patients greater choice about where they can seek treatment, making the best of NHS resources and providing services closer to their homes. However, big questions remain about how these sites will be staffed given the huge workforce challenges outlined above.


  1. We also welcome the plan’s focus on clinical prioritisation, particularly addressing health inequalities and reducing the health impact of social deprivation. We see the empowerment of local leaders to make local decisions based on clinical need as central to addressing the backlog fairly, and without worsen health inequalities for those most at risk, who may have been less likely to seek care during the pandemic.


Progress so far

  1. Since the publication of the strategy in February 2022, there has been some key progress on targets. The percentage of activity compared to pre-pandemic levels is now up from 93.8 per cent to 99.6 per cent - growing closer to the 104 per cent target set by NHS England as shown on the graph below.


  1. Though, recent data from the Institute for Fiscal Studies has shown that the NHS is not on track to meet its target of 30 per cent higher elective volumes in 2024–25 compared to 2019.


  1. In primary care, GP trainee numbers are up to nearly 4000 which is a hopeful sign for long term improvement and progress towards the target of reducing the number of patients per GP. This is positive as we can see that the UK has been falling behind other OECD countries in terms of number of patients per doctor.



National recovery plan implementation

  1. There are limited references to primary care in the elective recovery report, but recommendations include making them the primary point of contact for the secondary care backlog. Primary care is currently experiencing a workforce and demand crisis and taking primary responsibility for providing care to waiting patients is not a sustainable plan. Patients on waiting lists presenting in primary care are already exacerbating existing problems.


  1. Members in primary care tell us they are experiencing low morale given the pressures they face and the feeling that they are blamed for wider service problems. It would, therefore, be positive to see them involved in the plan and any proposals for tackling the backlog. If primary care can have a voice at the table and take part in integrated solutions, then outcomes will improve without worsening the existing access and workforce crisis. If they can be part of the plan, then they can also plan their own resources more easily and understand the pathways being put in place.


  1. Primary care already had a series of key performance indicators (KPIs) for cancer, including in the Investment and Impact Fund (IIF). The addition of an IIF indicator around two-week referrals and testing for lower gastrointestinal cancer in 2022 is in line with pre-existing practice and can help to incentivise work in this key area. However, due to the large number of KPIs in primary care, it is sometimes necessary to prioritise those which directly correlate to local demand and existing services. In addition, as some funding pots, like the IIF, provide payment after the service has been delivered, areas with limited funding and acute workforce challenges will prioritise the targets which they are most likely to reach, as they cannot afford to allocate additional resources to targets which may not bring in any funding and will have a negative impact on workforce pressure. Work is still completed on lower priority targets, but it may not be possible to deliver those targets to the standard currently being asked, without the support of additional workforce.


  1. The report’s suggestion that they will simplify the referral pathway and make specialist advice available within primary care is welcome. This would reduce the number of patients who experience a circular pathway of referral to secondary care then back into primary care for a different referral, greatly improving patient experience and


freeing up clinical time in primary and secondary care. Gateshead has ‘no wrong door’ models that co-locate primary and secondary services in hubs to address such issues.


  1. The independent sector is being commissioned to take on more procedures to tackle the waiting lists in the NHS. Whilst this is welcome as it can alleviate the pressure on the NHS, the independent sector will not have the capabilities, workforce or capital to take on the cases which are more complex in nature and acuity.


  1. The NHS will likely be left with the more complex and costly procedures to carry out because of the expertise and infrastructure needed. People on waiting lists, many of whom have been waiting several months, have deteriorated in their health and will need more complex care than they did when first joined the waiting list. Due to this, these patients will not have the choice to use the independent sector, and this further complexity of care means health inequalities worsen. Often these are patients with long-term and complex health needs from diverse socio-economic and ethnic backgrounds. Them having to wait longer for treatment further exacerbates health inequalities.


  1. The backlog in elective care is widening health inequalities on the whole. There will be patients who can afford to pay for independent sector care with shorter waiting times, but many cannot and are forced to wait for NHS care. This is reflected in waiting times having increased more in deprived areas than less deprived areas.


  1. Many find the independent sector more appealing a place to work than the NHS, demonstrated by the recent increase in private healthcare revenue. Given they are recruiting from the same pool of people as the NHS, this means less staff available to work in the NHS and some choosing to work more hours in the private sector. This is reducing NHS capacity further while not really adding to capacity.


  1. A key barrier to the implementation of the national recovery plan is the collapse of the social care workforce. With 165,000 vacancies, hospitals have been struggling to discharge medically fit patients to settings in residential care or the community due to a lack of available care packages.


  1. The fewer patients’ hospitals are able to discharge, the fewer they are able to admit, meaning longer ambulance waiting times, and people presenting to primary care and other settings because they are becoming more unwell whilst waiting for treatment.


  1. Therefore, whilst not part of the national recovery strategy on elective care, funding for social care, including the urgent release of the £500 million Adult Social Care Discharge Fund is critical to its success. In this vein, we welcome the Chancellors announcement in the Autumn Statement of investment that could lead to 200,000 more care packages.


  1. We have also been calling for the introduction of a national minimum care worker wage to boost retention of staff in the sector and see the newly announced increase in the national living wage as a good step in the right direction, but more needs to be done to support recruitment and retention in the sector.


  1. The below diagram highlights how better flow in the system is critical to tackling the elective and diagnostic backlog.




Diagram, timeline

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  1. GPs have been dealing with a backlog of patients who did not present during the pandemic and have since come forward and created a bottleneck for referrals. But with over 7 million people waiting for treatment, it is still unclear whether everyone who put off seeking treatment in the pandemic, has now come forward. Therefore, we may still not know the scale of the problem.


  1. Innovative use of the new Additional Roles Reimbursement Scheme (ARRS) staff allows Primary Care Networks to establish multi-disciplinary teams to provide more integrated health and social care services locally. This is being used to work with cancer patients outside of hospital, for example specialising the care coordinator role into a cancer care coordinator.


  1. Parts of the NHS began delivering virtual wards during the pandemic and have continued to provide these services to care for patients in their community. Again, this is a good way to deal with the limited resource and make progress on defeating the backlog.


  1. In a recent survey, 90 per cent of our members told us their efforts to reduce the waiting list are being hindered by a decade-long lack of investment in buildings and estate.


  1. The UK has one of the oldest health estates in the world. The NAO found in 2020 that 14 per cent of the estate pre-dated the formation of the NHS in 1948. Compounding this, successive UK governments have failed to invest enough in capital. As a proportion of GDP, the UK’s capital investment has remained far below (sometimes 50 per cent less) OECD peers from 2009/10 to 2019/20 inclusive.


  1. Our members consistently report that accessing capital remains difficult, and the business case sign-off process is opaque. It is critical that the government provides much quicker access to capital funding and invests in the estate, allowing integrated care systems to fulfil their potential to reduce health inequalities.


  1. The government has set out an ambitious programme of capital development with the New Hospitals Programme. A key plank of the Conservative Party’s 2019 manifesto, the programme promises 40 ‘new’ hospitals by 2030. Yet the long-term funding for these projects remains unclear, hampered by a shorter capital funding window than the programme’s intended ten-year timeframe.


  1. NHS leaders have also sounded alarm over the dire state of many rundown buildings and the spiralling maintenance backlog. All of this is putting patients at risk. Newer facilities and modern diagnostic equipment would enable patients to be diagnosed and treated faster.


  1. The Queen Elizabeth Hospital Kings Lynn NHS Trust’s ageing roof is at risk of collapsing and being held up by over 1,000 props. Last year the intensive care unit had to be evacuated and closed for three weeks because of fears the roof would collapse.


  1. Where organisations have been able to unlock funding, improvements are making a big difference.


  1. A new control room for the London Ambulance Service will boost IT resilience and enable the service to expand so it can manage more calls. The control room opened in June 2022 following a £9.6 million investment, and will also support faster dispatch of ambulances.


  1. A diagnostic centre, hosted by the Royal Free London, has boosted diagnostic capacity across north central London and provided patients with quicker and more convenient access to tests for conditions such as cancer, heart and lung disease.


  1. The government must protect the NHS capital budget. The failure to invest in capital is making the NHS less efficient than it could be. Any efforts to reduce the allocated capital budget will be felt for decades to come.


What is missing from the review

  1. The elective recovery plan states that areas such as mental health and community care are being addressed by teams across the NHS and social care, and in other such plans, and thus not in this strategy.


  1. There are significant backlogs in these other areas which is resulting in patients frequently presenting in primary care where access to more ARRS wellbeing staff would be useful as they provide dedicated non-medicalised mental health support.


  1. Meanwhile, an increase in patients who have been referred to secondary mental health services and come back to primary care while they wait for treatment (even though the severity of symptoms means the help they need is from secondary care). This is eroding patient and staff trust in the system.


  1. There were backlogs in people waiting for mental health support before the pandemic, but this has increased considerably since, partly linked to the increase in demand for mental health services. The Centre for Mental Health forecast that 10 million people (8.5 million adults and 1.5 million children and young people(CYP)) in England will need support for their mental health as a direct result of the pandemic over the next three to five years. In Q1 2022/23, there were about 1.2 million referrals to community-based mental health and learning disability services, yet to receive their second contact.  This metric is being used as a proxy to measure the backlog in mental health services.


  1. CQC’s recent report highlighted that mental health services are struggling to meet the needs of children and young people.


  1. Our members have told us that they have seen an increase in the severity of mental health needs in the adults and CYP they are seeing. This often results in them needing to be admitted to hospital and often stay for longer. Higher levels of acuity and longer stays means higher costs for the NHS, both now, but also potentially into the future as severe mental health problems are often ongoing, reducing the life chances of those who have them. It is imperative that we see a prompt and concerted effort to mitigate the backlog in these other areas.


  1. It is essential that our response to the growing waiting list looks at the impact of delayed care for CYP. Health conditions will rapidly worsen for CYP as they continue to wait for elective care, impacting their future health, prospect of co-morbidities, long-term ill-health, education, social lives, family dynamics and future quality of life.


  1. Particularly for musco-skeletal issues, a failure to administer treatment in a given timeframe may mean the chance to provide care is lost altogether due to development.


Key asks

  1. As mentioned previously, when patients are on long waiting lists, they often continue to present in primary care, driving up already high demand. We would like to see greater support for services to ensure they are helping patients on waiting lists with Waiting Well, which helps patients find other support while waiting.


  1. We would like to see recovery plans and commensurate funding for mental health and community recovery to mirror the elective recovery plan. As set out, these areas have severe backlogs too and this is just as important. It also has knock impacts on other areas of the NHS, meaning that if we do not tackle this simultaneously, we will never effectively deal with the backlogs in electives and other parts of the service.


  1. There are 132,000 vacancies in the NHS, therefore full costing and funding of the promisedworkforce plan is essential for a sustainable future for the NHS.


  1. As mentioned previously, the recent announcements around social care funding and the living wage increase are very welcome, but funding and pay for the sector must be kept under regular review.


November 2022