Written evidence submitted by British Medical Association (NWT0008)

About the BMA

The BMA is a professional association and trade union representing and negotiating on behalf of all doctors and medical students in the UK. It is a leading voice advocating for outstanding health care and a healthy population. It is an association providing members with excellent individual services and support throughout their lives.

1. Executive summary

1.1  Waiting lists in England remain enormous and the NHS continues to fall well short of its target for 92% of patients to wait 18 weeks or less from referral to treatment.[1] Whilst these lists are currently lower than their September 2023 peak, they remain drastically higher than prior to the pandemic and progress towards reducing them has, to date, been slow.[2]

1.2  In this context, and in line with its election promises, the Labour Government has centred its health policies on the reduction of both waiting lists and waiting times – principally, it is focussed on the NHS meeting the 18-week target by 2029 (the end of this Parliament).

1.3  With a view to hitting this overarching target, a new elective reform plan, ‘Reforming elective care for patients’, has been launched – seeking to change the way for which elective care is planned, delivered, and paid. This plan ultimately relies on both secondary care and general practice doing more and includes a major focus on making greater use of the private sector.

1.4  NHS England’s 2025/26 planning guidance operationalises the plan and sets out interim targets for elective performance, focused on increasing activity and productivity. This approach to elective recovery and its associated reforms and targets could have significant implications for the daily working lives of doctors.

1.5  The BMA views the creation of this plan, and its ambition, as a welcome sign that ministers are serious about addressing the challenges facing the health service. However, there are significant omissions from it that we believe need to be resolved – crucially, without serious action to properly value, retain, and expand the NHS workforce, efforts to tackle waiting lists will not make the progress that we so badly need. For example, if the Government is going to meet its target of restoring performance against the 18-week waiting time standard by the end of this Parliament, all financial barriers to extra work need to be removed – including those related to pension taxation and childcare provision that leave doctors worse off for taking on additional hours. This is an investment that will pay dividends in the future.

1.6  As such, for the Government to be successful in its mission of bringing down the waiting lists, we believe it must:

1.6.1        negotiate with the BMA on national minimum rates of pay for additional elective work, to avoid huge variation in rates between trusts and varying levels of uptake – contrary to this, DHSC has favoured local approaches to tackling waiting lists (including negotiating rates of overtime pay which has led to local disputes between doctors and employers)

1.6.2        resolve pension and taxation disincentives that prevent some doctors from undertaking additional hours

1.6.3        invest in GP practices to support them to manage the demand created by elective waiting lists, as many patients awaiting treatment in secondary care are left reliant on general practice for ongoing care and pain management

1.6.4        properly value doctors to retain them and invest in growing the medical workforce to meet the scale of the challenge

1.6.5        ensure transparency and value for money of independent sector provider contracts

1.6.6        increase capital funding for maintenance and new facilities and ensure that funding is directed to where it is most needed.

1.7  New technologies, and a reliance on the now largely depleted goodwill of staff, will not be enough to deliver the reform and progress towards achieving the 18-week target.

1.8  Our submission expands on these views, which we hope will be helpful to the Committee’s inquiry.

2. Progress on targets to increase elective activity and end long waits for treatment

2.1  Prior to the pandemic, the BMA raised persistent concerns about the sustained growth in waits that saw a then near-record high of 4.42 million cases awaiting treatment in February 2020 – almost double the record low of 2.32 million cases on waiting lists in January 2010.

2.2  The cessation of elective care services during the pandemic had an immense impact on total waiting lists. A lack of capacity and the necessary prioritisation of urgent care contributed to sky-rocketing waiting lists that reached a record high of 7.7 million cases in September 2023.

2.3  The current Labour Government has set an explicit goal of restoring performance against the 18-week treatment standard to 92% by July 2029. The BMA and its members want the NHS to achieve this aim, for the benefit of patients awaiting care and for the long-term sustainability of the NHS. 

2.4  While some progress has since been made to reduce both waiting lists and waiting times, progress has been slow and NHS waiting lists in England remain extremely large, with 7.4 million cases – consisting of around 6.24 million individual patients – waiting for treatment as of February 2025.

2.5  Of those 7.4 million cases, 3.02 million have been waiting for over 18 weeks. While approximately 4.4 million cases were seen within 18 weeks, representing just over 59% of total cases, performance continues to lag well below the 92% target. Performance against the 18-week standard has failed to exceed 60% since November 2022.   

2.6  Current progress towards reducing waiting times suggests that it may take longer than the Government is aiming for. 

2.7  Likewise for waiting lists, while we have seen progress towards reducing the total waiting list in recent months, at the current average rate of reduction of around 40,000 cases per month, it could take at least six years before waiting lists are even restored to their pre-pandemic high of 4.57 million. However, it is possible for the NHS to achieve its 18-week waiting time standard while also maintaining large total waiting lists.

2.8  In order to speed up the progress towards achieving the 18-week target, we believe it is absolutely essential that more is done to adequately incentivise doctors to take up the additional, out-of-hours work that is necessary to get elective care back on track. Specifically, this means tackling critical issues on pay, pensions, and childcare allowances. These are explored in more detail later in our submission.

3. Progress across the three areas of diagnosis, surgery, and outpatients

3.1  Whilst the BMA does not regularly analyse specific data on diagnostic, surgical, or outpatient appointments – i.e. to provide specific evidence on the progress made in these areas – we have repeatedly highlighted the challenges posed by long waiting lists and, in particular, by the lack of sufficient diagnostic capacity in England.

3.2  For example, as the Government has highlighted, there is a severe need to increase the number of CT scanners available within the NHS – with the available statistics indicating that there are only 10 CT scanners per one million people in the UK, compared to an average within the EU of over 20 scanners per one million people. This shortfall in capacity has contributed to lengthy waits for diagnosis, which has compromised patient care and outcomes.

3.3  It is, therefore, crucial that the Government’s commitment to double the number of CT and MRI scanners is met, and that the requisite staff to deliver the increase in service, such as radiographers and other allied health professionals, are also funded and made available.

3.4  More widely, the BMA has long called for greater capital investment into the NHS and wider health system. As noted last year in the Darzi Review into the NHS, the service has been “starved” of capital funding, with a shortfall of £37 billion over the past 15 years. Darzi also noted that 20% of the primary care estate predates the founding of the health service in 1948. This situation has not only led to the inadequate development of new healthcare estates, but also to the deterioration of those existing healthcare settings – with the maintenance backlog rising to £13.8 billion, more than the annual total the DHSC receives to invest in capital.

3.5  The extent of this deterioration in the condition of the NHS estate also poses a clear risk to the speed of elective recovery, as crumbling buildings and outdated facilities can directly limit the capacity of trusts to increase activity.

3.6  The BMA had also previously called for the removal of payment limits for elective activity that was initially included in the NHS Payment Scheme for 2025/26, on the basis that this would artificially inhibit activity. We therefore welcomed the decision from NHS England to scrap the cap in April 2025 and believe that this is a positive recognition of the concerns the BMA raised.

4. Governance and oversight of the transformation programmes

4.1  The Government’s transformation programmes and wider elective reform agenda have the potential to dramatically alter the way in which the NHS plans and delivers care – both positively and negatively. Therefore, they need to be subject to strong and consistent oversight.

4.2  In particular, we are concerned that the focus on expanding the role of independent providers carries serious risks of baking-in further private sector involvement in the NHS. In so doing, it would undermine the long-term financial sustainability of the health service – directing scarce resources to for-profit companies who are able to cherry pick more profitable services which destabilises the NHS. 

4.3  While the BMA has recognised the need to use all available capacity to help bring down waiting lists, we have stressed that the priority must always be long-term investment into NHS services and their capacity, and that deals with independent providers must be time limited and offer good value for money for the tax payer. However, the Government’s plans for longer-term and locally determined relationships with the private sector appears to go beyond this.

4.4  We are concerned that the Government’s focus on expanding the role of independent providers may reinforce longstanding problems linked to ‘cherry-picking’ – whereby private providers of NHS services concentrate on less complex cases that generate greater profit, while leaving the NHS to manage more complex and more expensive care.

4.5  While the Government has been clear that training opportunities should be made available within private providers of NHS services, we remain concerned that, without significant oversight, these opportunities could continue to be limited, and that NHS staff may be deprived of access to training for specific treatments which are frequently provided by private providers, such as cataract surgery.

4.6  More fundamentally, it is critical that there is full transparency regarding the use of NHS resources to purchase capacity in the private sector. Constant oversight is also needed to ensure that all contracts deliver genuine value for money, to avoid a repeat of costly and largely fruitless contracts with independent providers during the COVID-19 pandemic.

5        Specific impact of pay for additional work

5.1  To increase elective activity to the necessary levels, serious changes need to be made to better incentivise doctors to undertake additional work outside of their normal hours, starting with their pay for this work.

5.2  Currently terms and conditions and pay rates for extra elective work vary hugely across the country, with major variations between providers and ICBs. This variation has seen some providers and ICBs reduce, cap, and even ban premium rates for additional work, largely due to financial pressures – with the effect of doctors opting not to undertake additional work, as seen at University Hospitals Birmingham. Meanwhile, others, such as University Hospitals Sussex Foundation Trust, appear to have been able to generate significant additional elective activity by increasing their overtime pay rates.

5.3  Unless action is taken to address the unwarranted and unfair variation in local pay for additional work, we believe that efforts to increase the speed of recovery will continue to be impeded. On this basis, and in support of those grassroots campaigns, the BMA is calling for a nationally-agreed minimum rate of pay for extra-contractual work, to ensure fairness for doctors and to allow for elective recovery to progress at pace.

5.4  Steps also need to be taken address wider issues with the terms and conditions of extra-contractual work, including ensuring doctors have the option to accept time off in lieu (TOIL) instead of or alongside pay for this work, and that extra-contractual work includes paid breaks.

5.5  Efforts to reduce waiting lists are also impacted by staff vacancies. There were over 107,000 staff vacancies across the NHS as of September 2024 but, due to the financial pressures, many secondary care trusts have imposed recruitment freezes and even voluntary redundancy programmes. The latest data suggest that there are 7,768 medical vacancies in secondary care. The UK already has comparatively lower doctor numbers than many EU members of the OECD. For members with available data, there are an average of 3.9 doctors per 1,000 people. To reach this rate, the UK would require almost 49,000 additional doctors across the country.

6        Specific impact of pensions policy

6.1  A BMA survey of more than 5,000 doctors[3] found that significant proportions of senior doctors have reduced their work commitments by such an amount that, if replicated across the wider workforce, would be equivalent to the loss of around 5,400 full-time consultants. That is almost 10% of capacity that could be offered to the NHS in England to tackle waiting lists this year. For GP partners, reported reductions represent a potential loss of around 4 million appointments this year.

6.2  The problem largely centres on the tapered annual allowance (AA)[4]. The standard annual allowance is the amount by which doctors’ pensions can be deemed to grow before being subject to additional tax charges. The taper is a mechanism whereby this allowance decreases when doctors’ earnings exceed certain thresholds. This taper can be triggered by taking on extra work, such as initiatives to clear waiting lists, creating a “cliff-edge” where earning as little as £1 more can result in an additional tax bill of £22,500 – which would mean the doctor would be literally paying to work. Almost all of this extra work is non-pensionable, meaning it also does not result in increased pension benefits on retirement.

6.3  For consultants responding to the survey:

6.3.1        1 in 5 (21%) said they had reduced their “regular overtime” this year due to the tapered AA, with reductions averaging 1.4 sessions (or programmed activities, PAs) a week. Additionally, almost 1 in 6 (16%) consultant respondents have gone part time this year due to the tapered AA, with reductions averaging 1.9 sessions (or PAs). A full-time consultant works 10 sessions per week. Combined, these regular hours reductions represent potential lost capacity equivalent to around 3,500 consultants in England this year alone.  

6.3.2        Almost 1 in 4 (24%) reduced their “ad hoc” overtime sessions to clear waiting lists (‘waiting list initiatives’, or WLI) due to the tapered AA, with reductions averaging 5.1 hours a week. This implies a potential loss of around 3.2 million hours of WLI work that would have been offered to the NHS in England this year alone, equivalent to around 1,900 full-time equivalent consultants’ worth of work.

6.3.3        Combined, there has already been a potential loss of capacity of around 5,400 consultants' worth of activity – i.e. 9.3% of the total consultant workforce in England this year alone.

6.4  For GP partners responding to the survey:

6.4.1        Almost 1 in 4 (23%) reduced their regular workload this year due to the tapered AA, with reductions averaging 1.7 sessions per week.  This implies a potential loss of around 4 million GP partner appointments in England this year alone.

6.5  In June 2024, a snap survey of BMA members showed 71% of all respondents indicated that if there were no reforms to the tapered AA, this would prevent or limit their ability to take on additional overtime. These results from our March survey show that this has sadly come to fruition, with 68% of all respondents reporting that the tapered AA will limit or entirely preclude their ability to take on additional overtime in 2025/26 if nothing changes.

7        Specific impact of eligibility thresholds for childcare allowances

7.1  The below issues also act as a significant barrier for doctors to taking on additional work, such as waiting time initiatives.

7.2  Consultants, resident doctors, SAS doctors and GPs with childcare responsibilities can all face extremely high marginal tax rates due to the loss of 30 free childcare hours and tax-free childcare. These were introduced in 2017 to help working parents pay for childcare. This is particularly important for doctors given the unsociable, long working hours they frequently undertake, which often necessitate access to urgent, short-term and extremely expensive childcare.

7.3  Unfortunately, the eligibility threshold means that individuals earning over £100,000 do not qualify, creating another “cliff edge” for high income parents, exposing them to extremely high effective marginal tax rates for earning over that amount[5] – exacerbated by the income tax personal allowance taper beginning at the same threshold. This cliff edge has worsened, as it has not been adjusted by inflation since its introduction back in 2017.

8        Role of General Practice

8.1  General practice can help to stop avoidable additions to the elective care waiting list, both via the new Advice & Guidance Enhanced Service (A&G ES), which provides limited (£20 per episode) funding to practices for engaging in pre-referral advice and guidance pathways, which may assist the managing of patients within the community as much as possible. This approach is intended to ultimately result in fewer referrals reaching the elective care stage, which will both help the NHS get through the backlog but should also reduce throughput into secondary care.

8.2  Advice and guidance allows GPs to seek advice from consultants in acute trusts, with the aim of seeking to review if a patient’s (non-two week wait referral) condition can be managed outside of a hospital outpatients setting and, where possible, avoid subsequent referrals into secondary care services. While advice and guidance pathways have existed for several years, with a strong push from NHS England to promote its use as a way of reducing pressures on secondary care, this funding is inadequate and capped at £80million for 2025/26 and its use is non-mandatory: GP practices retain a contractual right to refer as is clinically appropriate.

8.3  The introduction of the A&G ES was agreed as part of the 2025/26 GMS contract changes to both further encourage its use, and to recognise the increased workload that this has for GPs. The £20 item of service payment is unlikely to cover associated costs, and with the total funding for the A&G ES currently standing at £80 million nationally, ICBs will have limited funding to draw upon, and may choose to put in place caps on the total numbers of requests under the A&G ES in their systems. This in turn, may impact future engagement by practices, as they stop receiving funding for the additional work.

8.4  Whilst a review of the impact of the A&G ES will be ongoing, wider efforts to potentially embed such services or move greater amounts of care into community settings will need to play a key role in discussions over substantive GP contract reform, with any shift in workload or services matched by commensurate funding.

April 2025