Written evidence submitted by Policy Exchange (CBP0040)


Policy Exchange is an independent, non-partisan educational charity seeking new policy ideas that will deliver better public services, a stronger society, and a more dynamic economy.


The Health and Social Care Unit at Policy Exchange looks to tackle the most pressing questions facing the NHS and social care sector today and to ensure that the needs of consumers are placed at the forefront of the national conversation.


We are pleased that the Committee is exploring this important issue. Our evidence submission focuses principally upon the recovery of elective services (also referred to as planned care). This draws upon research conducted and published in a recent report entitled A Wait on Your Mind: A realistic proposal for tackling the elective backlog. Elements of our response cover Emergency Care and General Practice.


The submission opens with a list of key messages, followed by direct responses to the questions posed by the Committee. We have chosen to not respond to questions six and eight.


Key Messages













Question 1: What is the anticipated size of the backlog and pent-up demand from patients for different healthcare services including, for example, elective surgery; mental health services; cancer services; GP services; and more widely across the healthcare system?


It is impossible to say. However, the total number of people waiting will grow substantially over the next 12 months, as a proportion of the 7.5 million people who did not seek treatment during the pandemic are referred by General Practice. Optimistic scenarios forecast that the size of the waiting list will approach eight million people by December 2021 and take between five and nine years to be fully addressed.


It would, however, be unwise to focus solely on the total figure given the different levels of risk contained within the total waiting list of patients for elective care. For example, we know that more than 4.2 million (80%) are awaiting a decision on treatment. This represents an enormous unknown clinical risk for the NHS which is arguably greater than those who have been diagnosed and are facing a long wait.


Question 2: What capacity is available within the NHS to deal with the current backlog? To what extent are the required resources in place, including the right number of staff with the right skills mix, to address the backlog?


There are well-documented bottlenecks in capacity, and extreme constraints in the workforce. Policy Exchange have identified the following issues and proposed several specific interventions:





Any agreement with the independent sector should be volume-based, comprehensive and give adequate investor confidence, and ensure best value for the taxpayer. A long-term approach could include reviewing the current Increasing Capacity Framework, and National Tariff prices to ensure the correct incentives are in place for IS providers to deliver an appropriate proportion of NHS work. The principles of ensuring that treatment remains free at the point of delivery must be upheld.






Question 3: How much financial investment will be needed to tackle the backlog over the short, medium, and long-term; and how should such investment be distributed? To what extent is the financial investment received to date adequate to manage the backlog?


Additional financial investment will be required. Reports in the media suggest that internal Government modelling shows that between £2bn and £10bn will have to be allocated per year for up to four years, on top of core NHS funding.


Most voices are calling for a long-term settlement for elective care. It would give the sector greater certainty and pave the way for some of the transformations require to embrace the positive changes from the pandemic, such as community and remote diagnostics.


On the other side of the debate, there is understandable concern within HM Treasury that delivering a significant multi-year funding package could not be an effective approach for making rapid progress on the waiting list, especially as the Health and Care Bill may lead to the use of high-volume incentives such as payment by results being scaled back.


On balance, we believe that the Secretary of State and NHS England Chief Executive should seek to negotiate a multi-year deal at November’s spending review, with around £2bn per year ringfenced for elective recovery. Within this, it is important to maintain the overall 18-week RTT standard, but with adjustments to separate out a diagnosis from treatment, with financial penalties introduced for ICSs which fail to meet them. This reflects the public’s priorities regarding access to routine services, and the requirement to get a quick and accurate picture of unknown clinical risk. Our specific recommendation for financial investment is as follows:



Question 4: How might the organisation and work of the NHS and care services be reformed in order to effectively deal with the backlog, in the short-term, medium-term, and long-term?


As outlined in our response to question 3, additional resource will be necessary. But this must also be a moment for reform.


The current approach to planned and outpatient care has remained remarkably unchanged since the NHS was formed nearly 70 years ago. This creates substantial opportunities for innovation.


Central to all our recommendations in this evidence submission is the need to boost operational transparency, now and in the longer term.

Operational transparency was pioneered in the commercial sector: companies that reveal their process (and efforts) have higher customer satisfaction and perceived value, even if the overall waiting time for that product is longer because it fosters deeper understanding. Research has demonstrated that the concept can be applied to public sector provision. Yet within the NHS it remains untested.[iv] 

How would this work in practice? Policy Exchange believes that every patient should be able to access their local hospital waiting times for each specialism. Patients should know their rights and be offered choice. At a senior political level, the UK Government should undertake a monthly press conference on elective recovery, emulating recent coronavirus briefings. These should be led alternately by the PM and Health Secretary, supported by the CMO and new NHS England Chief Executive. Further approaches to reform the existing approach to elective care





Question 5: What positive lessons can be learnt from how healthcare services have been redesigned during the pandemic? How could this support the future work of the NHS and care services?



Question 7: What can the Department of Health & Social Care, national bodies and local systems do to facilitate innovation as services evolve to meet emerging challenges?






[i]Diagnostics: Recovery and Renewal – Report of the Independent Review of Diagnostic Services for NHS England (October 2020), link


[ii] https://www.oecd-ilibrary.org/sites/eadc0d9d-en/index.html?itemId=/content/component/eadc0d9d-en


[iii] Lack of investment in NHS infrastructure is undermining patient care’, The Health Foun­dation, 8 March 2019, link


[iv]Ryan W. Buell, Ethan Porter & Michael I. Norton, ‘Surfacing the Submerged State: Operational Transparency Increases Trust in and Engagement with Government’, Harvard Business School Marketing Unit Working Paper No. 14-034, 6 November 2013, link


Sept 2021