Written evidence by Policy Exchange


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 Public Accounts 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.


The submission opens with a list of key messages, followed by direct responses to the questions posed by the Committee. We have responded to all questions.



Key Messages













Question 1: Before the pandemic, what were the root causes of the NHS’s deteriorating performance against the standards required for waiting times for elective care and cancer services?


It is well known that the waiting list is not just a COVID problem. Declining NHS performance in elective care can be traced back to the early 2010s. The situation began to significantly deteriorate in the winter 2018, when NHS England advised hospitals to cancel all elective surgery following a severe flu season.[3] Specific issues which have precipitated this situation include:


  1. Inherent issues within service configuration, for example by undertaking both emergency and elective activity in the same locations, increasing the likelihood of elective care being ‘paused’ during surge events.
  2. A focus on short term financial settlements, to backfill during periods of system stress (e.g. winters)
  3. Limited capital investment, which has in part led to a reduction in the total number of beds available.
  4. Poor quality data and strategic planning. The use of software to intelligently manage waiting lists is inconsistent across the provider landscape. Meanwhile core RTT submissions are often inaccurate – meaning that rather than a ‘single version of the truth’ there are different interpretations of demand and prioritisation within the system.


Question 2: What did the NHS do well and what could it have done better in providing elective care and cancer services during the pandemic?


The pandemic is ongoing. We therefore need to be cautious in not drawing definitive conclusions in what is a dynamic situation. However, it is possible to look at the first 18 months of the pandemic and set out some early findings and considerations. Two key observations are this point are:


  1. The NHS pause was longer than other comparable systems. Research from the Nuffield Trust indicates that the NHS had a longer hiatus of elective care procedures during the first wave of the pandemic (43 days) compared to other advanced healthcare systems such as Denmark (29 days).[4] Denmark also had similarities in terms of fundamental capacity – with similar levels of beds per 1,000 population.
  2. The NHS has since been slower to get activity levels back up to pre-pandemic levels. This includes activity and use of the independent sector (IS). The RTT figures to March 2021 demonstrate that GP referrals to the IS are around 25% lower than 2019 – suggesting inconsistent use of the eRS. This is reflected in reduced numbers of non-admitted completed pathways – meaning that less patients are being seen and treated. This is reflected in reduced numbers of non-admitted completed pathways – meaning that less patients are being seen and treated.


Question 3: What are the biggest challenges faced by local healthcare providers in recovering performance on waiting times for elective care and cancer services?


One of the most significant challenges will be to restore elective activity whilst at the same time managing the transition to new ways of integrated working under the model put forward by the Health and Care Bill, should it enter into law. Policy Exchange has shared our concerns that the reorganisation will consume vast amounts of managerial and change capacity in the NHS over the coming 18 months, whilst offering little remedy to the number one problem facing the health service.


Arguably the move towards integrated care, which is likely to lead to evolutions in the payment and incentive system, could run counter to the activity-led approach of payment by results set under a national tariff which characterised previous assaults on waiting times. A form of ‘blended’ payment system could bring advantages in meeting wider system goals, but a sensible compromise will need to be found to avoid the transition disrupting progress towards bringing waiting times for elective care under control.


Whilst reorganisations rarely have significant impact on front-line clinical roles, it is NHS leaders which will find themselves focused on a wider set of priorities. It will be important to not lose focus on the public and most pressing clinical priorities in this context.


Question 4: How should DHSC and NHSE support local providers to recover their performance?


As we outlined in our report, DHSC and NHSE must find a sensible balance between ‘carrot’ and ‘stick’. Some proposals put forward by Policy Exchange included:



Question 5: Are plans and funding announced to date enough to help the system recover or, if not, what in your view is still missing?


Broadly we believe that sufficient resource has been provided for elective recovery. Thus far the Government has committed to spend £2bn this year on tackling the elective backlog. In addition, it plans to spend £8bn in the following three years from 2022/23 to 2024/25.[5] This was consistent with the Policy Exchange recommendation which called for a multi-year spending commitment of around £2bn per year over the course of this Parliament.


We also are encouraged by the £2.3bn made available during the spending review to transform diagnostic services, including community diagnostic hubs, and the £1.5bn for surgical hubs. Thise again corresponds with key Policy Exchange recommendations.


The funding is welcome but does not amount to a strategy. We are still awaiting the publication of the elective recovery plan, which was initially promised by the end of November 2021. We anticipate that the plan, the development of which has been led by NHS England, will set out the broader transformation of planned care services. In our view is it important that the forthcoming plan: 1) Initiates a ‘data amnesty’ whereby providers can hand-in their waiting time data for cleaning and refinement, to improve the quality and the transparency; 2) Introduces a package of support to help patients whilst they experience long waits; and 3) Is the first step on a bigger reform of the current 18-week referral to treatment target, to ensure they are fit for purpose and do not lead to perverse incentives in the system.


December 2021.

[1] NHS England. NHS RTT waiting times data. October 2021. Link.

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


[3] The Royal College of Surgeons of England. A New Deal for Surgery. 2021. Link

[4] Reed, Sarah. Resuming health services during the COVID-19 pandemic. What can the NHS learn from other countries? July 2020. Link.


[5] UK Government. Build Back Better: Our Plan for Health and Social Care. 3 December 2021. Link.