Tackling the NHS backlog doesn’t just call for time and money, it needs transformation across the pathway, say Robert Ede and Sean Phillips

Much has been written about the waiting list for planned care in the NHS, which has now reached 5.45 million. A growing list brings a very real human cost, as millions of people endure long and uncertain waits. Polling also suggests that access to routine services will prove the defining NHS issue for the public going into the next general election

To date, discussions have focused on the time and resources required to clear the backlog. The forthcoming spending review, where a multi-year settlement for NHS recovery will likely be the single biggest bid assessed by the Treasury, represents a significant milestone. A satisfactory settlement is essential. But money alone won’t suffice. Instead, as we argue in a recent Policy Exchange report A Wait on Your Mind, this must be a moment for reform. 

Our report calls for transformation across the pathway—from referrals in general practice to post-operative recovery. We make 32 recommendations in total. Yet there are three areas with the greatest potential gains. All are affordable, achievable, and in the best interests of patient safety.  

Account for unknown clinical risks

In referral to treatment (RTT) terminology, the “clock starts” when a patient is referred from their general practitioner. Our research found that around 80% of patients on the waiting list are still awaiting a decision from a specialist, which is often the point at which they are referred for a diagnostic test. Having so many people within a “referral to decision” rather than “decision to treatment” cohort is an enormous unknown clinical risk to the individual and the NHS. We know, for instance, that one in five cancers are picked up following a non-cancer referral (more than four times all cancer screening programmes combined). 

However, hospital trusts receive no reward (or punishment) for achieving a timely decision about treatment. In an era of relatively short waits this is less problematic, but the average referral to decision time has increased substantially since the start of the pandemic. At the end of February 2020, 92% of incomplete RTT pathways that were without a decision to admit were within 22 weeks, yet that  rose to 37 weeks by the end of May 2021.

We believe the RTT framework should be reformed. As outlined by Sir Bruce Keogh, NHS England’s former national medical director, in his preface to our report, any changes we propose must factor in the tensions that new targets create. The best option, therefore, is to split the existing target, creating an eight week target for a decision, followed by a 10 week target for treatment. It would uphold the existing 18 week right as set out in the NHS Constitution, mitigate perverse incentives, and minimise the administrative burden. 

Adjustments to RTT must be accompanied by significant investment in diagnostic capacity and the NHS workforce. We have similar numbers of MRI and CT scanners as Hungary and Costa Rica, putting us in the bottom five countries in the OECD for this metric, yet our waiting list is already greater than the entire 5 million population of Costa Rica. We must grasp the generational opportunity to push most planned diagnostics into community settings, with investment made to bring the UK in line with the OECD average. This should be viewed as investment for the future, as aggregate demand for scanning technology rises over time.      

Support people while they wait 

A long and poorly managed wait can have dire consequences for a person’s mental and physical health, as well as affecting work and family life. Unfortunately, this experience is commonplace. In focus groups conducted for our research, most patients waiting for treatment were not updated about their likely wait, how it compared to their rights, or how prioritisation methodology (P1-P4) was applied. Many received news of cancellations at short notice. One participant felt “abandoned.”      

The NHS must transform its approach and look instead to turn waits into something meaningful. An enhanced digital offer led by the NHS that supports patients could be a central tool. Its services could include appointment scheduling, list status, and signposting to wider services including those offered by the voluntary sector. This should be developed alongside enhancing communications for those who are digitally excluded. All communication materials should incorporate wider healthcare information, ensuring that every interaction encourages and reinforces positive lifestyle choices. 

Improve operational transparency

Central to all our recommendations is the need to boost operational transparency. This concept 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 how it can be applied to public sector provision. Yet within the NHS it remains untested. 

With scrutiny of the NHS’s performance only likely to build as waiting times increase, the temptation to conceal information may grow. This would be the wrong move. The process of clearing the backlog should instead become more transparent. Patients should be able to access local hospital performance statistics via the NHS App, enabling informed choices about different providers. At a national level, we should learn the lessons from the successful vaccine rollout and host monthly presentations from the Number 10 podium on the number of operations and treatments carried out, led alternately by the prime minister and health secretary, flanked by the chief medical officer and new NHS England chief executive. This would not be a new idea: Tony Blair led press briefings on the same subject in the 2000s. 

Greater operational transparency brings benefits for the workforce too. Publishing data that meaningfully engage patients around their local waiting times creates opportunities for feedback loops. Why should patients on the waiting list not be able to “up vote” on the NHS app when their local hospital reduces the number of cancelled procedures from one month to the next? This cuts the other way too. The NHS collates huge amounts of patient experience data, but little of it is seen, let alone actioned, by frontline clinicians. We need to find new ways to mobilise these data effectively to create tangible changes in care and consign the anonymous feedback box to history. 

From grateful to empowered     

The recent job description for the NHS chief executive called for a leader who could encourage a shift from the “grateful patient” to the “empowered consumer.” If Amanda Pritchard is serious about delivering on this responsibility, then the journey to empowered consumer must begin with the elective care backlog. 

Robert Ede is head of health and social care at Policy Exchange.

Sean Phillips is a research fellow at Policy Exchange.

Competing interests: none declared.