Extra appointments alone won't meet key government waiting time pledge

The Government’s plan to deliver an extra 40,000 NHS appointments and operations each week will not be enough on its own to achieve the 18-week waiting time target by the end of this parliament, new analysis reveals. 

The government’s ambition is to hit the key target of 92% of patients starting routine hospital treatment within 18 weeks by the end of this parliament – a target that has not been met for nearly a decade. To do this it has pledged to deliver an extra 40,000 NHS appointments every week, equivalent to two million a year. 

This will be achieved by enabling neighbouring hospitals to share waiting lists, commissioning the independent sector to supply additional capacity, and incentivising NHS staff to work extra evenings and weekends.

But a study by healthcare consultancy CF (Carnall Farrar) and the NHS Confederation has found that 40,000 extra appointments per week will only deliver an estimated 15% of the extra activity needed to hit the 18-week target if demand carries on growing in line with current trends and care continues to be delivered in the same way it is today.

While extra capacity is a promising start, further reforms and transformation in care pathways are needed to bridge the gap. The report’s authors say this is possible, but it requires change in every step of the pathway of care. It needs both a strengthened focus on existing initiatives as well as a more radical approach to elective hubs – doubling the current capacity – and the creation of centres of expertise for complex care. Capital investment to boost infrastructure is essential. Some of this is already in place but the measures are not being universally adopted. 

The analysis has found to achieve the 18-week standard, 3.6m referrals should be managed at any one time to respond to the expected need for care and to keep the waiting list from growing further. This means that the majority of the 7.6 million waiting list (nearly 4.0 million unresolved open pathways) are part of a one-off requirement that has accumulated over the last decade.

Analysis of the 18-week target from the report also found:

• In 2023/24, the NHS completed 22.2 million outpatient appointments, 2.8 million day-case procedures and 740,000 overnight stays. 
• Without any changes to the way services are delivered, an additional 5.1 million outpatient appointments, 500,000 day-case procedures and 150,000 overnight stays would be needed this year (2024/25) simply to prevent the waiting list from increasing further. The total activity required to ‘stand still’ would therefore be 27.3 million outpatient appointments, 3.3 million day-case procedures and 890,000 overnight stays.
• The NHS will also need to treat an additional 3.96 million people who are currently on the waiting list to address the one-off requirement of eradicating the backlog of people waiting. Spreading this one-off requirement over the five years would take an additional 1.1 million outpatient appointments, 120,000 day-case procedures and 36,000 overnight stays, per year. 
• Demand for NHS services is growing at an average rate of 3.8% per year (faster than the rate of funding growth).
• Putting all of this together, and to go beyond standing still, in 2028/29 the NHS will need to provide 33.6 million outpatient appointments, 4 million day-case procedures and 1.1 million overnight stays to clear the waiting list back to levels that would sustain performance against the 18-week target in 2028/29. This is 50% more activity than is now being delivered.
• This modelling assumes there will be no changes to the way care is planned and delivered. If this were to be the case, then the Government’s extra two million appointments a year would only address about 15% of the additional activity required to meet the 18-week target. 
• Key reforms to service delivery will be essential to address the shortfall. With no interventions, the requirement for elective beds, both overnight and day-case, would increase to 15,000 in 2028/29 from current implied capacity of 10,500 in 2023/24 – this is a 43% increase. 

The report welcomes the focus on elective recovery by the new government and calls for a more transformational approach to both clear the backlog and sustain performance at the 18-week standard. It supports the various activities already underway through NHS England’s elective recovery plan but argues that the focus on 65 and 52-week waits has created distortion in how providers address the elective recovery challenge.  

It recommends a range of measures, including: 

• Digitising waiting list management and continuously validating the patient tracking list: Embracing tools available as part of the Federated Data Platform more widely to improve efficiency and accuracy and supporting staff to adopt digitally-enabled management practices for the elective pathway. If everyone on the waiting list had their reason for treatment validated, it is estimated that around 770,000 care pathways would be removed (around 10%). 
• Creating elective hubs for people whose treatment involves an admission to hospital: initiating an accelerated development programme to almost double the current dedicated elective hub capacity in hospitals that don’t deliver emergency care. If the NHS is to embrace the benefits of elective hubs and meet anticipated demand in 2028/29, an additional 730 theatres and 3,800 beds would be needed at ‘cold’ sites. Capital funding with streamlined decision-making will be essential to facilitate this, reinforcing the NHS Confederation’s call for capital funding in the English NHS to increase to at least £14.1 billion annually, a £6.4 billion increase from the current level.
• Creating centres of expertise for complex elective admitted care: establishing elective hubs creates capacity on ‘hot’ sites (hospitals that deliver emergency care), both to decompress them from high occupancy levels enabling better care for emergency patients, and to provide capacity for complex planned care that needs to be co-located with the other services on major hospitals. 
• Transforming care in this way means that by 2028/29, 3,600 fewer beds and 770 fewer theatres would be needed for elective care at hot sites, meaning occupancy levels could be reduced to improve emergency care. Capital to remodel the existing hospital estate, making it fit for modern practice, will again be essential.
• Transformation of outpatient elective care, for people who do not need a hospital admission: the adoption of the latest technology and innovation to transform outpatient care, including process automation, the application of artificial intelligence and robotics, will reduce the size of the list. 

Hannah Farrar, Chief Executive of CF (Carnall Farrar) said:

 “Achieving the 18-week target is a critical pledge, it means everyone being confident they will start treatment or have an operation within 18 weeks of referral. The Government putting this at the heart of their agenda is promising, however, the challenge in achieving it when it hasn’t been sustainably met in over a decade shouldn’t be underestimated. 40,000 more operations is an important element but a step change in the Government’s approach is also needed.

“This means a bold, transformational response to enable timely access to elective care, starting with embracing technology and treating patients holistically, and significantly accelerating the development of elective hubs and centres of expertise for complex care. The Government has a critical opportunity to change the trajectory of healthcare delivery, I believe adopting the mid- to long-term changes set out in this report could protect and sustain the NHS long into the future.”

NHS Confederation chief executive Matthew Taylor said: “NHS leaders share the government’s ambitions to restore performance on the 18-week target by the end of this parliament. 

“But to achieve this the government will need to use the Autumn Budget to deal with the short-term deficit that is leading to NHS organisations either cutting or freezing posts. This will inevitably impede efforts increase productivity and reduce the waiting list. As our analysis with CF shows, 40,000 extra appointments a week won’t be nearly enough to hit the target. 

“We also know that the government’s intention of paying NHS staff time-and-a-half for weekend and evening shifts to clear the backlog doesn’t go beyond what many NHS trusts are already paying. So this alone won’t cover the shortfall. 

“Ultimately, we know that in order to keep up with the healthcare needs of the population the NHS needs reform, not just ever more activity. This means shifting to earlier, more preventative services – including primary and community care – to slow the rise in demand for healthcare. It will also mean boosting productivity through using modern technology and having buildings and equipment that are fit for the 21st Century. This can’t be done without further investment in capital funding, which will make every pound spent on services go further.”

Notes to Editors

1. The 18-week Referral To Treatment target (RTT) was last met in for a month in February 2016 using data from NHS England’s monthly RTT data collection between April, 2007 and May, 2024
2. The size of the NHS waiting list dropped to its lowest point in 2009/10 and held roughly flat until 2012/13. By 2019/20 (pre pandemic), it had grown by 75 per cent. It then proceeded to increase by a further 75 per cent until 2023/24 (post pandemic)
3. There are 7.6 million care pathways that are currently open and have not been resolved through treatment. The 7.6 million care pathways are for 6.4 million individuals (i.e. some individuals have more than one care pathway open)
4. The ‘Government’s plan’ refers to Labour’s pledges to the NHS in their June 2024 manifesto
5. The extra activity needed to hit the 18-week target by 2028/29 is based on current levels of growth and demand for care and how care is currently delivered and no further government commitments to sustain achievement of 18-week performance

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