Scotland and England: Behind the NHS waiting list divide

People waiting for joint replacements, ENT (ear, nose and throat) procedures, urology, and general surgery - such as hernia repairs or gallbladder removal - are worst affected.

"Our recovery has been appallingly slow after Covid in Scotland," said Simon Barker, a paediatric orthopaedic surgeon in Aberdeen and deputy chair of BMA Scotland.

"We're still not back where we were in terms of capacity. When I speak to colleagues down south, they've bounced back.

"You can tell because they're presenting data now and they're all motoring through cases at a rate of noughts again.

"I couldn't do that - we don't even have enough people going through the system to present [data] at the moment.

"They'll say 'I've done 10 of these in the last month or 15 of those in the last couple of months'; we're still trickling through."

Mr Simon Barker, deputy chair of BMA Scotland (Image: Newsquest)

Exactly why such a gulf has emerged between Scotland and England appears complex.

Even the waiting list data itself is not black and white.

For example, England's "incomplete referral-to-treatment pathway" - the list of patients still waiting for hospital treatment - combines people waiting for outpatient appointments (around 80% of the total) and inpatient or day case procedures (roughly 3% and 17%, respectively).

In Scotland, outpatient and inpatient/day case waiting lists are reported separately.

Nonetheless, the vast majority of those with very long waits in England are waiting for operations.

By the end of March this year, the number of patients in England with two-year waits was 559 compared to 6,985 on the inpatient/day case list in Scotland.

For waits over 18 months, the figure was 10,737 in England versus 17,147 in Scotland.

The picture shifts, however, with median waits.

This is the 'midpoint' used to evaluate how long a typical patient waits.

It is arguably more relevant to the majority of people since very long waits are rarer; by March this year, 11.6% of the 147,241 patients on NHS Scotland inpatient/day case lists had been waiting over 18 months or two years.

CASE STUDY: Arrochar man waiting over three years for knee op says NHS 'just want me to pop my clogs'

Here, the median wait for a day case or inpatient procedure had reduced to nine weeks by January-March this year, approaching the eight weeks and four days of the same period in 2019.

For England, the figure was 12 weeks and five days, versus 10 weeks and four days in 2019.

"It's impossible to say who's 'better', because that depends on your perspective," said Mark Dayan, an analyst at the Nuffield Trust health think tank.

Mark Dayan, Nuffield Health think tank (Image: YouTube)

One other strange disparity between the two countries is on elective activity.

In England, the total number of elective admissions - people coming into hospital for planned treatment (excluding outpatients) - was just 1.6% short of 2019 levels by January to March this year.

In Scotland, the number of operations carried out remained 20% below.

The rate of last-minute cancellations also appeared much higher in Scotland - around 8.5% versus 1% in England - although this data is trickier to unpick.

READ MORE: What are the consequences of waiting list backlogs in the NHS?

Dayan said: "Two things that are clear is that NHS in England has recovered the amount of treatment that it does faster.

"Both for inpatients and outpatients, it's closer to being back at pre-pandemic levels in terms of the number of people it's treating each month and each quarter.

"But at the same time, it's not clear that that's actually translated into a stronger recovery in England in terms of the amount of time the average person waits.

"Both Scotland and England are still worse than they were on that measure of median waits, but in terms of who's recovering to back to their pre-pandemic performance it looks like Scotland is a bit closer."

So what does underpin the different trends north and south of the border?

Both governments at Holyrood and Westminster pledged to eradicate waits over two-years or 18 months, and both have missed their deadlines.

However, the feeling from those on the ground is that the political impetus was much stronger in England.

Mike McKirdy, a breast cancer surgeon and president of the Royal College of Physicians and Surgeons Glasgow (RCPSG), said: "The English health service has thrown a lot of energy and resource at the 104 week and 78 week waiters to bring that number down.

"But the thing is, if you look at their numbers, it was never that high."

At its peak in January 2022, there were around 24,000 people in England who had been waiting over two years for hospital treatment.

Yet Scotland, with just a tenth of the population, peaked at over 10,000.

The target timetables set out by the UK and Scottish Governments to eradicate two year, 18 month, and one year waits for NHS treatment (Image: Newsquest)

As a proportionately much smaller problem in England, it was always easier to solve.

The bigger conundrum is how Scotland ended up with such a massive backlog in the first place.

However, McKirdy points out that NHS Scotland is currently completing 56% of planned procedures and two thirds of outpatient appointments within 12 weeks.

"We're kind of dealing with the business as normal bit while attending to a proportionately larger number of people who are waiting more than 104 weeks.

"I don't have the intelligence on exactly why there is such a discrepancy between the English and Scottish health services on that number, but it will come down.

"Looking at the statistics on activity you would expect that, within the next year to 18 months, that number will reduce down to zero.

"I think that's the Scottish Government's plan - to reduce that number for the longest waits over a period of time, while dealing with business as it comes in day to day."

Staffing may be another factor.

While NHS England grew the size of its nursing workforce by 3.7% in the year to February, in Scotland it shrank by 0.9%.

"The biggest bottleneck we have right now in terms of the workforce is the trained theatre staff," said McKirdy.

"It's not the surgeons or anaesthetists - it's the nurses."

Mike McKirdy, president of the RCPSG (Image: RCPSG)

Vacancies and sickness absence can also be more disruptive in Scotland.

"We tend to have smaller departments which are much less resilient than they would be in the big conurbations in England," said Barker.

"If one member of staff out of five is off, that is a much bigger percentage hit that one out of 35.

"It's much harder to deal with, so our capacity to recover is just not there.

"You might say 'let's increase everybody's throughput by a certain amount' - in a big department you can make a big difference, but if there's only a few people their capacity to upscale is really very limited.

"That's a geographical thing, it's nobody's fault, but it is an issue."

READ MORE: Deaths in Scotland are on the rise - so what's the cause? 

Barker also wonders whether NHS England's "marketplace" approach has helped to spur recovery, although he stresses it is not a model he favours.

Under this system, trusts can be financially rewarded for hitting or exceeding elective targets.

Barker said this seems to incentivise clinician-led innovation.

"There's a kind of disincentivisation in Scotland where if you do what you're asked to do and then you do some more, all that happens is that people moan that you've taken too much resource from the system.

"It's a kind of perfect storm. One easy way to save NHS funds is to do less, but that means people don't get treated.

"I'm saying this through gritted teeth because I really don't like the whole marketplace philosophy - on a fundamental level, I would prefer it didn't work - but it does seem to have generated a better culture in terms of 'can-do' and 'let's get things done' in a way that we just don't seem to have up here.

"There doesn't seem to be any real sense of leadership from NHS Scotland or above to drive that forward.

"It feels like we're just coasting along without putting the pedals down."

As health secretary, First Minister Humza Yousaf pledged to eradicate very long waits in the NHS. Nearly a year on the targets are still far from being met (Image: PA)

It is a view echoed by BMA Scotland chair and Inverness GP, Iain Kennedy, who also blames "an abject failure of workforce planning".

He added: "What consultants tell us is that the Scottish Government does not engage them about solutions.

"And the Government took its eye off the ball on waiting times."

Of course NHS England also relies more heavily on the private sector.

As well as more private hospital beds per head in England, there is more political will to use them, with trusts instructed to ramp up their use of independent providers for elective care - including diagnostics and day-case procedures - to 120% of pre-pandemic levels.

READ MORE: Number of Scots paying for private ops up by 73 per cent 

According to the National Audit Office, NHS England was on track to achieve this in 2022/23.

Even still, it remains "a relatively small proportion" of all NHS elective activity - around 9% compared to 8% in 2019/20.

Behind the statistics are patients whose long waits are - in some cases - making them sicker, more disabled, and less likely to make a full recovery. 

Barker said: "We've got patients waiting so long we're having to see them again to make sure that things haven't deteriorated to the point where you have to do something different for them.

"That's happened a few times to me.

"You want patients to get in, get treated, and go home, not get worse and worse, which is the way it is at the moment."

A spokeswoman for the Scottish Government said it is "committed to eradicating long waits".

The first of two new National Treatment Centres (NTCs) - dedicated elective hubs - opened earlier this year in Highland and Fife, with two more due to open later this year. 

She added: “Through maximising capacity and redesigning services of care we will continue to address long waits, with NTCs providing significant additional capacity for orthopaedics, ophthalmic and diagnostic activity.”