NHS waiting lists: How has England cut the backlogs?

The scale of the challenge was laid bare on Thursday when the latest statistics for NHS England noted that there were 7.6 million people waiting for inpatient or day case procedures in hospital as of May this year.

Around 307,500 patients had already been waiting more than a year.

READ MORE: 

• Elderly people in Sweden don't sell their homes for care - how did they do it? 
• Is this beginning of the end for general practice - or a turning point? 
• Inside the NHS: What are we willing to cut to keep health service alive? 

By the end of the current parliament, the Labour government has promised that it will once again hit the 18 week referral-to-treatment target - something not achieved since 2015.

In England, that means ensuring at least 92% of people referred for non-urgent, elective care (such as cataract surgery or a knee replacement) wait no longer than 18 weeks.

As of May this year, that was being achieved for just 59% of patients.

Scotland uses a more ambitious 12-week "treatment time guarantee"  - covering 100% of patients - but this was last met in 2012.

By the beginning of this year, 57% of patients in Scotland were being treated within 12 weeks

When it comes to elective care, the median time to treatment is actually one of the few areas where NHS Scotland is still outperforming NHS England.

In England, a typical patient is spending around three and a half months on a waiting list, compared to two months in Scotland.

Health Secretary Wes Streeting has vowed to eradicate waiting list backlogs in England within the next five years (Image: PA)

For some specialties, however, the picture is much worse.

In orthopaedics, for example, the median wait for surgery is around 108 days in England compared to 217 in Scotland.

By far, the biggest disparity between the two nations lies in the longest waits.

Under the previous Conservative government, NHS England channelled resources into tackling the backlogs of patients who had been waiting years for treatment as a result of Covid disruption.

Waits in excess of two years were virtually eliminated back in 2022, and as of May this year there were 4,597 patients who had been waiting more than 18 months.

In Scotland, more 17,000 patients have been waiting over 18 months for inpatient and day case treatment.

This includes more than 7000 people who have been waiting over two years and 1,369 who have been waiting more than three.

John Swinney was asked to explain the waiting list disparity during a Question Time leaders' debate (Image: Getty)

Grilled on the situation during a BBC Question Time leaders' debate, ahead of the General Election, First Minister John Swinney suggested - somewhat perplexingly - that it was "probably to do with is the nature of some of the complex health conditions people are experiencing".

While it is true that Scotland does have comparatively higher rates of chronic ill health and multimorbidity than England - factors which can delay complex surgery - it cannot possibly explain why Scotland, with a tenth of the population, has nearly four times times as many long waiters.

A better clue is in overall elective activity.

Despite industrial action, England has been consistently exceeding pre-pandemic levels of activity since July last year in terms of the number of routine, planned procedures completed.

As of May 2024, activity was up 6% on 2019/20.

In Scotland, elective recovery has been much slower.

The number of planned operations being carried out still lags 13% behind 2019 levels, with considerable regional variation.

Elective activity is slowly recovering in Scotland, but remains significantly below pre-pandemic levels (Image: PHS)

In Highland, where a National Treatment Centre opened in April 2023, elective activity is almost back to 2019 levels, while in Lanarkshire and Lothian it is still down by a staggering 21% and 32% respectively.

An NTC in Forth Valley has been repeatedly delayed, while work on NTCs for Lothian, Grampian and Ayrshire were all paused in January "until the necessary capital funding...becomes available".

Lanarkshire - originally scheduled to open its standalone elective hub in 2026 - remains in limbo.

This has certainly hindered NHS Scotland's recovery, but it doesn't fully explain the gap with England.

One contributor may be NHS England's Pay by Results (PbR) model, which incentivises hospitals to exceed elective activity targets on the basis that the more they do the bigger the financial reward.

In simple terms, "the more patients they treat, the more they get paid".

This has helped to encourage initiatives such as weekend 'super-clinics' where surgeons perform large numbers of the same procedure back-to-back, operating in one room while prepping another patient in the theatre next door.

On the downside, hospitals underperforming due to factors outwith their control (such as a social care shortages leading to bed blocking) can be penalised.

Nicola Sturgeon officially opened NHS Fife's National Treatment Centre in March 2023, before stepping down as First Minister. Many other NTCs have been delayed or paused (Image: Getty)

The original timetable for Scotland's NTC network, as set out in the August 2021 recovery plan. The Fife and Inverness hubs opened in 2023, Forth Valley and Golden Jubilee are due to open in 2024, but the rest are paused. Delays were initially blamed on Omicron, and latterly on the impact of inflation and capital budget constraints (Image: Scottish Government)

In Scotland, health boards schedule elective activity based on the budget available.

There are no fixed targets or performance-related bonuses, and ramping up elective activity means taking funds from elsewhere.

In addition, NHS England has always used the private sector more - partly because there are more private beds per head, but partly because it is more politically palatable.

In May, nearly 406,000 patient procedures carried out in independent hospitals were funded by NHS England, and half of NHS cataracts patients are treated in private clinics.

Wes Streeting says he wants to use "spare capacity" the private sector to drive down waiting lists faster, but it has its pitfalls.

With soaring demand for private treatment from self-paying and insurance-funded patients, private providers may be reluctant to accept less lucrative NHS contracts.

Secondly, there is the question of value for money for taxpayers: outsourcing is more expensive compared to the cost of doing the same procedures in the NHS.

READ MORE: 

• Is two-tier healthcare now inevitable? And how the private sector affects NHS
• Rapid increase in number of private GP clinics in Scotland since Covid 
• Power cuts, 'black mould', and near misses: Inside the crumbling NHS estate

Furthermore, as money flows into private hospital work, NHS nurses and doctors tend to follow, leaving NHS departments even more understaffed.

Labour is gambling that getting more people back to health is good for the economy and growth - and it might be.

Meanwhile, the Scottish Government might want to swallow its pride and reconsider previous offers to send some of our longest waiting patients to NHS England for faster treatment.

Either that or accept there are some lessons to be learned from NHS England and put them into practice here - before we fall even further behind.