With demand for hospital treatment outstripping capacity even before COVID-19, it is no surprise that the demands of delivering care during a pandemic have led to significant backlogs and longer waits for patients.
This page provides analysis on capacity in secondary care services and is updated monthly with new data.
Last updated in November 2023
A growing backlog of care in England
What is the backlog?
The backlog in secondary care consists of the care that the NHS would normally have delivered but which was disrupted as COVID-19 impacted service delivery. This includes:
- patients on a waiting list for treatment who would ordinarily have been seen by now
- patients who have not yet presented to their GP to seek a referral for symptoms due to concerns of burdening the health service or fears around COVID-19 infection
- patients who have had procedures cancelled
- patients who have had referrals delayed or cancelled
- patients who have had referrals refused due to a lack of capacity.
It will take years to clear the backlog. The ongoing need for stringent infection prevention control measures and workforce shortages mean it will take even longer to work through as demand continues to rise.
More patients than ever are waiting for treatment
High waits for treatment are not new. Prior to the pandemic in February 2020 there were already 4.43 million people on a waiting list for care.
At the beginning of the pandemic, the combination of suspension of non-urgent services and changes to individuals’ behaviour meant that the number of people joining the waiting list initially dropped. However, this has since been rising - and despite some improvements earlier in the year, waiting times remain far higher than pre-COVID:
The latest figures for September 2023 show:
A record high waiting list of 7.77 million, consisting of approximately 6.5 million individual patients waiting for treatment,
nearly 3.29 million of these patients waiting over 18 weeks;
around 391,000 of these patients waiting over a year for treatment – which is around 254 times as many as in September 2019, before the pandemic began.
a median waiting time for treatment of 14.7 weeks – almost double the pre-COVID median wait of 8 weeks in September 2019.
NHS England recently announced that up to 400,000 patients waiting over 40 weeks will be offered the opportunity to travel to a different hospital to be seen sooner. However, many people may feel unable to travel, particularly without support networks.
The new King’s Fund report on “Tackling health inequalities on NHS waiting lists” found that in August 2022, people who lived in the most deprived areas in England were twice (2.1 times) as likely to wait more than a year for elective treatment as people who lived in the most affluent areas. The government must make a firm commitment to taking a more ‘inclusive approach’ to tackling hospital waiting lists.
The hidden backlog is growing
The waiting list is a visible backlog, but what we refer to as the growing 'hidden backlog' remains an unknown for the health service.
The hidden backlog consists of patients who require care but have either not yet presented, or who have had referrals cancelled due to the impact of Covid-19 on the NHS; patients who, in normal times, would have been referred for treatment, received elective care and attended outpatient appointments, but who for a number of reasons relating to the pandemic have not yet found their way into the health system.
Despite improvements in 2021 and 2022 compared to the first year of the pandemic, the number of electives and outpatient attendances currently being carried out is still well below pre-pandemic levels.
This is storing up greater problems for the future. These backlogs are likely to result in worsened conditions down the line, leading to greater demand on health services.
Cancer targets continue to be missed
Performance against cancer care targets continues to be poor, with services operating well below operational standards. NHS England announced that changes to cancer waiting times standards will come into effect from 1 October 2023. There are currently 10 different waiting times standards applied to NHS cancer diagnosis and treatment, but these will be replaced with the following three core measures:
- 28-day Faster Diagnosis Standard (75%)
- 62-day referral to treatment standard (85%)
- 31-day decision to treat to treatment standard (96%).
While the number of patient referrals has surpassed pre-pandemic levels, the proportion of patients seen by a specialist consultant within two weeks of an urgent GP referral for suspected cancer remains low.
The 93% performance target for patients to be seen within that time frame has not been met since May 2020. In September 2023, this stood at 74.0% (a slight decrease from 74.8% the previous month).
The percentage of patients receiving their first treatment within two months of attending a screening service dropped dramatically during the initial few months of the pandemic. This stood at 64.6% in September 2023, a slight decrease from the August 2023 performance of 65.1%. This also remains below the operational standard of 90%.
The decline in these key indicators shows the level of pressure the system is under, and is a clear sign that significant investment in capacity is needed.
Patients are waiting longer for emergency care
Prior to the pandemic, the situation in A&E was increasingly difficult with demand soaring and the percentage of people being seen within the four-hour target reaching an all-time low over the 2019/20 winter.
At the start of the pandemic, A&E attendance decreased significantly which led to performance improvements. However, since lockdown eased demand has steadily risen, reducing performance against targets.
These pressures on emergency care persist into 2023, despite small improvements in certain areas. Demand for care across all A&E departments remained high in October 2023, with total A&E attendances standing at 2.22 million, up from 2.17 million in September 2023. 70% of people attending A&E were seen within 4 hours – a slight decrease since the previous month. It remains to be seen whether the NHS target of 76% will be met.
Waiting times have rocketed
The combination of ongoing pressure on services, the backlog of care and chronic workforce shortages means waiting times have increased to record highs.
The number of patients waiting over 12 hours from decision to admission increased by 35% since September 2023, and stood at 44,655 in October 2023. This is similar to October 2022 (43,792), and 62 times as high as it was in October 2019 (458). Note that this number also represents an underestimate of actual waiting times, as patients will have been waiting for additional time before a ‘decision to admit’ was made.
In part, these long waiting times are due to poor patient flow, as thousands of patients who are fit for discharge remain in hospital because there is no space for them in social care.
GPs are finding it harder to make referrals
We can track GP referrals into consultant-led outpatient services alongside the waves of COVID-19: as the waves have peaked, referrals into secondary care have dropped. These drops are likely due to a combination of changes to patient behaviour alongside capacity issues in secondary care effectively forcing GPs to take a more cautious approach with timings of referrals to avoid having referrals rejected.
GPs can still refer patients, but the pressures in hospitals means there is little capacity in secondary care, and those referrals are often rejected.
The number of GP referrals to consultant-led outpatient services that have been unsuccessful because there are no slots available has jumped from 238,859 in February 2020 to a staggering 401,115 in November 2021 (an 87% increase).
When GPs are unable to refer into hospital services, the care for these patients does not disappear. Instead, these patients need to be cared for by GPs while they wait for hospital treatment to go ahead, adding to the pressure in primary care.
The role of the private sector
Enlisting the help of the private sector is one of the measures the Government has taken to reduce pressures on hospitals and help cut waiting lists.
Purchasing private capacity is not new, but the pandemic has demanded unprecedented block-booking arrangements.
A recent BMA survey found that under these arrangements, 60% of private practice doctors who responded were unable to provide care to their patients at the time.
The extent to which private hospitals will be able to take on NHS waiting list initiatives going forward is unclear given the increased demand in the self-pay market and the backlog of private sector patients.
Given that the NHS and the private sector largely draw on the same pool of doctors, additional capacity may be less than it initially appears. This was made clear in the 2020 block-booking arrangements, which saw the NHS gain facilities rather than the workforce to run them.
What the BMA is calling for
Given the immense strain on secondary care, the BMA is calling for immediate actions to be taken to prevent waiting lists from growing faster than they already are and to prevent increased pressure on hospitals. Actions can be found in our weathering the storm report.
The extent to which the NHS can address these capacity challenges is in large part determined by the resources available to it. That is why the BMA has called for an additional £7 billion on top of the £10 billion previously announced. Existing resources and funds must also be directed to where they are needed the most.
The BMA is advocating for measures to prevent attrition of doctors, including:
The Government must develop a credible plan to meaningfully increase NHS hospital capacity and ensure that the NHS is not reliant on private sector capacity in the long-term.
Over the longer term, the BMA has called for increased measures to support effective collaboration between primary and secondary care.
This will help tackle:
- waiting lists
- high workload
- the need to adapt physical spaces to prevent the spread of infection
- lack of joined up IT and data sharing
- lack of consistent communication and trust between different parts of the health system.