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What caused the UK’s elective care backlog, and how can we tackle it?

The latest statistics on elective (non-emergency) care in England are making headlines for all the wrong reasons – the waiting list is over seven million1 , and over 400,000 have waited more than a year. Why is this? And what can be done about it?

The NHS was struggling before the pandemic…

Between February 2012 and February 2020, the elective care waiting list grew by nearly 2.2 million. Comparing to other countries, it is easy to find potential reasons.:

  • Funding: between 2013 and 2019, UK per capita spending on healthcare grew by 2 per cent per annum, compared to 3 per cent in the EU2.

  • Staffing: in 2020, the UK had 3 doctors per 1,000 people, compared to 4 in the EU2 .

  • Capacity: the UK had 2.4 hospital beds per 1,000 people in 2020, compared to 5.0 in the EU, and an above average occupancy rate (90 per cent in 2019, compared to 73 per cent in the EU).

… so Covid-19 had a greater impact on elective care

With little spare capacity in the NHS, it was inevitable that elective care services would be more disrupted in the UK compared to other countries (an impact worsened by demand initially falling as people stayed away from hospitals). The latest report from the Organisation for Economic Co-operation and Development report shows this disruption clearly; between 2019 and 2020 there was a 46 per cent fall in hip replacements and a 68 per cent drop in knee replacements (the EU average was 14 per cent and 24 per cent, respectively). The figure below shows the impact of the pandemic on elective surgery in the UK compared to other European countries.

Line graphs showing Elective surgery was severely disrupted in the UK during Covid-19

It will be a long road back …

No country’s healthcare system was able to avoid disruption from Covid-19 entirely, but the UK’s pre-pandemic struggles, and the disruption from the pandemic itself means it will take longer for health services to recover. The Nuffield Trust found that ‘in some countries, such as Italy, Portugal and Spain, waiting lists appear to be stabilising or even decreasing.’ But analysis from the Institute for Fiscal Studies predicts that the NHS waiting list will only start to fall from mid-2024.

… but there are ways forward

Greater investment

While the number of staff in the NHS has grown, rising demand means the workforce is struggling to cope, and recruitment and retention remain a concern; the vacancy rate is currently 12 per cent and rising, and the staff considering leaving the NHS is 31 per cent and rising. Without investing in staff, it is hard to see how the backlog can be tackled. Hopefully the upcoming workforce plan will help with this. 

As well as staff, sustained investment is needed throughout the sector, both in hospitals (between 2010/11 and 2022/23 the number of overnight hospital beds fell by 11 per cent) and beyond, from social care to enable prompt discharge, to community care to treat people without the need for hospital admission. 

Boosting supply

The introduction of surgical hubs could help – they aim to deliver nearly two million extra routine operations over the next three years. This dramatic increase in supply would substantially reduce the waiting list but will cost a lot of money and use a lot of staff. Without sustained investment and enough people, hubs will be unable to deliver. 

Some trusts are finding innovative solutions to reduce their waiting lists, with promising results. Barts Health NHS Trust, for example, has a range of initiatives such as using artificial intelligence to detect heart disease in just 20 seconds, compared to around 13 minutes when analysed by a human. And Guy’s and St Thomas’ NHS Foundation Trust has used high- intensity theatre lists, which focus on one type of procedure at a time, and can treat three times more patients than a regular surgical list. Such good practice needs to be more widely disseminated and emulated. But again, with insufficient and burnt-out staff, innovation could fall victim to more urgent tasks. 

Decreasing demand

Without efforts to reduce demand the NHS will always be under pressure. Other countries have had some success through prioritising patients based on need or severity, and the NHS also aims to do this. But it will have limited impact if the health of the population continues to worsen; tackling demand needs to start with prevention. 

Preventive interventions to promote and maintain good health, especially in an ageing population, will help to reduce demand pressures for elective surgery. For example, improving musculoskeletal health could substantially impact the demand for hip and knee replacements. Working on these is, of course, a slow process that will take investment and workforce. But it is vital for lessening the pressure on the NHS in the long term, so it is important it doesn’t get lost underneath quicker fixes.


The NHS was struggling pre-Covid-19, was severely disrupted by the pandemic, and is now dealing with a massive backlog in elective care. There are routes forward – increasing workforce and investment, expanding and innovating, focusing on prevention – but it will be a long, hard road.