Are elective recovery targets achievable? A look at the evidence

This week, the NHS published its plan to tackle the elective backlog. The overarching commitments include two key interim targets: first, by March 2026, 65% of patients will wait less than 18 weeks for elective treatment; and second, every trust will need to deliver a minimum five percentage point improvement against the 18-week target by March 2026.

Is this achievable? I’ve looked at what the historical data tells us, as well as the evidence around what works in reducing waiting lists.

Let’s start with the national target. 65% of people starting consultant-led treatment within 18 weeks is a 5.9 percentage point improvement over current rates. That is ambitious, but this level of improvement has happened before in 2007, when the target was first measured nationally. In just eight months, between August 2007 and March 2008, the waiting list went from 57% to 66% of people seen within 18 weeks. And it would more or less put the NHS on a pathway towards the 92% target by the end of this parliament – although the rate of improvement will have to ramp up further in future years.

What about locally? We don’t have provider level data going back to the period when the last heroic improvement in waiting list targets was achieved, so let’s look at recent history. In 2023/24, only one third of NHS trusts made any improvement at all in the percentage of patients seen within 18 weeks. So far in 2024/25 just over half (58%) have made improvements. Hospital performance data only goes up to November, but currently less than one in five trusts (16%) are on track for a five percentage point improvement this financial year. There would have to be a sizeable shift if each trust is to make a five percentage point improvement in the next financial year. Of course, until recently, trusts have been asked to focus on long waits rather than the 18-week target, so the specific emphasis may focus minds and bring results.

What can we learn from the last time there was a significant improvement in the 18-week wait?

A review of evidence and consultation with experts at the time suggests there were multiple factors, which are to some extent at play again. First, an aggressive political focus on the target (tick). Second, an extremely tight performance management regime linked to the target with strong sanctions for poor performing managers (sort of tick – performance management will mostly be through existing tiering but there will be a new NHS Oversight and Assessment Framework to assess performance alongside league tables tracking performance). Third, alignment of financial incentives so that providers were not disincentivised from carrying out additional activity (sort of tick – the financial envelope is constrained and providers will have to agree on how much they can deliver, with uncertainty on whether over-delivery will be financially rewarded, although there will be a capital incentive scheme for trusts performing well). Fourth, a focus on doing things differently and more efficiently, for example through the rollout out of day surgery units (tick – the plan includes an aim to reform diagnostic pathways and make more use of technology to enable patients to monitor their own conditions).

But in other ways, things are very different. In 2007, the waiting list was just over half of what it is currently (4.2 million compared to 7.5 million now). Funding increases were much higher, with average annual increases of 6%–7% compared to an expected increase of half that next financial year. And staffing pressures were not nearly as tight – with a concerted focus in the early 2000s on expanding workforce numbers but also improving pay and working conditions. There is a particular concern now that the planned expansion of surgical hubs and community diagnostic centres (and to some extent increasing capacity in the private sector) will rely on an already overstretched pool of staff. For example, in 2022 The Royal College of Radiologists found that 89% of community diagnostic centres are staffed with existing trust employees.

Will the new capacity be enough to meet the 65% target?

On balance it seems possible with herculean effort. But the government has also said it wants transformative change to the way the health service operates, shifting from a service focused on sickness to one focused on prevention, and shifting care out of hospitals closer to home. And we are currently seeing the impact on urgent care of an overly pressurised system, with multiple hospitals declaring incidents because of flu already this year and shutting down elective care to focus on the acute emergency.

If ministers and NHS leaders throw everything at it, the 18-week elective target might just be achievable, but doing so will leave them little energy or resources for the bigger, more fundamental NHS reforms that are needed. In the long term, it is vital that the health care system is put on a more sustainable footing, which will be impossible without transformative change. To drive that change, there needs to be realistic conversations about trade-offs and we would hope the forthcoming 10 Year Health Plan would include a review of NHS targets.