NHS waiting times: a symptom of the health of the health service

All kinds of numbers – percentages, pound signs, performance, productivity and, of course, waiting times – are used to describe the state of the NHS. But what do these numbers really tell us about people – both those waiting for and those delivering care – and their experiences?

Let’s begin with a run of numbers: waiting lists currently stand at more than 7 million ‘patient pathways’. The number of people waiting longer than one year for treatment stands at 387,000. The NHS is expected to achieve 129 per cent productivity in 2024/5 compared with pre-Covid-19 pandemic levels, even though the most recent estimates from 2021 indicated that productivity in the health service was estimated to be 16 per cent lower than before the Covid-19. The funding made available to the NHS to support the recovery of elective care services cannot keep up with inflation, meaning the health service must find a way of increasing its productivity with less resource than anticipated.

The NHS has been here before – not in this precise situation, of course, but there are some distinct similarities with years gone by. Workforce shortages. Poor pay. Unprecedented waiting times. Numbers give some indication of the scale of the challenge and of change over time. But to make full sense of the numbers – and to find ways to make progress towards more palatable numbers – we need to dip beneath the surface to recognise the stories and the experiences of the people the numbers represent: the people waiting for care and the people who will provide that care. As we found in the course of our research on strategies to reduce waiting times, focusing on numbers at the expense of the people can yield some undesirable consequences.

Waiting times are the product of a number of dynamic forces that contribute to the ‘life’ of the health care system, which is an ecosystem rather than a machine. Specifically, growing waiting times are the product of imbalance and misalignment between the supply of health care, demand for health care, and conditions within the health care system – including the culture and the processes – under which staff deliver and patients receive care.

'Waiting times are the product of a number of dynamic forces that contribute to the ‘life’ of the health care system, which is an ecosystem rather than a machine.'

Numbers only take us so far in understanding this dynamism and, therefore, the strategies that might be most effective to reduce waiting times within the health care ecosystem: a system which is, after all, comprised of people; not cogs, nuts and bolts. In our research, we found that less successful attempts to reduce waiting times expect the NHS to run as a machine: treating people faster, working people harder, desperately pulling levers and pressing all kinds of buttons to try and yield a result. Any result.

So while our research may not have pointed us in the direction of any one silver bullet about ‘what’ might be done to reduce elective care waiting times, it underlined the necessity of giving careful thought to the ‘how’. We spoke to 14 experts who were involved with designing, implementing and reviewing waiting times policy in England from 1997 onwards. In particular, between 2000 and 2008 elective care waiting times fell to a median of five weeks. The experts’ views about what contributed to this success? Valuing the people working in the NHS and investing in them. The cultivation of relationships and the recognition of leadership at all levels of the health care system. A clear, central vision and goal for waiting times but, crucially, for the health service as a whole: a vision into which those working within it feel personally invested, valued, supported and towards which it was clear about its contribution.

'The experts’ views about what contributed to this success? Valuing the people working in the NHS and investing in them.'

And, conversely, the reasons for the ‘managed decline’ of waiting times in the years preceding Covid-19 and the surging backlog since? Running the NHS ‘machine’ ever harder without adequate maintenance until parts start to fall off. Setting waiting times targets or productivity targets that take no account of the individual: that do not engage with what and how much people working in the NHS have to give – and how much they have left. This has implications, not only for the state of the workforce and for elective care waiting times, but also the type and quality of care that the health service is capable of providing to those who need it.

What started as a research project about elective care waiting times opened a window onto a much bigger, perhaps even existential question. What could – should – our National Health Service look and feel like? Waiting times are one measure of the health of the health service; growing waiting times a symptom that all is not well. As history shows, it is possible to treat the underlying cause at its heart – and people are the heart of the NHS.