Waiting times for elective (non-urgent) treatment: referral to treatment (RTT)

Waiting times consistently rank as one of the public’s main concerns with the NHS and have a big impact on patient experience. Here we explore how long people are waiting for treatment and what impact Covid-19 has had on the numbers.

Meeting the referral-to-treatment (RTT) standard

The NHS Constitution sets a standard that 92% of people waiting for elective (non-urgent) treatment (such as cataract surgery or a knee replacement) should wait no longer than 18 weeks from referral to their first treatment. This standard was last met in September 2015. Since then, performance has declined steadily, until the Covid-19 pandemic, when it deteriorated rapidly. Performance has stabilised more recently, but the waiting list remains high, at 7.5 million in March 2024. As some people may be on the waiting list for multiple conditions, this equates to 6.3 million unique patients.

The number of long waits

In addition to the 18-week standard, to prevent very long waits for treatment NHS England introduced a policy in 2013/14 that stated no one should wait more than 52 weeks from referral to first treatment. The number of people waiting more than a year was maintained at a low level for a long period of time but has never reached zero. In 2018, long waits started to creep up again, and then increased substantially during the pandemic. In October 2022, there was a post-Covid-19 peak of 411,000 before the numbers started to fall. The 2022 plan for tackling the elective care backlog includes an aim to eliminate 52-week waits by March 2025.

Specialty RTT performance

Over the past four years all specialties have seen a fall in performance, and none are currently meeting the RTT standard. The specialty with the highest number of waits is trauma and orthopaedics, with more than 800,000 people on the waiting list in March 2024. Ear, nose and throat has the highest proportion of waits of more than 18 weeks, at 51%. The impact of long waiting times on patients is not regularly captured but can mean that people are waiting in pain for longer and that their condition may deteriorate while they are waiting.

Referrals higher than treatments

In simple terms, the waiting list is growing because people are joining it (being referred) at a faster rate than people are leaving it (being treated). There are lots of factors that can contribute to this – for example, a growing population leading to more demand, and workforce shortages in the NHS meaning that capacity to deliver treatment is limited.

Referrals compared to pre-Covid-19

The Covid-19 pandemic has had a big impact on elective waiting times. In order to prioritise hospital capacity for Covid-19 and emergency patients, the NHS paused elective (non-urgent) treatment in April 2020, meaning that waiting times grew quickly. However, during the national lockdowns fewer people were referred for treatment so the overall waiting list remained fairly stable. Despite expectations of a backlog of people seeking treatment, referrals in 2021 and 2022 remained below pre-Covid-19 levels, before returning to pre-pandemic levels in 2023.

The King's Fund view

Waiting times consistently rank as one of the public’s main concerns with the NHS and have a big impact on patient experience of the service. The Covid-19 pandemic caused both elective waiting times and the overall size of the waiting list to grow substantially. However, even before the pandemic the NHS was already missing these key waiting time standards, and the numbers of people waiting continued to increase after the Covid-19 lockdowns ended.

Although there are signs that numbers are starting to stabilise, it will take considerable time and resources to reduce waits for routine NHS care. Building on the collaboration seen during the pandemic, there is an opportunity to think about how services can be provided in more innovative and efficient ways that reach those most in need, address health inequalities, and can sustainably meet the waiting time standards, both for elective care and more widely across the NHS.