Can this government really recover NHS performance standards within a single parliament? And what are the costs of trying?

There are reports that the government is willing to think differently about NHS waiting time targets and their relative priority. But if it is serious about driving through reforms to the health care service, the government should go further and conduct a fuller review of targets.

Nearly thirty years ago, the New Labour government wanted to slash waits for NHS care. New waiting time targets were introduced, more staff were recruited, and new payment systems were created to reward NHS organisations for doing more activity. As a result, access to some health care services improved dramatically over subsequent years.

But then a combination of staffing shortages, slowing funding growth, rising demand and a global pandemic led to the long waiting times and huge waiting lists we now experience.

A new ambition to recover old targets

The current Labour government has promised to redress that pain and wind back the clock. The Labour manifesto focuses on tackling long waits for planned (or ‘elective’) hospital care. It’s easy to understand why: the waiting list for planned care visibly ballooned after Covid-19 and is a recurring concern when the public is polled; the pathway for elective care is arguably more within the span of control of a single provider than more complex emergency pathways that involve the ambulance service, A&E departments and fracture clinics; the private sector has a clearer offer and capacity on high-volume, low-complexity elective care and there are separate payment systems that can be used to incentivise better access to elective care; and there are specific existing manifesto commitments (and now funding) to increase appointments and build surgical hubs to reduce elective care waits.

But elective care is not the only target the NHS has. And elective care is not the only service the public cares about. So it’s not surprising that the Health and Care Secretary has said that his ambitions are wider: alongside improving access to GP appointments, all NHS ‘constitutional’ performance standards across ambulance, cancer, A&E and diagnostic tests are to be met over this parliament (see annex 2 to Labour’s document Build an NHS fit for the future for more details). 

And if you thought (as I did) that the government wanted Lord Darzi’s recent investigation into NHS performance to temper expectations, then we need to think again. Although Lord Darzi said, ‘it is unlikely that waiting lists can be cleared and other performance standards restored in one Parliamentary term’, the Health and Care Secretary has doubled down and promised to go ‘hell for leather’ on meeting all targets.  

Are waiting times recoverable… and should they be recovered? 

Waiting times matter. I’ve sat in those queues. I’ve felt that pit in my stomach. I’ve felt the panic as you wait for the care you or your loved ones need. And so have you. Although the science isn’t exact, we know that the longer you wait, the worse your clinical outcomes will be for some health conditions. There are reasons why we measure how long it takes for an ambulance to respond to a person who has stopped breathing, or how long you wait for suspected cancer to be ruled out or confirmed.

But Lord Darzi’s review should make us stop and think about two things. First, can the targets be met at all, and second, even if the targets can be met, would it be worth the cost?

So, can targets be met? Many of these targets have not been met for nearly a decade, despite increases to NHS funding and staffing numbers. The last time targets were sustainably improved and met, NHS funding growth was far higher than the levels we can expect over the next few years. Although some respected models suggest that individual performance targets could be met, there is no evidence that all targets in totality could be achieved. I think Lord Darzi’s pessimism – or rather, realism – is justified.

Meeting the targets would come with significant opportunity costs. Just think of the powerful gravitational force of this policy, which would pull new staff and funding for the NHS towards the services that are already covered by targets. But what about services that are important but not covered by targets, such as assessments for ADHD? Or other policy priorities, such as moving to a more prevention-focused health service?

For too long, there has been an implicit narrative that the NHS needs to ‘stabilise to transform’, and that we must wait until hospital performance targets are reliably met again before greater investment can be made in preventive services. In reality, history tells us that areas left outside the reach of targets will also be neglected. A health care system can probably only do one big thing at a time – do we really want it to be the same thing that was achieved 25 years ago?

But even if you can imagine a time when all waiting time targets were being met day in, day out across the country, there would still be a strong argument to change them. 

It is important to remember that targets are not preserved in aspic. They never have been. The A&E waiting time target was once for 98% of people to be seen in four hours, not 95%. We used to have separate 18-week targets, rather than a single consolidated target for planned hospital care – with further changes planned to this target before Covid-19. How we categorise and measure ambulance response times was changed seven years ago. The ten cancer waiting time standards were consolidated into three targets in 2023. During the Covid-19 pandemic new ‘p-categories’ were popularised to prioritise surgical care.

Targets need to change to reflect advances in clinical care and the government of the day’s priorities for the health service. If this government is serious about the three shifts it wants the health care system to achieve, the targets it uses to measure performance need to be more focused on the future achievement of those shifts.

And in a world when the three shifts have been attained, it is hard to see how the targets as they are currently constituted would even be achievable – because in a preventive-focused, community-based and digitally-enabled system, only the sickest and most clinically complex patients would be captured by existing hospital targets.  

Another way – changing the ambition to recover NHS targets 

If the government were going to reconsider its commitment to recover NHS performance targets, how could it approach this? I think there are several different options, which are not mutually exclusive (see Table 1). 

Table 1

What next? 

Waiting times standards matter to the public, for good reason. The political reality is that the government made a promise to meet those targets in its manifesto, and those promises, and the mandate they represent, are important.

In revising its commitment, the government may receive a concentrated burst of criticism for a volte face. But it will also forego the sustained criticism it would receive month after month as waiting lists remain stubbornly high and access targets are consistently missed between now and the next election.

By pausing the new hospital building programme and plans to cap lifetime social care costs, this government has already shown it is willing to rethink hugely significant commitments. We also have a Health and Care Secretary who clearly wants to define himself by making the tough choices and trade-offs that are needed to change our health care system – this is an opportunity to turn those speeches into reality.

Changing the commitment to recover NHS performance targets would not be an easy decision. But if the government is serious about reforming the NHS it needs to review existing targets urgently to make sure they are pulling towards, rather than against, the overall health mission this government is trying to accomplish. As a patient and citizen, of course I want all those access targets to be met. The song lyric that comes from my heart, and a place of fear and emotion is, ‘I want it all, and I want it now.’ But the lyric that comes from my head, and from my experience, is a different one: ‘You can’t always get what you want’.