In the face of record high waiting times for elective care, we undertook research to understand the strategies that have been used to reduce waiting times in England and elsewhere in the past 20 years.
We found that successful strategies are typically associated with a concert of activities that simultaneously ensure sufficient supply of health care, manage demand and optimise the conditions within the health care system itself.
In England in the 2000s, a number of activities were associated with reduced waiting times. These activities were concentrated within the categories of increasing supply and optimising conditions within the health care system itself to achieve the goal of an 18‑week referral to treatment target by 2008. These activities were underpinned by a bigger idea about what the health service as a whole should look and feel like, and incorporated how waiting times are brought down as much as what activities might be used.
For the experts we interviewed, the achievement of the 18 weeks target was made possible as a result of: valuing and investing in people working in the NHS; a clear, central vision and goal for waiting and an ambition that those working within health care felt equipped to take on; cultivating relationships and leadership at all levels of the health care system; accountability, incentives and targeted support to encourage performance against waiting times targets and other measures of quality of care; and seizing the momentum of wider NHS reform.
Whereas the improvement in waiting times performance of nearly 20 years ago took place in a very different political and economic context, the research highlighted not only hope but opportunities to reduce waiting times in the present day: by addressing shortages of health care staff and physical resources urgently; by working with integrated care systems in the spirit of prevention, collaboration, inclusion and community‑based models of care; and by aligning a vision for the health services with a plan that brings staff, patients and the public along on the journey to get there.
About this report
This report was funded by the National Institute for Health and Care Research (NIHR) Policy Research Programme (grant number NIHR200702) as part of the Partnership for Responsive Policy Analysis and Research (PREPARE) – a collaboration between the University of York and The King’s Fund for fast‑response analysis and review to inform the Department of Health and Social Care’s policy development. The views expressed herein and any errors are those of the authors only and not those of the NIHR or the Department of Health and Social Care.
Findings from the literature review
We explored of the approaches that have been used in England and elsewhere to reduce waits for elective care through an extensive review of published literature. Spanning the past 20 years across 15 countries, the literature afforded us an enhanced understanding of the underlying features and overarching principles of waiting list and waiting time management as well as the specific approaches that have been used to reduce waiting times in a wide range of contexts.
Very simply, elective care waiting lists and waiting times are a product of the fluctuations in and disparities between the demand for and available supply of health care. Understanding the root causes of these disparities and taking corrective action to restore balance between demand and supply and optimising the conditions within the health care system is therefore considered key to any strategy to reduce waiting times and sustain them at that level.
The forces affecting supply and demand of health care are numerous, broad and change over time. Through our analysis of the literature, we found that these factors fall into three overarching categories.
Supply‑side factors, including levels of funding, investment in and capacity of the health and care workforce, beds, equipment, facilities and technology to deliver health care.
Demand‑side factors, including the health care needs of the population, levels of presentations to health care services, the availability of treatments, thresholds and criteria for administering treatment and the attitudes and approaches of health care professionals in referring for/administering treatment.
Factors impacting the conditions of the health care system that affect the management of waiting lists and waiting times, specifically:
cultural and environmental factors
operational and practical factors.
We have presented a review of the evidence regarding specific actions in the main report and a full summary of the literature can be found on the PREPARE website.
The published literature highlighted a number of key points: the myriad factors that contribute to waits in the first place; the importance of adopting a system‑wide approach to tackle these problems at their source; and the value of combining activities that consider supply, demand, and the conditions of the health care system itself to reduce waiting times and sustain them at that reduced level.
Learning from previous strategies to reduce waiting times: interviews with key experts
The story we heard about the strategies used to reduce waiting times in England 1997–2022 was one of many different but synchronous strands held together as part of a broader direction of travel towards a transformed health service. The publication in 2000 of the NHS Plan: a plan for investment, a plan for reformmarked a turning point not only for prioritising waiting times (including introducing maximum waiting times for care) but reforming the health service as a whole.
Other initiatives introduced in the early 2000s that were directly or indirectly linked to reducing waiting times include:
activities to increase the supply of health care including additional funding (particularly for workforce) and the use of private sector capacity
activities that shaped the environment and culture of the health service including waiting time targets (underpinned by a framework of performance management and targeted support), the introduction of foundation trusts and Payment by Results
activities to enhance the practical capability of the health service to reduce waiting times and sustain them at that level such as granular data collection and analysis and quality improvement and efficiency programmes.
While the experts emphasised the role of different activities to varying degrees, generally they agreed that the achievement of the 18‑week referral to treatment target in 2008 was made possible by a number of factors:
increased funding and capacity – especially for the workforce
central direction and oversight
performance management and incentives
leadership and relationships at all levels
mobilising the know‑how and skills on the ground
wider NHS reform.
However, in the period since 2009 waiting times for elective care have increased and the Covid‑19 pandemic has added to the scale of the challenge.
The findings from our literature review and expert interviews diverge in their assessment of the specific activities deemed to be more or less ‘successful’ in reducing waiting times. In part, this is due to the difficulties of studying a specific activity in isolation from the host of other factors that affect the health care system and waiting times; it is also a matter of perspective and of what matters to those working in health and care – that is, what kind of health and care system they aspire to create. What happened in England between 1997 and 2008 was the setting in motion of several chains of events, some of which specifically aimed to reduce waiting times, while others may well have impacted waiting times but via transformation of the health service more generally.
The most successful efforts to reduce waiting times tend to comprise a number of activities that simultaneously promote alignment between the supply of and demand for health care, cultivate favourable conditions and optimise practice within the health care system.
In our report, we pose key questions for policy makers and health care leaders to consider for each of the categories.