Welcome to HSJ’s Performance Watch expert briefing. Our fortnightly newsletter on the most pressing performance matters troubling system leaders. Contact me in confidence here.

Performance Watch understands that NHS England is finalising funding for local commissioners to put elective waiting times performance back on the right track.

Details are yet to emerge but the plans will underpin NHS England’s commitment that the service will do no worse on the referral to treatment waiting time standard in March 2019 than in March 2018.

System leaders are, however, under no illusions that the big problem is how providers will find the capacity to do the work even when the commissioner side funding allocations are finalised.

And NHS Improvement’s 2017-18 Quarter 4 data published last week laid bare the depth of the referral to treatment problems as well as the sector’s financial woes widely reported last week.

As we reported, it showed the number of patients waiting a year or more for elective treatment has risen by 75 per cent year-on-year while the total waiting list rose to 4.1 million, higher than at any point since August 2007.

Performance against the 18 weeks waiting time mark between January and March was 87.2 per cent against the 92 per cent target. This is nearly three percentage points worse than the 90 per cent record for the same period in 2016-17.

Interestingly, the report also revealed there had not been as many cancellations following system leaders’ order trusts to halt elective work in January as anticipated.

Some 22,800 procedures were postponed following the national emergency pressures panel’s intervention – under half the 50,000 predicated cancellations.

The circa 23,000 cancellations, however, represent a relatively small chunk of the 300,000 shortfall in elective procedures completed in 2017-18 against what the service had planned.

The report said 7.78 million elective procedures were completed in 2017-18 against a plan for 8.08 million operations. The number of procedures completed was also less than the 7.86 million carried out in 2016-17.

This arguably supports the theory that the RTT die was cast long before winter when NHS England’s Next steps on the Five Year Forward View effectively gave trusts licence to let RTT performance slip last March.

Finance policy advisor for NHS Providers David Williams told HSJ: “Not only did performance against the 18 week standard drop, but there were fewer elective admissions in 2017-18 than the year before.

“That’s bad for patients, and for trusts, and was one of the main causes of the provider-side deficit revealed by NHS Improvement last week.”

NHS Providers said trusts should be involved in drawing up recovery plans. They called for measures to increase capacity across the system. “Providers stand the best chance of recovering on RTT if capacity is increased in mental health, community and social care as well as acute inpatient beds,” Mr Williams said.

Bed numbers have been falling for several years. There were 103,358 general and acute beds in the last quarter of 2017-18, 5,532 fewer beds than the 108,890 in the last quarter of 2010-11, according to NHS England’s official data.

The rhetoric coming from senior NHS England figures is all about freeing up beds and smarter use of existing capacity rather than adding capacity.

As revealed by HSJ in April NHS England’s calculations are predicated on the assumption that it needs to free up around 4,000 beds.

A cornerstone of their winter plan will be to create the extra capacity by cutting the length of stay of patients who have been in hospital for more than three weeks, the so-called “super stranded” patients, of which there were recently estimated to be as many as 18,000.

With relatively little time to hire staff and build any new capacity before next winter, no one would argue focusing on better use of existing space and resource is not a good idea.

But there is a sense that there is only so much that can be done within the existing physical capacity constraints.

Jeremy Hunt’s desire for eye-catching pledges for the government’s long term NHS plan, like our story on a big promise on cancer, is understandable. But dealing with the existing problems such as the waiting list must top the list. It is not clear what, if any, resource will be left once these issues are addressed.