Elective recovery is leaving minority ethnic patients behind

Few health and care statistics come under as much scrutiny as the size of the elective care waiting list. After more than a decade of growth, including a staggeringly sharp increase during the covid-19 pandemic, the current government has pledged to reduce the size of the waiting list and bring 92 per cent of elective care waits down below 18 weeks. While this standard has not been met since 2015, recent months have seen some progress towards this goal.

Despite this pledge being a major national priority, until recently, analyses of the waiting list have tended to be confined to the headline figures. We know how many people are waiting and for how long. But less clear is who waits longest and what happens to people while they wait.

New evidence has begun to fill these gaps. NHS England’s recent breakdown of waiting times by demographic characteristics found that people from the most deprived areas and with Asian or Asian British backgrounds are more likely to wait for longer than 18 weeks than any other groups.

The latest briefing from The Health Foundation’s Networked Data Lab (NDL) takes a more detailed look at the experiences of people on the waiting list. Using linked local data from four areas of the UK, it explores how long different population groups wait for elective care, how people use healthcare during their wait, and why they leave the waiting list.

The NDL’s findings in context

The NDL’s analysis found stark inequalities among those on the elective waiting list in the four areas, similar to those observed at a national level by NHSE. People who live in the most deprived areas tended to wait longer for treatment than those living in more affluent areas, were more likely to use emergency care while waiting and more frequently had their waits end due to missed appointments.

People from Black, Asian or mixed ethnic backgrounds tended to wait longer than white patients – even when accounting for differences in age and deprivation – and those on waiting lists for multiple specialties waited longer than those on a single list.

Overall, the analysis found that people who waited for 36 weeks or less saw their use of healthcare decline in the three months following treatment, as might be expected. But people who waited for longer than three months used services at a greater rate following treatment than they did while waiting, underlining the knock-on impact on services of long waits for treatment and indicating that those waiting longer could benefit from support in preparing for surgery and minimising adverse outcomes after treatment. It also found that use of primary care while waiting outstripped other forms of unplanned healthcare use.

The average weekly cost of primary care use for people on the elective waiting list in NDL areas was more than double that of accident and emergency attendances, despite the cost of an A&E visit being far higher than a GP appointment. However, in deprived areas, people were more likely to use emergency care while they were waiting for treatment compared to people living in more affluent areas.

NHSE’s plan for elective recovery places a strong emphasis on reducing health inequalities. The plan’s focus on empowering patients and improving communication could address concerns we heard through our engagement with patients and the public about the impersonal and alienating experience of waiting for elective care. Its proposals to improve data collection on demographic characteristics should also help improve our understanding of inequities. However, the NDL’s analysis suggests that these measures may be insufficient to address the full complexity of the issues and that some groups of patients may require more targeted support.

Elective recovery and the 10-Year Health Plan

The 10-Year Health Plan sees a central role for technology in making and managing appointments and communication with patients. However, digital exclusion is well documented as overlapping with other forms of disadvantage. Without careful consideration of these risks when designing and rolling out new technological solutions, such a shift could exacerbate inequalities in elective recovery.

The analysis found that people living in the most deprived areas were more than twice as likely to have their waits end due to missed appointments than those in the least deprived areas. Given that non-attendance is often linked to difficulties in communication and navigating the system, could planned reforms ingrain these challenges more deeply for communities who are already digitally excluded?

The plan’s proposal to increase the involvement of the independent sector in providing elective care similarly risks widening inequalities in access to and waits for care, given existing evidence that independent provision tends to be concentrated in more affluent areas.

Returning elective care to the 18-week standard will be a significant challenge. The inequalities uncovered in the NDL’s and NHSE’s analyses show that doing this equitably will be an even greater challenge.