- New research lays bare full impact of “unreported removals” on waiting list for first time
- These “unreported removals” include cases being taken off the list following validation, and other data processes, rather than more patients actually being treated
- While ministers say recent waiting list reductions were due to a recovering NHS, the research finds the fall was driven by the c.245,000 “unreported removals” every month
The recent reduction in the waiting list repeatedly cited by ministers as evidence of the NHS’s recovery has given a “misleading” impression to the public about the service’s underlying performance, leading policy experts have warned.
The warning follows health and social care secretary Wes Streeting announcing last month that the reduction in the elective waiting list by “more than 260,000 since we took office” was “not a coincidence”, but was because this government had got “our NHS moving in the right direction”.
However, a new report shared exclusively with HSJ concludes recent waiting list reductions were mainly due to “unreported removals”. These removals are not explicitly reported in published data, so researchers have had to calculate them manually.
They include removals following list validation exercises, but also a range of other factors, such as the design of the data reporting methods and the nature of software management processes (see box below – Explainer: What are unreported removals?).
And when factoring in these removals, the report from Quality Watch, a joint funded-project between The Health Foundation and the Nuffield Trust, concludes the majority of the waiting list reduction was therefore not produced by increased clinical activity.
The authors call on ministers to be far more open about the impact of unreported removals on the waiting list and point out that even the NHS’s “own data shows it is still treating fewer patients than are being referred”.
The Quality Watch report says the government does not make the impact of validation and other “unreported removals” sufficiently clear. The analysis follows ministers’ messaging to the public consistently focusing on the government’s claim that the service is being turned around because more appointments are being made available.
The report adds: “Until more transparent reporting is provided, accountability around unreported removals remains impossible and the planned care waiting list will continue to be a misleading indicator of how the NHS is dealing with demand.”
The report is the latest blow to the government’s campaign to convince the public it is accelerating the recovery of NHS elective care.
On Monday, HSJ reported the “4.6 million extra NHS appointments” which the government said had taken place since it came to power had only had a “modest impact” on reducing waiting list clock stops.
That news followed analysis showing the 4.6 million figure represented a smaller uplift in activity compared to the same period during 2023-24, which saw an extra 5.5 million appointments carried out.
The only explanation
The analysis represents the first time the full impact of all unreported removals on the waiting list has been uncovered.
The report says there were around 245,000 unreported removals each month between April 2023 and March 2025, equating “to around 3 per cent of the waiting list”. This equates to around 2.4 million removals between August 2024 and May this year.
The report authors explain that the ratio of completed cases to new referrals has long been at a level which means the waiting list would be expected to grow, but instead there has been a gradual reduction in its size since last summer. And it is only the unreported removals which explain the “contradiction in the data”.
It continues: “While the waiting list has started to go down, unreported removals have gone up [see graph]… In fact, they have repeatedly outnumbered the additional incomplete referrals that join the waiting list every month… This tells us that, across several months, there were more [unreported removals] than pathways joining the list.”
While there have always been unreported removals, they have recently had a “more noticeable impact. Since September 2023, this [increase in unreported removals] has helped the NHS get control of the waiting list,” the report says.
The impact of waiting list validation has been repeatedly highlighted by HSJ as a major contributor to reducing the backlog. HSJ also revealed concerns back in January that plans to pay trusts to validate their lists could be “wide open to gaming” and create a public perception problem.
But while NHS England has also acknowledged some of the impact of validation, the figures they have highlighted appear far smaller than the total number of unreported removals taking place and quantified by this new report.
NHSE and DHSC respond
NHS England said: “NHS staff have made significant progress in reducing waiting lists in the last year – down by more than 260,000 since June 2024 – and this is driven by the fact that 2,300 more patients are receiving treatment every day compared to last year.”
“While the validation process has a small impact on the overall waiting list – as is made crystal clear in our published monthly waiting list data – it’s right we regularly clinically review those waiting so hospitals can prioritise patients more accurately and deploy their resources efficiently.”
The Department of Health and Social Care said: ”Our drive to clear the huge waiting list backlog we inherited includes making sure all patients are getting the right treatment as quickly as possible.
“That’s why we are supporting GPs to seek specialist advice before making referrals, and screening existing waiting lists to check that all patients need to be on there - freeing up capacity to get more people seen more quickly.
“This is one element of our wider work to cut waiting times for patients and improve productivity through our Plan for Change, through which we have already delivered over 4 million extra appointments and cut the waiting list by 260,000.”
Read the report here: Why is the planned care waiting list coming down and what does the data really tell us?
Explainer: What are unreported removals?
The three key factors driving “unreported removals” are:
- Validation: the removal of pathways from the list which should not be there. These include tackling errors and duplicates through data cleaning exercises and contacting patients to see whether treatment is still desired and/or necessary.
- The design of the reporting process: if a patient does not attend a first appointment after a referral, this effectively strikes the outstanding referral from the record. If the referral has already been reported as an incomplete pathway by the time the patient does not attend, it may later become an unreported removal without a corresponding completed pathway.
- Software and data management processes: some referrals made via the e-Referral System are not immediately booked into appointments and join a list called “Appointment Slot Issues”. The problem with this system is that referrals are automatically removed from the list after 180 days without an action. Referrals waiting on ASI lists are required to be reported in routine RTT data submissions, but this does not always happen. As a result, it is unclear to what extent any referrals which disappear from local ASI lists after 180 days contribute to unreported removals, or whether instead they may never be recorded in RTT data and therefore represent an unquantified, and potentially lost, additional waiting list.
How “unreported removals” are identified
The report says: “Unreported removals [are] the number of pathways that are in the expected waiting list but not the reported waiting list, namely pathways that no longer appear in the total incomplete pathways, but are not reported as completed pathways. The calculation for unreported removals = expected waiting list – reported waiting list [incomplete RTT pathways].”
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