Testing Labour’s waiting list pledge

A year ago, Keir Starmer pledged: ”The next Labour government will deliver… planned treatment within 18 weeks. No backsliding, no excuses – we will meet these standards again.”

In an analysis for HSJ at the time, I reckoned it was feasible. Now the general election has been called, and it is time to check their homework again.

A few things have changed over the last year. Labour has quantified the extra activity they would fund. And the waiting list has continued to grow, although not as fast as before and there are recent signs that it is stabilising.

So the question here is: if Labour delivered the promised extra activity, would it be enough to restore the statutory 18-week target within five years? Looking at the latest numbers, I reckon their pledge still looks feasible.

Labour’s commitments

What exactly is Labour promising, if elected?

We saw above that Mr Starmer has promised “planned treatment within 18 weeks… we will meet these standards again”, which we can safely interpret as re-achieving the statutory “18 weeks” referral-to-treatment (RTT) standard.

He promised to do it during “the next Labour government” which is a timeframe of up to five years.

That’s the result, so what about the resources?

The Labour website makes several promises about extra funded activity, some of which talk about appointments (“40,000 more evening and weekend appointments each week”, and the equivalent of “two million more appointments a year”), and some of which add diagnostics and operations into the mix (“more operations, appointments and diagnostic tests during the evenings or at weekends”, and “an extra 2 million operations, scans, and appointments in the first year”).

Although it isn’t crystal clear (and that phrase “in the first year” is a confounder) I think – given the obvious scale of the challenge – that we can interpret this as meaning: 40,000 more operations, appointments and diagnostic tests per week for up to five years. (Although they would probably want to transition fairly quickly from costly evening and weekend working into mainstream capacity such as surgical hubs.)

One more thing. To do the calculations properly we need to make an assumption that is too geeky to be spelt out in an election campaign speech or website: the definition of “more”. Given that trend demand growth would overwhelm this amount of extra activity in only a few years, I think we can reasonably assume that it comes on top of the usual baseline increases in activity that happen every year in response to trend growth in demand.

Labour’s health team has had the opportunity to review these assumptions, and they have not corrected me.

Is it enough?

A national waiting time recovery comes in three parts: keeping up with demand (the recurring activity), clearing the backlog (the non-recurring activity), and achieving the right shape of the waiting list (so that there isn’t a significant “tail” of long waiters, such as one high-cost speciality that didn’t benefit as much as the others).

Here is a summary of my calculations, based on data from the financial year 2023-24.

According to the official overview time series data, the waiting list grew by 210,000 incomplete patient pathways over the financial year. We need to add another 40,000 to allow for community services dropping out of the data from February, giving a total shortfall of 250,000 pathways. Not all outpatient and diagnostic activity results in a “clock stop”, because some patients continue to wait for admitted care, so the shortfall converts into nearly 270,000 activities per year.

The next question is: how small does the waiting list need to be before the 18-week standard can be restored across England? I calculate this figure each month in my RTT reports for HSJ. If the shape of the waiting list returned to the glory days of 2013-16, then 18 weeks could be delivered with a list size of 3.7 million patient pathways, but if the shape remained as poor as now then it would have to shrink further to 3 million. Here I will split the difference and go for 3.4 million, which is about 4.2 million pathways smaller than today’s waiting list. Converting that into activity comes to over 4.5 million, which is the total required no matter how long it takes.

Adding it all up, if Labour took the whole five years to deliver 18 weeks, they are looking at about 270,000 activity per year to keep up with demand, plus 4.5 million in total to clear the backlog, which comes to 5.9 million activity over five years, or 23,000 per week. Which is comfortably within the 40,000 promised.

Or to put it another way, 40,000 extra activity per week would deliver the 5.9 million total in less than 3 years, which leaves plenty of elbow room even if it took a few months to ramp up the extra activity.

What could go wrong?

The first thing to consider is whether the extra activity is deliverable. Two million extra activities per year is about an 11 per cent increase compared with the 7 per cent weighted activity increase that is already targeted in NHS England’s planning guidance for 2024-25. On the assumption that NHSE believes their 7 per cent to be deliverable, and that they are not envisaging a lot of evening and weekend working for it, the further 4 per cent in Labour’s plan (allowing for trend growth in demand) is a few hours per week in every clinic and theatre, which is significant but far from unimaginable if Labour’s promised “staff overtime rates to do extra shifts out of hours” are sufficiently attractive. Hospitals are already able to stand up waiting list initiative sessions at a few weeks’ notice, so it should be possible to achieve this quickly if staff are willing.

Next, we know that many patients are missing from the reported RTT waiting list figures, and the biggest numbers are probably overdue follow-up outpatients. Nobody knows how many because a lot of NHS trusts cannot even count them, but for the sake of illustration if about 2 million are missing then that is about one year’s worth of Labour’s funded extra activity. That would increase the effort to nearly four years of extra activity which is still within the five years promised.

This is a good thing because it should give Labour the courage, if elected, to hold an amnesty on RTT data quality, to make all the missing patients visible so that care can be safely arranged for them and the target genuinely achieved for everyone.

The next issue is the waiting list shape, which at the national level is mostly the result of large variations in waiting time pressures between different specialities and hospitals. The extra activity needs to be directed fairly accurately at those local services with the greatest underlying pressures; you can’t achieve the 18-week standard if only some hospitals make progress, or if the activity is spent on appointments and diagnostics at the expense of operations, or if the ophthalmology list is cleared but the long waiters are left behind in orthopaedics.

The biggest things that could go wrong, however, are not about elective care at all. Other parts of the NHS are under considerable stress, including emergency care and cancer, and their patients have higher clinical priority than long-waiting routine elective patients. If there is extra money and capacity going around, then it will naturally (and rightly) tend to channel where clinical need is highest. And if inpatient and even day case beds are full of emergency medical patients then it will be hard to get much surgery done.

Even the Blair government struggled to ramp up elective activity when the 18-week target was being achieved for the first time. As Nick Timmins wrote in the FT shortly afterwards: “Spending on the NHS has doubled in real terms… The extra cash has gone to many NHS services – family doctors, mental health, emergency and urgent admissions to name just a few – not to mention pay rises all round. It is impossible to work out how much went specifically on waiting list surgery, which grabs the headlines but in fact accounts for only about 10 to 12 per cent of all NHS expenditure.” Doubling in real terms. That kind of money is impossible today.

Nevertheless, if we take these waiting time pledges on their own terms, I reckon they do add up: 40,000 extra activities per week should be enough to achieve the statutory 18-week RTT standard within five years.