Achieving the 18-week standard for elective care

Key points

• Extra NHS appointments alone will not be enough to solve the NHS waiting list crisis. The new Labour government has pledged to ensure 92 per cent of patients wait no longer than 18 weeks from referral to treatment (RTT) – a target that has not been hit for nearly decade – by delivering an extra 40,000 NHS appointments, operations and diagnostics every week, equivalent to 2 million a year. 

• There are currently over 7.5 million unresolved open care pathways, impacting an estimated 6.4 million individuals in England. Nearly 4 million of these unresolved open pathways are part of a significant backlog that has accumulated over the last decade.

• To meet and sustain the 18-week standard, two fundamental objectives must be achieved simultaneously:

• The NHS must provide enough consistent care to achieve the 18-week standard annually, recognising the growing and ageing population, increasing complexity of cases and continuous adoption of innovation.

• The additional backlog that exists must be tackled through additional treatments. The additional capacity required to achieve this should be viewed as a one-off requirement.

• Treatment often requires a combination of outpatient, diagnostics and inpatient care (through day-case procedures and overnight stays). On average a pathway of care that does not require an admission to hospital includes 1.4 outpatient appointments. Twenty per cent of people go on to an admission which typically requires a further 0.9 outpatient appointments and a hospital admission, 80 per cent of which are day cases and 20 per cent involve an overnight stay. Diagnostics form a significant element of the pathway but are not considered in this report due to constraints in access to diagnostics data at healthcare specialty level.

• Treating sufficient referrals to maintain the business as usual (BAU) waiting list in 2024/25 – in line with the 18-week standard – requires 27.3 million outpatient appointments, 3.3 million day-case procedures, and 890,000 overnight stays. In 2023/24, the NHS completed 22.2 million outpatient appointments, 2.8 million day-case procedures, and 740,000 overnight stays related to RTT pathways, when industrial action is accounted for. Consequently, without transformation, an additional 5.1 million outpatient appointments, 0.5 million day-case procedures and 150,000 overnight stays are needed this year, simply to prevent the waiting list from increasing further.

• Achieving and sustaining the 18-week standard also means planning for increased future demand. The historic trend is that this demand grows in aggregate at 3.8 per cent per year – noting there is significant geographical and healthcare speciality variation that needs to be considered. 

• Based on current levels of growth in the need for care and how care is currently delivered, this means that, by 2028/29 the NHS will need to do 50 per cent more elective activity than it is currently doing to clear the wait list and sustain achievement of 18-week performance. Without being accompanied by change and reform, the government’s promise of an extra 2 million appointments, operations and diagnostics a year addresses about 15 per cent of the additional requirement.

• A more transformational response is required to ensure the public can be confident the NHS can offer timely access to elective care. Change is needed in every step of the pathway of care: it requires both a strengthened and renewed focus on existing initiatives as well as a more radical approach to the creation of elective hubs and centres of expertise for complex care. Taking each step of the pathway in turn, the required elements of the response are as follows:

• Assessing the drivers for rising demand for elective treatment, and ensuring people are receiving the right care: by preventative interventions that reduce the need for care in the first place as well as streamlining the referral process between GPs and specialists, and ensuring people living in deprivation have equal access to services.

• Digitalising waiting-list management and continuously validating the patient tracking list: embracing tools available as part of Federated Data Platform more widely to improve efficiency and accuracy and supporting staff to adopt digitally-enabled management practices for the elective pathway.

• Transformation of outpatient elective care for people who do not need a hospital admission: through more integrated, holistic care, involving fewer appointments and resources for people with more than one open care pathway; standardising care with defined best practice pathways considering each speciality and different patient needs; the adoption of the latest technology and innovation to transform outpatient care, including process automation, the application of artificial intelligence and robotics.

• Creating elective hubs for people whose treatment involves an admission to hospital: initiating an accelerated development programme to almost double the current dedicated elective hub capacity on sites without emergency activity – an approach already proven to work – providing quicker access and ringfencing planned care resources. Capital funding with streamlined decision-making will be essential to facilitate this. 

• Creating centres of expertise for complex elective admitted care: combining this approach with optimal use of elective hubs creates capacity on ‘hot’ sites, both to decompress them from high occupancy levels enabling better care for emergency patients, and to provide capacity for complex planned care that needs to be co-located with the other services on major hospitals. Capital to remodel the existing hospital estate, making it fit for modern practice, will again be essential.  

• Focusing on the enablers of change critical to transforming care: long-term aligned planning is needed that brings together capital investment; pathway-based funding; workforce planning linked to demand; fostering clinical leadership and accountability; high-quality booking and scheduling; continuous improvement of data quality and widespread adoption of digital innovations; and staff, including team-based training and development to enhance improvement capabilities.

• Addressing the residual backlog of patients waiting: acting on points two and three, alongside early implementation of points four and five with the capacity needed for 2029/30 put in place by April 2026 would address much of the excess numbers of people waiting. However, more would still be needed. To address this, a combined approach is needed, including incentivising NHS staff to work out of hours, using insourcing providers to make additional use of NHS capacity out of hours and outsourcing activity to private healthcare providers.

• If all of the opportunities in this report were implemented together, the government’s early promise of an additional 2 million appointments, operations and diagnostics a year would deliver the additional requirement. While improvements are underway across the country, major transformation is required in the way care is planned and delivered, with significant investment, energy and government commitment to make it happen.