Planned or elective care, covers a broad range of non-urgent services, usually delivered in a hospital setting, from diagnostic tests and scans to outpatient care, surgery, and cancer treatment. The elective waiting list had been rising year-on-year before the pandemic - between February 2012 and February 2020, the waiting list grew by 2.2 million (NHS England, 2020). The pandemic exacerbated these waits, leading to a sharp rise in the number of people and length of time waiting to access elective care. As of the end of April 2024 (the latest data available at the time of publication) 7.57 million people were on the waiting list, with around 42% waiting more than 18 weeks for treatment (NHS England, 2024).
The patient experience and safety impacts of these delays is well known and is set out in commentary from many organisations, including the Royal College of Surgeons and the Patients Association (NHS Providers, 2017). These include: patients living with the consequences of debilitating conditions for longer; the risk of the condition worsening, requiring more complex, difficult and expensive treatment; and in the most extreme examples, conditions becoming permanent and untreatable. In addition, waiting for treatment can impact other aspects of people's lives, for example making it harder to maintain independence or continue to work or attend school. People living in disadvantaged areas already experience poorer health outcomes (The King's Fund, 2024). Recent analysis highlights the disparity in waiting times around the country and a correlation with deprivation: on average a person living in one of the most deprived areas is 1.8 times more likely to wait over a year than someone living in one of the least deprived areas (The King's Fund, 2023).
The national elective recovery plan set out ambitions to eliminate waits of longer than a year by March 2025, and within this eliminate waits longer than two years by July 2022, waits of over 18 months by April 2023, and of over 65 weeks by March 2024 (NHS England, 2022). Overall significant progress was made on long waits during 2023/24 in the face of significant financial, operational and workforce pressures, including industrial action. The overall list is down from its peak in September 2023 (7.8 million), but as of the end of April 2024 was still 2% more than a year earlier, and 72% more than five years ago (before the Covid-19 pandemic).
In order to improve access, the national delivery plan for tackling Covid-19 backlog of elective care published in February 2022 (NHS England, 2022) recommended that systems establish elective surgical hubs. As dedicated planned care facilities, these are designed to allow providers to focus on high-volume routine surgery. They enable more patients to be seen more quickly, reduce long waits, and improve patient outcomes by creating centres of excellence.
A long-standing barrier to improving access to elective care is the availability of operating theatres, clinic rooms and other highly specialised estate. Access to capital funding is a well-documented and serious challenge facing the health system (NHS Providers, 2023): inadequate funding has major impacts on the delivery of routine care, and to the safety of patients and staff. Within a constrained capital environment, the government allocation at the Spending Review in 2021 of £1.5bn in funding over three years to deliver more than 50 new surgical hubs (HM Treasury, 2021) was welcome.
This was made available through a targeted investment fund (TIF), which trusts and integrated care systems were invited to bid for, with a focus on ensuring that additional capacity would support system-wide improvements in waits for care. Systems were asked to demonstrate how the investment would achieve significant increases in elective activity, and form part of a broader clinical strategy for elective recovery, including where different types of activity should be located, and how clinical pathways could follow best practice as standard. In addition, to support growth in activity, the proposals were asked to demonstrate how they would deliver 130% of business-as-usual activity levels (GIRFT, 2022).
The TIF has supported the development of approximately 50 new hubs (as announced by the government in early 2022), bringing the total to 133 once all are up and running (DHSC, 2022). At present around 100 hubs are operational (GIRFT, 2024). The hubs developed with TIF funding aim to provide an additional 100 operating theatres and more than 1000 surgical beds (DHSC, 2022). The aim is that in total, the hubs will deliver one million extra procedures during 2024/25 (DHSC, 2022).
To provide this extra capacity and help reduce system-wide waiting lists, many of the existing hubs, and those in development have been established as system-wide capacity. Provider collaboration has been key to this, from hubs supporting trusts to share waiting lists across wider geographies, to providers collaborating on business cases for TIF funding, or jointly staffing the hubs.