On the day briefing: reforming elective care for patients

On 6 January 2025, the prime minister announced a new national plan published by NHS England (NHSE) setting out how the NHS will reform elective care for patients in England.

This briefing highlights the key points from the plan and includes NHS Providers’ view and press statements.

Waiting list data for 2024 consistently showed that over 6 million people are waiting for elective care, accounting for 7.4 million episodes of care. In May 2024, in its manifesto ahead of the general election, Labour pledged to recover the constitutional standard of 92% of patients receiving treatment within 18 weeks for planned care. This was reaffirmed in the government’s Plan for Change presented to parliament on 5 December 2024.

In recent months, the NHS has shown it is now delivering more elective care than ever before with record levels of activity across diagnostics and cancer checks. However, despite progress on eradicating the longest waits over two years, many patients are still waiting too long for care.

By the end of 2024, around one in nine people in England were waiting for elective care – around 1 million more than in February 2022 – and the total waiting list had grown by over 1.3 million pathways. While the proportion of those waiting for more than a year has decreased by almost half, the proportion waiting for longer than the 18-week constitutional standard is still high.

Today, the government published a new plan that not only commits to delivering its Plan for Change but promises to build a sustainable NHS where ‘elective care looks and feels different to patients and NHS staff’.  In his speech to launch the plan, the prime minister committed to delivering 40,000 additional appointments a week within the first year of this Parliament. He touched on a few specific measures including expanding the number of surgical hubs, extending access to community diagnostic centres and reforming the NHS app. 

To meet the 18-week standard and reform elective care by March 2029, NHS England will focus on the following areas:

• empowering patients by giving them more choice and control, and by establishing the standards they can expect to make their experience of planned NHS care as smooth, supportive and convenient as possible
• reforming delivery by working more productively, consistently – and in many cases differently – to deliver more elective care
• delivering care in the right place to make sure patients receive their care from skilled healthcare professionals in the right setting
• aligning funding, performance oversight and delivery standards, with clear responsibilities and incentives for reform, robust and regular oversight of performance, and clear expectations for how elective care will be delivered at a local level. 

Meeting the 18-week standard

• Nationally, the NHS will meet the 18-week standard by March 2029.
• By March 2026 the percentage of patients waiting less than 18 weeks for elective treatment will be 65% nationally.
• Every trust will need to deliver a minimum five percentage point improvement by March 2026.
• NHS England then expect sufficient increases annually (exact figures to be confirmed in the planning guidance) to reach 92% in 2029.
• Improvements in performance against the cancer waiting time standards are also expected with further details to be set out in a dedicated national cancer plan and in the annual operational planning guidance.  

Empowering patients

The plan states that NHSE will:

• work with patients, carers and their representatives to publish the minimum standards patients should expect to experience in elective care by September 2025 and actively promote and monitor patients’ right to choose when and where they receive care
• expand the NHS App and Manage Your Referral website to improve information and appointment management on elective care for patients, as well as parents and carers through proxy access by March 2027
• work with providers to make the NHS App and Manage Your Referral website the default route
• collate and publish data to help improve the uptake of national health inequalities initiatives, throughout 2025/26.

Integrated care boards (ICBs) are also expected to:

• ensure patients and carers are aware of new experiences expectations and their right to choose
• set a clear local vision for how health inequalities will be reduced as part of elective care reform, and ensure interventions are in place to reduce disparities for groups who face additional waiting list challenges by March 2025.

NHS elective care providers will be expected to:

• name an existing director who is responsible for improving experience of care in each ICB and provider by April 2025
• make customer care training available to non-clinical staff with patient-facing roles, as well as ensure take up of the training already available on the eReferral Service (e-RS) to support effective referral, booking and waiting list management processes
• implement agreed local interventions to reduce disparities for groups who face additional challenges accessing healthcare
• by the end of March 2025, 85% of acute trusts will enable patients to view appointment information via the NHS App
• by March 2027, the NHS App will be significantly expanded to improve information for patients in elective care, as well as their parents and carers through proxy access
• make the NHS App and Manage Your Referral website the default route so patients can choose their elective provider or decide not to make that choice themselves.

Reforming delivery

NHS England state they will:

• provide quicker access for patients to common surgical procedures by launching 17 new and expanded surgical hubs by June 2025
• deliver significantly improved elective pathways by extending the minimum standards for community diagnostic centres (CDCs) to open 12 hours per day, 7 days a week, delivering same-day tests and consultations, an expanded range of tests, with direct referral from primary and community care, new consulting rooms and at least 10 straight-to-test pathways by March 2026
• boost bone density scanning (DEXA) capacity by investing in up to 13 DEXA scanners in the highest priority locations, providing an estimated 29,000 extra scans
• refresh the relationship with the independent sector with a new partnership agreement. 

Integrated care boards are expected to: 

• implement the new standards for CDCs, particularly increasing direct referrals and rolling out at least 10 straight-to-test pathways by March 2026
• ensure contracts with the independent sector are in place to mitigate the waiting list challenges in each system, as well as a broader range of diagnostic tests.

NHS elective care providers are expected to:

• make optimal use of the new diagnostic capacity by implementing the new standards for CDCs, particularly extended opening hours, increasing same day tests and consultations and the range of tests offered
• ensure a range of options are in place for patients to have more responsive and accessible follow-up care, including standardising remote consultations, remote monitoring and digital support for patient initiated follow-up (PIFU) across all major specialties.

Delivering care in the right place

NHS England state they will:

• ensure both primary care and secondary care are funded to deliver advice and guidance (A&G), by splitting the existing elective tariff to deliver better outcomes for patients. GPs will receive £20 per A&G request. NHSE expect more patients to benefit from their GP accessing rapid specialist advice, so they receive the care they need in primary and community care settings, as opposed to being added to the elective waiting list. This expansion will deliver up to 4 million advice requests from GPs in 2025/26 (up from 2.4 million in 2023/24), which NHSE expect could increase diversions from elective care from 1.2 million in 2023/24 to 2 million in 2025/26.
• support systems to optimise the use of A&G by providing access to a range of metrics, dashboards and toolkits
• work with patients, carers and clinicians to establish a consistent model of ‘collective care’ approaches, including group appointments and one-stop clinics, so that patients can benefit from this innovative practice by September 2025
• set out clear expectations for significant elective care reform to be delivered in at least five specialties – ENT, gastroenterology, respiratory, urology and cardiology 
• increase the quality and expand the availability of elective reform Federated Data Platform (FDP) products, and support adoption of the FDP to 85% of all secondary care trusts by March 2026 
• work with primary and community care clinicians to expand functionality within NHS e-RS and the NHS App to support delivery of expectations on referral optimisation and patient choice.

Integrated care boards are expected to:

• consistently optimise referrals using A&G and effective triage, increasing the proportion of patients being treated in the most appropriate care setting by March 2026
• expand remote monitoring across all long-term conditions where clinically appropriate, helping to remove up to 500,000 lower value follow-up appointments per year from 2026/27 onwards 
• implement all requirements in the delivery plan for recovering access to primary care, including those that support effective working across primary and secondary care
• standardise pathway referral criteria, maximise A&G opportunities, and put in place clinical triage standard operating procedures for high-volume specialties
• by September 2026, dedicated system leadership will focus on reducing variation in discharge processes and expand opportunities for self-management through shared decision-making tools
• transform pathways with opportunity to deliver activity in the community, starting with at least the following five priority specialties; ENT, gastroenterology, respiratory, urology and cardiology.

NHS elective care providers are expected to:

• ensure PIFU is offered as standard in all appropriate pathways by March 2026
• significantly increase the uptake of PIFU to at least 5% of all outpatient appointments, including through the enhanced identification of suitable patients using AI and automation by March 2029
• implement a consistent model of ‘collective care’ approaches, including group appointments and one-stop clinics, so that patients can benefit from this innovative practice
• work with system partners to implement standardised pathway referral criteria, maximise A&G opportunities, and put in place clinical triage standard operating procedures for high-volume specialties. 

Aligning funding, performance oversight and delivery standards

NHS England state they will:

• update the payment scheme to reflect elective priorities, with a stronger focus on activity that directly ends a patient’s wait for their care, and by developing, testing and introducing relevant tariffs throughout the duration of this plan
• run a capital incentive scheme for providers that improve the most in meeting RTT standards
• deliver the NHS IMPACT Clinical and Operational Excellence Programme to apply proven improvement approaches for elective reform, including training for at least 8,000 clinical and operational leaders in effective elective pathway management by March 2026
• run a strong elective performance oversight programme, including through tiering which contributes to the new NHS Oversight and Assessment Framework, with greater transparency on the performance and delivery of elective care
• set expectations for outpatient activity as part of job planning within providers, to clearly describe the types and balance of activity, including sessions within the community  

Integrated care boards will be expected to reflect elective activity targets and funding allocations in local commissioning arrangements.

NHS elective care providers are expected to:

• put robust arrangements in place to performance manage and deliver elective care targets and standards, including making best use of NHS IMPACT improvement support, national metrics, dashboards and toolkits
• work with system partners to ensure adoption of best practice including reformed patient pathways, improved clinical job planning and partnership with the independent sector.

Strengthening the relationship with the independent sector

Alongside the plan, NHSE published a partnership agreement between the NHS and the independent sector – the first of its kind in 25 years. The plan acknowledges the need for the NHS to use all available capacity to bring down the waiting list, including in the independent sector, paid for at NHS prices and free at the point of use for patients.

The agreement sets out the expectations for reducing the elective care waiting list, maintaining quality and patient safety, and how both parties will support the most challenged specialties such as gynaecology and ENT. The agreement also ensures patients in deprived areas are offered choice of provider as a priority.

The plan sets out how NHSE and the independent sector will review prices for activity where the independent sector can provide significant help to reduce waits. NHSE will also work with the independent sector to review clinical exclusion criteria with the expectation that a broader range of patients will be safely treated by the independent sector as a result. Additionally, work will be carried out to better align systems so patients can see appointments on the NHS app and to encourage ICBs to put in place longer-term contracting agreements to ensure greater choice for patients.

Reforming care for elective patients sets out a comprehensive plan to tackle the backlogs across elective care, diagnostics, and cancer care by 2029. The plan has clear, targeted actions for NHSE, ICBs and NHS providers of elective care, setting out key responsibilities and accountabilities across the health and care system.

It will be imperative that the approach set out here is fully integrated with the vision and actions expected in the forthcoming 10 year plan to achieve the government’s three shifts. It is vital that the 10 year plan addresses backlogs in other sectors including those in community and mental health services, as well as wider pressures across the NHS.

Relating to elective care, NHS Providers welcomes the commitment to empower patients, with a significant focus in the plan to both reduce waiting times and improve patient experience by setting new ‘experience expectations’, increase patient choice and the right to choose a preferred provider, and improve the functionality of the NHS app.

The document also sets out a quantifiable plan to create more capacity including 17 additional surgical hubs, five CDCs and extended opening times for CDCs across the country. Further expanding surgical and diagnostic capacity within the NHS will build on the significant and positive work led by trusts over the past few years to get these new, efficient and smarter services up and running – with their impact being borne out in recent record level activity data.

The ambition set out in the plan to deliver care in the right place emphasises the key relationship between primary and secondary care in providing a patient centred experience for planned care. Increasing the uptake and use of A&G in primary care should help to ensure patients are seen in the best and right place, helping facilitate the shift from acute to community care. It will be important to keep this approach under review to ensure it successfully translates to reduced referrals.

The plan does not address staffing issues across the NHS, including how the additional surgical hubs and CDCs will be staffed, as well as shortages across certain specialities, for example anaesthetist shortages, that impact the expansion of elective capacity. It would be helpful to see more detail, including if any incentives will be made available for elective care providers to offer staff to undertake additional work to meet the commitments.

The foreword from the Secretary of State explains that the NHS will be resourced to deliver the plans. We expect the elective recovery fund to be replaced and although the plan guarantees funding certainty for the NHS and independent sector, much of the detail on this will be set out in the changes to the NHS payment scheme. These changes are subject to consultation and are not yet available. We will need to see further detail in both the NHS payment scheme and 25/26 planning guidance.

The inclusion of the duty on ICBs to set a clear vision and plans to reduce health inequalities is a positive step in addressing inequalities that we know exist within the waiting list. The partnership agreement between the NHS and independent sector also sets out a clear priority for patients in deprived areas to be offered choice of providers as a priority. This is a welcome development in improving access and coverage of providers to those in deprived areas.

Lastly, the independent sector has been a long-standing partner of the NHS and. the partnership agreement published today takes things a step further in helping overcome some existing challenges experienced by trusts, including relating to short-term contracts and uncertainty with commissioning. The agreement should also expand the types of cases the independent sector can see which has been a previous limiting factor. The partnership agreement promises to ensure that the NHS can maximise the use of the independent sector in a more strategic way.