With demand for hospital treatment outstripping capacity even before COVID-19, it is no surprise that the demands of delivering care during a pandemic have led to significant backlogs and longer waits for patients.

This page provides analysis on capacity in secondary care services and is updated monthly with new data.

Last updated on 15 November 2024

A growing backlog of care in England

What is the backlog?

The backlog in secondary care consists of the care that the NHS would normally have delivered but which was disrupted as COVID-19 impacted service delivery. This includes:

• patients on a waiting list for treatment who would ordinarily have been seen by now 
• patients who have not yet presented to their GP to seek a referral for symptoms due to concerns of burdening the health service or fears around COVID-19 infection
• patients who have had procedures cancelled
• patients who have had referrals delayed or cancelled
• patients who have had referrals refused due to a lack of capacity.

It will take years to clear the backlog. The ongoing need for stringent infection prevention control measures and workforce shortages mean it will take even longer to work through as demand continues to rise.

More patients than ever are waiting for treatment

High waits for treatment are not new. Prior to the pandemic in February 2020 there were already 4.57 million cases on a waiting list for consultant-led care.

At the beginning of the pandemic, the combination of suspension of non-urgent services and changes to individuals’ behaviour meant that the number of people joining the waiting list initially dropped. However, this has since been rising - and despite some improvements earlier in the year, waiting times remain far higher than pre-COVID.

The latest Referral to Treatment (RTT) figures for September 2024 show:

• The waiting list stood at 7.57 million cases, consisting of approximately 6.34 million individual patients waiting for treatment
• Around 3.14 million of these patients have been waiting over 18 weeks;
• Almost 249,300 of these patients have been waiting over a year for treatment – a decrease from around 282,700 the previous month (August 2024).
• A median waiting time for treatment of 14.4 weeks – nearly double the pre-COVID median wait of 8.0 weeks in August 2019.

The target in the elective backlog recovery plan (February 2022) to eliminate waits longer than 65 weeks by March 2024 has been missed. The longer-running target that 92% of patients should receive treatment within 18 weeks of referral has not been met since September 2015.

NHS England announced in October 2023 that up to 400,000 patients waiting over 40 weeks will be offered the opportunity to travel to a different hospital to be seen sooner. However, many people may feel unable to travel, particularly without support networks.

The hidden backlog is growing

The waiting list is a visible backlog, but what we refer to as the growing 'hidden backlog' remains an unknown for the health service.

The hidden backlog includes patients who require care but have not yet presented to healthcare providers. Furthermore, the referral to treatment waiting list does not include waiting for non-consultant-led treatment, or patients waiting for follow up appointments once they have begun treatment. Therefore, the number of patients included in the headline waiting list figures does not show the full extent of the backlog.

Cancer targets continue to be missed

Changes to cancer waiting times standards came into effect from 1 October 2023 with the following three core measures replacing the previous standards:

• 28-days wait from an urgent referral to patient told whether they have cancer or cancer is definitely excluded standard (75%)
• 31-days (one month) from a decision to treat to first or subsequent treatment standard (96%)
• 62-days (two months) wait from an urgent referral or consultant upgrade to a first definitive treatment standard (85%)

Despite the changes in the cancer care targets, services continue to operate well below operational standards.

The percentage of patients told they have cancer within four weeks (28-days) of an urgent referral decreased from 75.5% in August to 74.8% in September 2024 – below the operational target of 75%.

The percentage of people receiving their first cancer treatment within one month from a decision to treat decreased from 91.7% in August to 90.6% in September 2024. This is below the 96% operational standard.  

The percentage of patients receiving their first cancer treatment within two months (62-days) of an urgent referral decreased from 69.2% in August to 67.3% in September 2024. This is significantly below the operational standard of 85%.

The poor performance against these key operational standards illustrates the level of pressure the system is under, and is a clear sign that significant investment in capacity is needed.

Patients are waiting longer for emergency care

Prior to the pandemic, the situation in A&E was increasingly difficult with demand soaring and the percentage of people being seen within the four-hour target reaching an all-time low over the 2019/20 winter.

At the start of the pandemic, A&E attendance decreased significantly which led to performance improvements. However, since lockdown eased demand has steadily risen, reducing performance against targets.

These pressures on emergency care persist into 2024, despite small improvements in certain areas. Demand for care across all A&E departments remained high in October 2024, with total A&E attendances standing at 2.36 million.

73.0% of people attending A&E were admitted, transferred or discharged within 4 hours in October, a decrease from the previous month (74.2%). The current operational target is to improve this to 78% by March 2025. In the past 12 months (from November 2023 to October 2024), approximately 1.66 million people have waited more than 4 hours in A&E.

In March 2024, NHSE introduced three new targets as part the Urgent and Emergency Care capital incentive scheme. The trusts that met these performance targets would be eligible to receive additional capital funding in 2024-25.

These included:

1. The 10 trusts delivering the highest level of 4-hour performance during March will each receive £2 million.

2. The 10 trusts who deliver the greatest percentage point improvement in March (compared to January 2024 performance) will each receive £2 million.

3. The next 10 trusts who deliver the greatest percentage point improvement in March (compared to January 2024 performance) would each receive £1 million.

The BMA has raised concerns regarding the introduction of the capital incentive scheme, on the basis that it risks creating perverse incentives for Trusts, diverting support away from where it is needed most, and widening existing health inequalities.

Waiting times have rocketed

The combination of ongoing pressure on services, the backlog of care and chronic workforce shortages means waiting times have increased to record highs.

The total number of patients waiting over 12 hours for an emergency admission increased significantly from about 38,900 in September to approximately 49,600 in September 2024. The number of patients waiting over 12 hours for an emergency admission in October 2024 was around 68 times higher than in October 2019 – pre-pandemic. Note that this number represents an underestimate of actual waiting times, as patients will have been waiting for additional time before a ‘decision to admit’ was made.

These long waiting times are, in part, due to poor patient flow. General and acute bed occupancy has consistently been at over 90% since September 2021, and patients regularly remain in hospital despite being fit for discharge because there is no capacity for them in social care.

GPs are finding it harder to make referrals

We can track GP referrals into consultant-led outpatient services alongside the waves of COVID-19: as the waves have peaked, referrals into secondary care have dropped. These drops are likely due to a combination of changes to patient behaviour alongside capacity issues in secondary care effectively forcing GPs to take a more cautious approach with timings of referrals to avoid having referrals rejected.

GPs can still refer patients, but the pressures in hospitals means there is little capacity in secondary care, and those referrals are often rejected.

The number of GP referrals to consultant-led outpatient services that have been unsuccessful because there are no slots available has jumped from 238,859 in February 2020 to a staggering 401,115 in November 2021 (an 87% increase).

When GPs are unable to refer into hospital services, the care for these patients does not disappear. Instead, these patients need to be cared for by GPs while they wait for hospital treatment to go ahead, adding to the pressure in primary care.

The role of the private sector

Enlisting the help of the private sector is one of the measures the Government has taken to reduce pressures on hospitals and help cut waiting lists.

Purchasing private capacity is not new, but the pandemic has demanded unprecedented block-booking arrangements.

A recent BMA survey found that under these arrangements, 60% of private practice doctors who responded were unable to provide care to their patients at the time.

The extent to which private hospitals will be able to take on NHS waiting list initiatives going forward is unclear given the increased demand in the self-pay market and the backlog of private sector patients.

Given that the NHS and the private sector largely draw on the same pool of doctors, additional capacity may be less than it initially appears. This was made clear in the 2020 block-booking arrangements, which saw the NHS gain facilities rather than the workforce to run them.

What the BMA is calling for