55th Report - Reducing NHS waiting times for elective care

NHS England’s plans to transform outpatient services were not credible, even though it had already acknowledged that more efficient outpatient services would make a material difference to the waiting list. The outpatients transformation had aimed to free up capacity in outpatients services and NHS England had set a target to reduce follow- up outpatient appointments by 25% (compared to 2019–20 levels) by March

NHS England’s approach to transformational change was deeply flawed in both monitoring of progress and the delivery of intended outcomes. NHS England’s diagnostic transformation programme displayed positive features of programme management and achieved planned increases in numbers of diagnostic tests. The planned number of Community Care Centres were also delivered on time. However, the programme did not deliver the intended outcomes of reducing waiting times. Internal NHS England analysis found that there was a shortfall of 3.6 million tests. This led to the recovery target of 5% of waits for diagnostic tests being no more than six weeks being missed, with 22% of patients waiting over six weeks. These flaws have been compounded by NHS England and the Department not setting up the surgical and outpatients transformation programmes effectively enough to measure their impacts and benefits. Ultimately, the Department has approved billions of pounds of spending without sufficient focus on what exactly these programmes will deliver. recommendation The Department of Health and Social Care and NHS England should: a. Set up data collections or processes for tracking costs and benefits as early as possible when setting up new services or transforming existing services including the recent extension of specialist telephone advice to GPs. b. Focus reporting on the achievement of policy aims (expected outcomes for patients) to ensure that the capital funding provided delivers intended outcomes. 3

We are not confident that the Department is being realistic about the immense effort needed to reduce NHS elective care waiting times, and see a significant risk that digital solutions are being treated as a ‘cure- all’ as the 10 Year Plan is being implemented. While NHS England and the Department for Health and Social Care have outlined an ambitious programme for future change, the current picture of performance for transformation is poor. The integration and sharing of digital records across the NHS is a key weakness and the NHS lacks some of the basics in IT connectivity, with General Practitioners, hospital trusts and consultants still working on different systems. With technology moving quickly, the timing and funding of digital change remains uncertain. At the same time, we are sceptical that digital change can satisfactorily reach all patients as there is likely to always be a part of the population who find digital technology and tools too difficult to use. recommendation NHSE and the Department should set out: • how the elective care transformation programmes are practically affected by the ‘analogue to digital’ shift in the 10 Year Plan; • how it will solve the problem of legacy IT equipment and ensure that the IT systems used in different parts of the NHS are properly connected; and • whether the 10 Year Plan itself has sufficient funding to deliver the digital transformation required by the plan.

NHS England’s performance to date has not demonstrated that it can secure the clinical engagement that will be necessary to transform waiting lists. Clinical engagement has worked best when there been close working between national and local clinical leaders, and specific and expert support between peers. The diagnostic transformation programme and the surgical transformation programme benefitted from clinical leadership and the support of relevant Royal Colleges. NHS England recognises that this is central to securing change and acknowledged that it still has to work out how it can get better clinical engagement, particularly for the outpatients programme. While NHS England has now set new incentives and priorities, the scale of engagement necessary to achieve full clinical support for the outpatients programme remains a significant challenge. Some progress has been demonstrated by NHS England through other outpatients programmes such as the Further Faster 20 programme to reduce long-term economic inactivity, although formal evaluation of the programme by NHS England and the Department has not yet been completed. 4 recommendation The Department should set out what it plans to do differently to secure clinical engagement on the outpatients transformation programme to improve waiting times.

We are concerned that the Department for Health and Social Care and NHS England are still announcing major reforms without either delivery plans or secured funding. We do not accept that it is prudent to make a major change, such as the structural changes that are being made to Integrated Care Boards (ICBs) and NHS England without ensuring there is funding in place to pay for the changes, and without conducting an impact assessment or taking other steps to safeguard value for money. These changes, especially the planned cuts to ICBs, could have a significant negative impact on patients and on the healthcare workforce through the level of uncertainty they create, and because they may limit the ability of NHS organisations to plan for the future. We are concerned that these poor practices, previously seen with the New Hospitals Programme and the High Speed 2 programme are being replicated here and will lead to wasted effort. recommendation The Department should • confirm to us that it will not announce unfunded commitments; • set out the likely costs, with associated funding, together with an impact assessment, for the ICB redundancies and the absorption of NHS England; and • set out how organisational changes at local level relate to, and are properly linked with, other partner organisations such as local authorities. 5 1 Progress in reducing waiting lists for elective care Introduction

On the basis of a report by the Comptroller and Auditor General, we took evidence from the Department for Health and Social Care (the Department) and from NHS England (NHSE) regarding NHSE’s management of transformation programmes to reduce elective care waiting times.1

We also received written submissions from a range of individuals and organisations including clinicians and academics, royal colleges representing medical disciplines, care providers, think tanks and charitable organisations. A full list of the written evidence we received is available on the inquiry page of the Committee’s website.11 Particular issues and concerns drawn to our attention included: • demand for elective care is increasing, placing pressure on waiting lists, due to both an ageing population and other social and economic factors contributing to ill health; • there is a shortfall in capacity due to the under-resourcing of specialist care and high competition for specialty training; • discussion on elective care has focused more on hospital care and more focus on community-based care may be necessary; • research suggests that there are regional inequalities in waiting times for elective care and diagnosis; • ageing digital infrastructure can cause delays and constrain productivity; and 6 Letter from the Permanent Secretary at the Department for Health and Social Care, 10 September 2025 7 C&AG’s Report, para 2; 2.13 8 Letter from the Permanent Secretary at the Department for Health and Social Care, 10 September 2025 9 C&AG’s Report, para 2 10 C&AG’s Report, para 11 11 Committee of Public Accounts, Reducing NHS waiting times for elective care written evidence 7 • long waits for elective care can negatively affect patient and staff wellbeing and safety. Progress against elective care waiting time targets

NHSE’s 2022 recovery plan ambition was to eliminate waits of longer than a year for elective care by March 2025. Within this, NHSE aimed that no one would wait longer than two years by July 2022, that there would be no waits of over 18 months by April 2023, and no waits of over 65 weeks by March 2024. The NAO reported that, while none of these targets on long waits were achieved, waits of two years had reduced by 87% by July 2022, waits of over 18 months had reduced by 83% by April 2023 and waits of no more than 65 weeks had reduced by 69% by March 2024. NHSE also missed statutory targets. Since 2013, NHS regulations have included a statutory requirement for patients on 92% of elective care pathways to wait no more than 18 weeks from referral.12 In March 2025, 60% of patients had waited for up to 18 weeks.13 For diagnostics, the post-COVID 19 recovery target was that, by March 2025, 95% of patients waiting for a test should receive it within six weeks of referral. As of January 2025, 22% of patients waited more than six weeks for their test.14

NHS England (NHSE) told us that the additional diagnostics capacity it had created had been quickly backfilled by growth in demand. Its progress on achieving the diagnostics recovery target remained stuck, with the number of patients waiting more than six weeks remaining fairly flat over the past twelve months at around 20%. It acknowledged that a great deal of focus would be required over the next year to make progress. NHSE told us that the growth in diagnostic demand was far in excess of the modelling it did to map out the delivery path.15 NHSE had not set a specific requirement for NHS organisations to meet the diagnostic target for 2025–26, although it wanted them to work towards it. It would consider whether to reset the diagnostic waiting time target as a requirement for next year.16

We received written evidence that long waiting times can put patients at risk. Evidence from Dr Rob Findlay noted that if it is not known what is wrong with undiagnosed patients then some of them will unexpectedly turn out to have a clinically urgent condition such as cancer.17 The National Institute 12 C&AG’s Report, paras 1.2 and 1.7-1.8 13 NHS England, Consultant-led Referral to Waiting Times Data 2024–25: Monthly Referral to Treatment waiting times for incomplete pathways, March 2025. 14 C&AG’s Report, para 1.16 15 Qq 12-13 16 Qq 79-81 17 Rob Findlay (NWT0003) 8 for Health Research Policy Research Unit also told us that waiting longer for elective care can impact health because patients’ ability to benefit from care will reduce as their health deteriorates and ultimately there is a risk of mortality.18

In July 2025 NHSE started publishing new data alongside the existing monthly Referral to Treatment Waiting Times data that showed that people from deprived communities and minority backgrounds are more likely to be waiting longer than 18 weeks for care than other groups.19 NHSE told us that one of the challenges it faces is ensuring equity of access and that it is working on addressing access needs in a sensitive fashion that takes inequalities and other factors into account.20 NHSE also told us that it is asking all local systems to make sure that they examine the data to understand what is driving differences. One example of a factor that may create inequalities, is when working parents are offered appointments that take place when they need to take their children to school and so more flexibility in appointment timing may be required.21 Planning for outpatients transformation

NHSE has aimed to free up capacity in outpatient services to allow more patients from the waiting list to be seen. In 2022, NHSE set a target to reduce outpatient follow-up appointments by 25% compared with 2019–20 levels by March 2023. The outpatients programme spent £52 million from 2021–22 to 2023–24. The NAO reported it had not seen evidence of any assessment of the funding and resources required to achieve the 25% reduction. The NAO also reported that performance reporting was sporadic, with performance against the target only reported to NHS England’s elective recovery board in eight out of 24 months when the target was live. The reporting that did take place showed a reduction in follow-up appointments of only 0.1% (between June 2022 and July 2023). NHSE then dropped the 25% target and it has been removed from operational planning guidance and reporting packs.22

In 2022 our predecessor Committee was told by NHSE that the area where it has most potential to free up clinical time and see more patients is in outpatients services because “80% of the waiting list is tied 18 NIHR Policy Research Unit on the Economics of Health and Social Care Systems and the NIHR Policy Research Unit on Economic Methods of Evaluation in health and care interventions (NWT0040) 19 NHS England, NHS publishes waiting list breakdowns to tackle health inequalities, england.nhs.uk, 17 July 2025 [accessed 30 September 2025]; NHS England, Waiting List Minimum Data Set (WLMDS) Information, 2025 [accessed 30 September 2025] 20 Q 15 21 Q 47 22 C&AG’s Report, paras 11, 2.21 and 2.23-2.24 9 up by outpatients”.23 NHSE told us at our September 2025 evidence session that outpatients remains the key to solving elective waiting lists, and that it was committed to reducing waiting times by transforming outpatient care. Making use of remote consultations and patient-initiated follow-up (PIFU) aimed to address concerns in the clinical community that patients who need a follow-up might not get one if there was too much focus on reducing the number of follow-up appointments.24 However, the NAO reported that the proportion of outpatient appointments delivered remotely actually declined during the programme from 21.5% in June 2022 to 18.8% in November 2023 against a target of 25%. NHSE originally aimed to increase of PIFU take-up by 5% by March 2023 but the target has now been extended to 2029.25

NHSE told us that it had got very close to achieving large changes to outpatients services, but a long period of industrial action had disrupted appointments and that a new plan and better clinical engagement was required.26 NHSE told us that there should have been more of a focus on outpatients and that the programme was under-resourced.27 Other organisational factors also hindered NHSE’s oversight and control of the programme, as in its early stages, outpatients transformation was managed by a different part of NHSE from the other transformation programmes.28 NHSE also accepted that more work needs to be done on outpatients transformation.29

NHSE said that it had made progress in some areas, partly where necessity during the Covid 19 pandemic had driven the adoption of technology. NHSE highlighted the advice and guidance scheme, which allows GPs to request specialist input without going through a full referral. This scheme had seen continued growth with 1.1 million requests expected to go through the system this year. To incentivise the use of this system, NHSE are making payments to GPs who have used the system.30 The NAO reported that NHSE had aimed to achieve 16 specialist advice requests for every 100 patients by March 2023. This target was exceeded in the first month of reporting (22 per 100 in June 2022).31 23 Committee of Public Accounts evidence session on 28 November 2022, Managing NHS backlogs and waiting times, see Q98 24 Q 32 25 C&AG’s Report, para 2.26 26 Q 32 27 Q 34 28 Q 66 29 Q 57 30 Qq 43-45 31 C&AG’s Report, para 2.26 10 Delivery of surgical and diagnostic hubs

The Department wrote to us on 10 September 2025 to confirm that it has drawn down £2.2 billion of capital funding for diagnostic transformation and £1.04 billion for surgical hubs. It also confirmed that 122 surgical hubs were operational in England.32 The Department had previously written to tell us that 169 Community Diagnostic Centres (CDCs) were active, with one further CDC that had been active but was temporarily offline while it moved to a permanent location. Of those 170, 98 CDCs were reported by the Department as operating 12 hours a day, seven days a week.33

The NAO report found that while CDCs are operational and have provided an increasing proportion of diagnostic activity, NHSE analysis in June 2024 showed that it would not meet waiting list targets due to a shortfall of around 3.6 million tests.34 We questioned the Department whether for CDCs there had been a failure to track whether spending had been properly linked to outcomes at the local level. The Department told us that it did not think there had been a failure to track this and it was trying to strike a balance between targeted investment and local flexibility, but acknowledged that the C&AG’s report had found a failure to track the impact of programmes.35 Similarly, the NAO report found that additional activity in surgical hubs was below planned levels by an average of 48% between April 2023 and September 2024.36

NHSE told us that the additional diagnostic capacity it has created has been quickly taken up by growth in demand and that the NHS was also trying to control non-elective urgent demand.37 We were told however that while it was still struggling with waiting times, patient satisfaction rates are around 93% and the expansion of capacity had been welcomed by the NHS. NHSE also told us that there had been issues separating out the amount of surgical work that has gone on in hubs, particularly for those that were part of an adjacent organisation. It also told us that work was ongoing to clarify the exact number of completed hubs as there had been some confusion as to the exact number of hubs delivered, as the NAO report had found that different numbers were being reported to the two different oversight boards.38 NHS England subsequently wrote to the Committee on 6 November to explain the unfortunate circumstances under which 32 Correspondence from the Permanent Secretary at the Department for Health and Social Care, 10 September 2025 33 Correspondence from the Permanent Secretary of the Department of Health and Social Care and the Chief Executive Officer at NHS England, 1 September 2025 34 C&AG’s Report, para 2.10 35 Q 64 36 C&AG’s Report, para 2.16 37 Q 12 38 Qq 17-18 11 the management information system tracking Targeted Investment Fund schemes was not aligned with other governance processes. It considered the new National Capital Reporting System would allow a single source of truth in future.39

The NAO report found that the diagnostic programme has the most established governance structure and there was evidence of in-depth reporting, while governance was less developed for surgical transformation hubs.40 The Department told us that whilst it had previously had two teams and two boards providing separate governance arrangements, it had now moved to a single oversight arrangement.41 The Department told us that NHSE was doing enough to track the impact of programmes in order to balance reporting and bureaucratic load.42 However, the NAO report outlined that for surgical hubs the programme measurements were misaligned with the intended outcomes as whilst it was tracking the number of delivered surgical hubs, the actual aim of the programme was to increase overall activity. The report found that NHSE does not know what contribution surgical hubs had actually made to total elective activity.43 39 Correspondence from NHS England, dated 6 November. 40 C&AG’s Report, para 3.2 41 Q 54 42 Q 69 43 C&AG’s Report, para 2.18 12 2 Achieving future elective care transformation The feasibility of current transformation plans

The Department of Health and Social Care (the Department) told us that future plans for transformation will involve changing the way that care is delivered, including using digital technology in different ways.44 The Department said that in practice the transformation plans outlined in the 10 Year Plan will involve putting as much as possible in the hands of people who use healthcare services. This could be through the NHS app and other digital technologies so that people who do not need to physically come in for outpatient care have other options.45 NHSE told us that in diagnostics, digital transformation will allow test results from a clinician in one part of the country to be seen in another part of the country to prevent the need for undertaking repeat tests which might inflate the demand for diagnostics.46

NHSE told us that integration and record sharing across the NHS system features heavily within the 10 Year Health Plan, aiming to address a key weakness of the current system. NHSE said that digital transformation in the NHS presents unique challenges, compared to other healthcare systems, as there are no other systems that are as comprehensive as the NHS.47 NHSE told us that a lot of technology is now being made available to the NHS and time will need to be spent determining what the role of the centre of government is in adopting new technology, including whether the NHS moves away from central capital procurement towards allowing local organisations to procure on a smaller scale. We were told by NHSE that modern technology is “cheaper and easier to procure, but [NHSE’s] processes currently do not support that.”48 44 Q 73 45 Q 41 46 Q 13 47 Q 84 48 Q 84 13

Evidence submitted by the Royal College of Ophthalmologists and the Royal College of Radiologists noted that technology can be used to eliminate waste in the system and prioritise patients better. However, the Royal College of Physicians told us in their evidence that while technology presents opportunities, it had conducted a survey in which only 62% of physicians said they had the hardware they needed and just 59% said that they had software capable of delivering outpatient care remotely.49 Securing clinical engagement

NHS England (NHSE) engaged clinicians on the transformation programmes in various ways including working with representative bodies and embedding National Clinical Directors within the programmes to provide medical leadership. The surgical transformation programme benefited from in-person engagement and support from the Royal College of Surgeons of England.50 On the diagnostics programme an independent review gave proposed changes credibility. However, clinical engagement on the outpatients programme, which involves a much wider range of clinical specialities, was significantly more challenging. The NAO report notes that local NHS systems accepted outpatients services could be improved but did not agree that reducing follow-up appointments was the right solution, and NHSE failed to get support from the Royal College of Physicians for the target to reduce follow-up appointments.51

NHSE told us that it had struggled to get the clinical community uniformly behind the outpatients programme and that engagement had also been highly variable from specialty to specialty. We heard from the Department and NHSE that in their view the outpatients programme required extensive change to the way everyone in an acute hospital works, from clinicians to administration staff. The fundamental nature of these changes, we heard, meant that industrial action caused significant disruption to the ability of the programme to make progress at the operational level.52 NHSE told us that it had not applied all of the expertise available to them and accepted that it had not communicated the opportunity for change that it sees in the outpatients programme. The NAO report found that while NHSE recognised that progress towards outpatients targets had been slow by September 2022, it did not reset the programme until 2024.53 49 The Royal College of Radiologists (NWT0002); Royal College of Physicians (NWT0025); The Royal College of Ophthalmologists (NWT0032) 50 C&AG’s Report, paras 17, 4.9 51 C&AG’s Report, para 4.9 52 Q 45 53 C&AG’s Report, para 4.10 14

NHSE accepted that any reform or change management programme cannot work without clinical engagement, and told us that it was now carrying out a range of activities to secure clinical support for the outpatients programme. NHSE explained that, among other measures, it was providing access to performance data at a local level, embedding clinical oversight at the regional level and having two national clinical directors involved in the programme at a national level.54 The NAO report suggests that there are signs that NHSE is now achieving better engagement on outpatients transformation.55 However, we heard that the model for outpatient care is the same one that has been in place for decades and that the whole model needs to change.56 The Department’s approach to making major changes

On 13 March 2025, the Government announced that NHSE would be abolished within two years and that the Department would put in place arrangements to deliver the responsibilities currently delivered by NHSE.57 On the same day, as part of our evidence session on the 2023–24 Annual Report and Accounts of the Department for Health and Social Care, we asked the Department and NHSE about reports that Integrated Care Boards (ICBs) had been ordered to cut costs by 50%.58

At our March 2025 session, NHSE told us that it was having discussions with the Cabinet Office and HM Treasury and that changes of this scale would require a redundancy scheme. NHSE told us that ICBs employed approximately 25,000 further staff and that it expected reductions to achieve around £700 million to £750 million of savings each year once fully delivered.59

In the September session, NHSE told us that the changes had been very dramatic and that a lot of work had been done very quickly to start to reduce the variation in running costs for ICBs as well as some of the key cost drivers.60 We were told that redundancies at the national level had been thought of and discussed at the outset. However NHSE confirmed that there was still no resolution with HM Treasury on the source of the 54 Qq 37-38 55 C&AG’s Report, para 4.10 56 Q 33 57 C&AG’s Report, para 6 58 Committee of Public Accounts evidence session on 13 March 2024, DHSC Annual Report and Accounts, see Q 9 59 Committee of Public Accounts evidence session on 13 March 2024, DHSC Annual Report and Accounts, see Q 9 and Q13 60 Q 2 15 significant sums that would be required to fund redundancy compensation payments.61 NHSE accepted that the uncertainty over job losses and cuts being faced by ICBs was unsatisfactory.62 We were, however, assured by NHSE that despite their scale, the cuts would be made without any direct implications for service provision.63

Reports by this Committee and its predecessors have highlighted the risks to value for money raised by sudden policy changes that are not supported by sufficient funding and planning. In 2023, the Committee reported that the decisions made by the Department in planning the New Hospitals Programme could not be justified as no supporting documentation existed.64 In September 2025, we found that announcing projects or programmes too early, or where the design of the proposed changes are immature, presents serious threats to governance.65 Much greater emphasis should be placed on producing an impact study to accompany these large changes. 61 Q 3 62 Q 5 63 Q 7 64 Committee of Public Accounts, The New Hospitals Programme, First report of Session 2023–24, HC 77, 17 November 2023, paragraph 28 65 Committee of Public Accounts, Governance and decision-making on major projects, Forty-fourth report of Session 2024–25, HC 642, 4 September 2025, paragraph 1 16