Managing expectations: the NHS’s challenging activity and efficiency targets

The NHS in England approached the Autumn Statement amid deep concern over rising costs and alarming performance statistics. The extra £3.3bn allocated in 2023/24 and 2024/25 will have been greeted with relief. Although NHS England’s Chief Executive Amanda Pritchard said this funding should be ‘sufficient’ to fulfil the NHS’s key priorities, it is hard to overstate the scale of the task ahead.

Is the NHS on track to meet its elective care recovery target?

One of the most visible challenges facing the health service is the waiting list for elective care, which stands at 7.2 million and growing. As part of the elective recovery plan, the NHS committed to deliver 129% of 2019/20 activity by 2024/25.

The NHS has an intermediate ambition for systems to deliver 110% of pre-pandemic activity (104% on a cost-weighted basis) by the end of 2022/23. Although activity, spurred by the rapid adoption of advice and guidance by GPs, may now have recovered close to pre-pandemic levels, this remains a tall order.

In the 12 months to October 2022, we estimate completed patient pathways stood at 97% of its pre-pandemic level (Figure 1). To achieve the 110% ambition, the remaining months of 2022/23 would have to see almost a quarter more activity than before the pandemic. This looks implausible.

Meeting the 129% activity target set out in the elective recovery plan will now require stupendous leaps in the volumes of patients seen over the next few years. Should 2022/23 finish with elective activity at its pre-pandemic level (by no means a given, but a more realistic prospect than reaching 110%), the rise required for 2023/24 and 2024/25 would be 14% per year. To put this in context, the average annual increase in activity between 2015/16 and 2019/20 was 3.6%. The raw arithmetic is daunting.

Such a sharp increase in activity would also require more staff at a time when vacancies across the health care system are rising. The overall staff vacancy rate in trusts was 9.7% in September 2022, above pre-pandemic highs. At 11.9%, the registered nurse vacancy rate was just below its pre-pandemic high of 12.3%.

This comes on the back of the intense workload and burnout experienced by many staff during the pandemic, and at a time when the cost-of-living crisis is likely to have a further adverse impact on staff pay, morale and retention. Discontent is already visible through industrial action being taken by nurses, ambulance workers and other health care staff, which will have implications for patient care and the ability to reduce waiting lists.

Are the NHS’s efficiency targets realistic?

Another challenge to increasing activity is the enduring hit to productivity experienced by the health service due to COVID-19. For instance, despite recruiting 5,000 more hospital consultants (full-time equivalents) in the 3 years to September 2022, a fall in the number of hospital admissions has led to a 15% fall in the number of admissions per consultant.

That’s largely because, for the NHS, COVID-19 has not gone away. Since April 2022, the number of hospital beds occupied by patients with COVID-19 has not dropped below 3,800 and averaged over 5,000 in November 2022. Continued infection prevention and control measures add time and effort to activity. Patients who contract the virus in hospital take longer to discharge. And there are persistent delays in discharging people who are medically fit to leave hospital. All this means that after the average length of stay in hospital declined by almost 50% in the past two decades, it has now increased sharply again. If patients take longer to treat, each consultant can see fewer patients.

The government’s response has been to call for another increase in efficiency. This isn’t new; pandemic aside the NHS has been getting more efficient, by 0.9% per year between 2008/09 and 2016/17. What is new is the pace of the increase. The efficiency target for 2022/23 to 2024/25 is 2.2% per year, double the 1.1% agreed as part of the NHS Long Term Plan (Figure 2). Achieving that is hard to envisage at present, not least because there is less scope to repeat many past efficiency gains, such as reducing the time patients spend in hospital, switching to generic drugs and cutting the tariff paid to providers.

Meanwhile, with extra funding assigned for COVID-19 falling even as the virus continues to represent a significant burden for the health service, the actual efficiencies required of the NHS may be still higher (around 5% in 2022/23 alone, according to NHS England). It is very hard to see how anything close to that can be delivered without hitting front-line services. Indeed, there are reports of cuts to funding earmarked for priorities such as cancer, primary care and maternity services.

Increasingly tough times ahead

What does this all add up to? In the face of these pressures, the NHS risks being unable to deliver on its targets and many more patients will find themselves waiting for care. The size of the waiting list depends on a mix of factors, including how much activity is performed, but also how many referrals are made. The latter is particularly uncertain owing to the number of patients who did not receive a referral during the pandemic – so-called ‘missing referrals’. These patients may or may not return in significant numbers, and any projection must acknowledge that uncertainty.

In one set of scenarios, illustrated below, we model different levels of activity increase – the 29% target, but also a 21% increase – alongside a range of returning missing referrals (25–50%). This modelling shows that a 21% increase in activity could result in the waiting list reaching 9–12 million in 2025. In comparison, if the 29% target is achieved, the waiting list could peak at around 8 million and fall thereafter.

Ultimately, although there is much that policymakers and system leaders can do to help the NHS increase efficiency and activity (recent investment in adult social care to support hospital discharge is one example), there is also much that lies beyond their control. It seems particularly important that COVID-19 costs and inflation pressures abate, yet here the NHS is a hostage to fortune. Heading into what is expected to be a very difficult winter, it looks increasingly challenging for the NHS to meet its targets despite the additional funding assigned.