When Sunak made his pledges, the elective waiting list stood at 7.21m incomplete cases. That level itself was historically high, having increased 58% since January 2020. While the sharp increase is in large part due to the impact of the pandemic, waiting lists have been increasing year on year since April 2012.

Have waiting lists been cut?

No. The situation has in fact worsened since Sunak made his five pledges. The elective waiting list in England did fall modestly, to 7.71m, in October 2023 (the most recent month for which we have data) but that is still close to half a million cases higher than in January. Hitting this target before the end of the parliament was always going to be difficult, but has been made harder for several reasons.

Waiting times for emergency care were also at their worst level on record when Sunak made his pledge. A&E waiting times in England have very marginally improved in the past year, with 55.4% of people seen within four hours in November 2023, up from 54.5% in November 2022, but this remains far lower than pre-pandemic levels, and is way off the government‘s 2023/24 target of 76%.

Why have NHS waiting lists continued to rise?

Despite record funding and staffing levels, the NHS has not returned to trend levels of activity after the pandemic due to pre-existing and long-running productivity issues. Covid certainly worsened the picture, but it mostly exacerbated pre-existing issues, namely underinvestment in capital, worsening staff morale and a lack of management capacity. This means that despite more than 15% more doctors and nurses in hospitals compared to February 2020, elective activity in 2022/23 was 2.7% lower than in 2019/20 and more than 10% lower than it would have been if pre-pandemic trend increases had continued.

This reduced activity has made it harder to work through the elective waiting list. Activity is slowly improving, but likely not quickly enough to allow the government to hit its elective target.  

Industrial action has also increased the elective backlog, with hospitals being forced to cancel or reschedule more than 2m appointments since December 2022. But while the government is right to attribute poor elective performance (at least in part) to striking NHS staff, the government’s approach to negotiations has likely extended the length and severity of industrial action in the health service (and indeed across all public services).

A year on, the government has resolved industrial disputes with the ‘Agenda for Change’ workforce, which includes nurses, and negotiated a pay offer with the British Medical Association’s Consultants Committee, which consultants are voting on.

But no agreement has yet been reached with the BMA for junior doctors, who have announced further dates for industrial action and whose strikes to date have been the most consequential for the elective backlog: as of December 2023, more thanof all rescheduled appointments (54.8%) were due to industrial action by junior doctors alone, with a further 20.4% from joint strikes by junior doctors and consultants. ⁴¹ NHS England data, ‘Potential industrial action in the NHS – impact of carious strike actions’, 2023.  Ongoing strike action over winter will be incredibly disruptive as they will coincide with the peak of the now-annual ‘winter crisis’, making further progress on cutting waiting lists in the near future even more difficult.

NHS finances have also been under immense strain in 2023/24. ⁴² Financial performance update, NHS England, 27 July 2023, retrieved 15 December 2023, www.england.nhs.uk/long-read/financial-performance-update/  High inflation has increased costs and ongoing strike action has forced organisations to pay higher rates for temporary staff and lose income due to reduced activity. A request in November for funding to close its £1.2bn deficit saw the NHS receive only £100m and receive permission to re-allocate up to £500m of its existing capital budget and £200m of ‘winter pressures funding’. The NHS has since downgraded its elective activity target for 2023/24 from 107% of 2019/20 levels to 103%. ⁴³ Addressing the significant financial challenges created by industrial action in 2023/24, and immediate actions to take, NHS England, 8 November 2023, retrieved 15 December 2023, www.england.nhs.uk/long-read/financial-performance-update/

This was a legitimate decision for the government to take, but one that will almost inevitably reduce the likelihood of hitting its target. 

Can waiting lists be cut before the election?

Unlikely. Meeting this target by January 2025, the latest possible general election date, would require cases to fall at a rate not seen over a 12-month period since March 2009. According to the most optimistic scenario in work carried out by the Health Foundation – which assumed no strikes after October 2023, an outcome which will no longer happen – the waiting list would still be more than 500,000 cases higher in January 2025 than in January 2023. ⁴⁴ when will it peak?, Health Foundation, no date, retrieved 15 December 2023, www.health.org.uk/waiting-list