Did COVID-19 and the NHS strikes cause the elective care backlog?

The misconception that there weren't long waiting lists before the pandemic and industrial action is explained here.

13 February 2024


With the disruption caused by the COVID-19 pandemic followed by industrial action across junior doctors, consultants, nurses and other NHS staff, there has been a temptation from some quarters to argue that waiting list increases and missed government targets have solely been due to these external factors. 

On its website, the Department of Health and Social Care says:

"As with other health services around the world, backlogs have inevitably built up because patients were understandably deterred from coming forward for help during the covid pandemic."

The Prime Minister also attempted to shift focus on to the impact of strike action when questioned on his pledge that ‘NHS waiting lists will fall’. The overall elective waiting list in England now stands at an estimated 7.6 million* compared to 7.21 million at the time of the pledge in January 2023. Later that year, the he said:.

“We were making progress on bringing the overall numbers down. What happened? We had industrial action, we’ve got strikes.”

*The total waiting list for procedures and appointments fell from 7.61 million in November to 7.6 million in December.

The latest waiting list data, which covers November 2023, does add some credence to that argument. During that month there was no strike action and the waiting list fell by 96,000. This was the biggest reduction in the waiting list since May 2020 (when many fewer patients sought treatment due to the UK being in lockdown). If you take out those months affected by COVID-19, the reduction in November 2023 is the biggest since September 2014.

However, these are extenuating circumstances. 

The waiting list in England has been steadily rising for much of the last decade due to a variety of different reasons. COVID-19 and the strikes have undoubtedly played a part, but there has been a much longer general trend that has seen the waiting list steadily rise. 

Exploring the evidence

How has the elective waiting list changed and why?

From 2010 to the eve of the pandemic (February 2020), the waiting list doubled from 2.3 million to around 4.6 million, so the problem of lengthening waiting lists is not a new one. Looking at how waiting lists have changed since the December 2019 election is difficult, with the pandemic and industrial action significantly limiting factors and the pandemic starting so soon after the election. However, there were other challenges that have prevented the NHS from being able to reduce the waiting list, and we can explore these both pre and post 2019.

    • Lack of capital investment: Lack of capital investment in the NHS compared to other OECD countries: This has contributed to a less productive service hampered by, among other things, Victorian estates, too few diagnostic machines and outdated IT systems that cannot communicate across and between hospitals and other parts of the NHS.
    • Lowest real terms increases in NHS revenue funding: The lowest real terms increases in NHS revenue funding in its history during the decade of austerity in the 2010s, coupled with an ageing society (age-adjusted funding increase are even lower) and higher acuity.
    • Low number of hospital beds: The NHS having a low number of hospital beds relative to its population and when compared to other similar countries. Along with hospital flow issues, this has contributed to consistently high bed occupancy levels.
    • Large numbers of workforce vacancies: Staffing in hospital and community settings has increased, but there are still large numbers of vacancies in the NHS – consistently over 100,000 in recent years – and there have not been increases in key areas such as primary and social care which contributes to delayed discharges in hospital. 

Exploring the factors in more detail

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Capital investment

While NHS leaders continue to invest in innovative ways to make the service more productive, one significant blocker is access to capital funding.

The NHS has lagged behind comparator countries in terms of capital investment over the last decade, having been comparable at the end of the 2000s, and more investment is needed to replace old estates, outdated IT systems and ramp up the number of available diagnostic machines.  

In 2022, NHS Confederation polling showed that nine in ten health leaders thought reducing waiting lists was being hindered by a decade-long lack of investment, with a lack of capacity or appropriate estate making it harder to work through the backlog and limiting the potential for maximising the use of digital technology. It is a key reason the backlog was rising before COVID-19 and then industrial action has added to challenges since December 2022.

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There are many arguments around funding and whether the NHS has the resourcing it needs or is spending it effectively, but the picture throughout the 2010s is a key reason for why the waiting list has risen. Although funding in cash terms is higher than it has ever been, since 2010 funding increases have been well below the average 3.6 per cent annual rise the NHS has seen over the longer term. Under the coalition government this rise was just 1.1 per cent (2009/10 to 2014/15) and 2.5 per cent under the Cameron and May Conservative government. 

This has been inadequate as the population ages and has more complex needs, and it has contributed to the long-term trend of waiting list rises. Health Foundation analysis following the 2023 Autumn Statement showed that when NHS funding growth is adjusted for population size and age, growth has been even lower – by 2024/25 this would be just 1.4 per cent growth per year since 2013/14 when age-adjusted per person, and 1.8 per cent when adjusted for population.


Bed capacity

Linked closely to capital and investment in the NHS’s estate is bed occupancy. The NHS has consistently lagged comparable countries in terms of bed numbers. As per the latest OECD figures, the UK has 2.4 beds per 1,000 population, well below the OECD average of 4.3. As noted by the King’s Fund, fewer beds is not necessarily a bad thing and could mean shorter hospital stays/a more efficient health system. However, the NHS has had stubbornly high bed occupancy, suggesting a shortage.

The 2023/24 planning guidance targeted reducing adult general and acute bed occupancy to 92 per cent or below.  However, looking at this winter (2023/24), even with additional beds adult general and acute occupancy has been higher than targeted, and was at 94.2 per cent for December 2023. During the month, ten of the 42 integrated care systems reported adult general and acute occupancy over 96 per cent.

While first outpatient appointments have surpassed 2019/20 levels, procedures that require admission have not. This cannot be helped by a lack of available beds, and this winter we have again seen points where over 13,000 of the bed base has been taken up by patients who no longer meet the criteria to reside in hospital (most recently, 13.2 per cent of the general and acute bed base).

While NHS Confederation members have worked consistently to do what is within their power to improve discharge, social care is a key part of that strategy, and is why we continue to call for a workforce plan for social care, funded appropriately, as well as to move care closer to home. Data in 2019/20 showed 855,000 emergency admissions of older people could have been avoided, and older people tend to experience longer discharge delays meaning poorer outcomes and experiences for the patients involved, as well as fewer beds available for elective admissions. Collapsing social care capacity has contributed to a long-term rise in the waiting list.

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Workforce and productivity

Overall staffing of the NHS in hospital and community settings has increased by almost 16 per cent since December 2019 and the government can fairly point to meeting the 50,000 nurses target. The NHS Confederation has welcomed the long-term workforce plan, which will be implemented over several years. However, the plan is predicated on highly ambitious productivity increases that have not been achieved in the past.

Commentators have quite rightly pointed to this productivity problem. The health service needs to find a way to leverage that increase in staff to generate increased levels of activity in the context of the waiting list: although we are not there yet, there have been shoots of recovery. If you look at the raw numbers of people coming off the waiting list because they have had outpatient appointments or inpatient procedures, this was at 105.2 per cent of 2019/20 levels in November.

However, there are other areas of staffing that have not been invested in that have impeded the NHS’s attempts to improve productivity. Firstly, successive governments have had a long-held policy ambition to deliver more care in the community and in people’s homes, but investment in primary care has not matched that ambition. There are also significant variations in primary care staffing across the English NHS. In addition, the last decade has seen a lack of investment in social care, with many local services in crisis. There are around 160,000 vacancies in social care, which play a part in continued high delayed discharges out of hospitals.

Impact of strikes

None of this is to say that industrial action has not had an impact more recently. Industrial action data shows a total of approximately 1.4 million cancelled operations, outpatient, community and mental health appointments going back to December 2022. Trusts have also pre-emptively avoided booking care for periods of industrial action, so cancellations are much lower than the early period of industrial action.

NHS leaders have also recently told us about the disruption to staff time with around a third of their time being taken up with administration such as rebooking cancellations – despite Health Foundation analysis estimating that consultant and junior doctor strikes up until the end of October 2023 had increased the waiting list by approximately only 210,000.

At a time the NHS needs to increase productivity, the success of bringing down the waiting list by 96,000 in November (when no industrial action was scheduled) shows potential for the service when this additional barrier to progress is removed.

The bottom line

The long-term rises in the waiting list cannot be put down to COVID-19 and industrial action alone. A lack of capital investment, long-term funding, bed capacity and a productivity problem have all contributed. Recent investment in the NHS workforce is positive, and our members are working hard to ramp up productivity, but there also needs to be investment in other parts of the workforce, notably in primary care and social care.

It is true that COVID-19 saw the waiting list rise more significantly than the long-term trend, and that industrial action is a limitation on performance now. Recent data has shown that the waiting list fell by 96,000 when there were no strikes, an additional factor in the NHS Confederation’s continued calls for an end to industrial action. Yet these external factors have meant the waiting list is over 7.6 million instead of around 5.5million. Solutions need to tackle problems that go back much further.

Read more from our series of explainers, providing facts and figures to challenge common misconceptions in health and care.