Social care, patient flow and the elective backlog

Capacity in social care is critical for patient flow in hospitals and easing the backlogs in elective care and diagnostics.

10 November 2022

The elective waiting list in England has risen to 7.1 million pathways. The current picture is complex but as we head into winter, here’s a refresher on how we got here and how issues with patient flow and poor performance in A&E departments, caused in part by the crisis in social care, are constraining efforts to tackle the elective and diagnostic backlog. 


This infographic shows the knock-on effect of limitations in social care on A&E admissions, elective care and diagnostic assessment. 

At a glance

Graphic of a townscape with a hospital, row of homes and care homes spotlighting five key points that account for patient handover delays
  • What is the impact of social care on patient flow and the elective and diagnostic backlog?

    1. The elective waiting list has risen to a record 7.07 million, despite the best efforts of NHS organisations to tackle the elective backlog. The service is still short of activity targets surpassing 2019 that would allow it to make inroads.
    2. The elective waiting list has risen to a record 7.07 million, despite the best efforts of NHS organisations to tackle the elective backlog. The service is still short of activity targets surpassing 2019 that would allow it to make inroads.
    3. The social care crisis is also a key part of the problem. In October, just 39.9% patients were discharged when they were ready to be, with an average of’ 13,613 beds a day occupied by those who are medically fit for discharge but are unable to be cared for at home. This leaves poorly patients waiting for a bed.
    4. Pressure in A&E is also compounding the situation. In October 2022, 45.2% patients in major A&E departments experience attendances of over four hours, compared to 25.6% in October 2019 or 17% a year earlier. Resourcing will be further reduced for elective and diagnostic backlog when trusts need to increase bed capacity and staffing to handle winter pressures. 
    5. The median wait for one of the main diagnostic tests is 3.2 weeks but those waiting for elective care may be waiting much longer for diagnosis. A decade of lower capital spend, resulting in less imaging equipment and machines than the OECD average, has also hampered diagnostic capacity. 

    Workforce capacity is also constraining elective and diagnostic activity. There are increasing shortfalls in key roles such as anesthetists and radiologists, while our members report shortages of administration staff to book in patients. The often-reported 132,000 vacancies is still a concern, alongside ongoing reports of staff exhaustion, burnout and COVID-19 absence and the potential impact of strike action. 

    Ahead of a challenging winter, the NHS still faces a number of impediments to attempts to get through the elective backlog.

In detail


The elective waiting list in England has risen to 7.07 million pathways, with confirmation from NHS England last week that this features approximately 5.5 million unique patients (just shy of 10 per cent of the population). 

The waiting list was 4.42 million in February 2020, and below we can see the significant rise after the onset of the pandemic. The sharp rise of the last two years has several reasons, including the crisis in the care sector. You can scroll across the three charts below to see the total waiting list, comparisons of elective activity levels and the volume of joiners to the waiting list compared to pre-pandemic: 

Staff across the NHS have made great strides to ramp elective activity back up to close to pre-pandemic levels, but with joiners to the waiting list at comparable levels to 2019 now, it’s no surprise to see the waiting list continue to rise. 


So why are we still highlighting issues in social care as a key reason for continued growth in the waiting list? Data for the month of October shows just 39.9 per cent of patients were discharged when they were medically ready to be, with over 13,000 beds on an average day occupied by patients who could have been discharged. Many are waiting for care at home.  
And the knock-on effect of the inability to discharge these patients is that beds are occupied by people who don’t need to be in hospital, while poorly patients wait for care. Last month we also highlighted this as a big factor in causing ambulance handover delays.


Performance at the front door of the A&Es continue to get worse, hampered by this inability to discharge patients for care at home. In October, the percentage of patients at major A&Es whose attendances were less than four hours was a record low of 54.8 per cent, while a record 43,792 patients waited more than 12 hours from decision to admit to admission. The two time series charts below show these in more detail. 

If staff and bed capacity is needed for emergency care, it can’t be used to tackle the elective and diagnostic backlog. And as the NHS braces for winter, this is expected to get worse.


Another challenge in terms of inroads into the elective backlog is diagnostics. The latest monthly diagnostic data shows 29.8 per cent of patients waiting over six weeks for one of the main 15 diagnostic tests, which is over 463,000 people. On the brink of the pandemic in February 2020, this was just 2.8 per cent. Some patients on the elective list will also be waiting longer for diagnosis as they wait to be seen. 
Diagnostic capacity is hampered by years of lower capital spending meaning the UK lags behind other European nations and the OECD average on diagnostic equipment such as MRI and CT scanners.

A question of the workforce 

Long-term workforce problems in the service aren’t helping either, with 132,000 staff vacancies, concerns over retention and reports of shortfalls in occupations like anaesthetists and radiologists, alongside exhausted staff after over two years of the pandemic. Those issues are combined with a pension system that is not working, and news this week of forthcoming strike action; a set of issues that will not be fixed overnight and impair the service’s ability to tackle the backlog.

The bottom line

As shown by the cycle of problems in our infographic, one thing the government could do to improve flow and capacity for the service to tackle the elective backlog is to invest in social care wages. Skills for Care note the median pay of £9.50 leaving care workers amongst the worst paid roles in the country, with 165,000 vacant posts and 400,000 leavers in the last 12 months.