The government is pushing the NHS further and faster on elective recovery
The prime minister and health secretary have set their sights on the elective waiting list.

The government’s elective reform is hardly revolutionary, but it could have wide-ranging implications for the entire health and care system, says Stuart Hoddinott
When announcing the government’s plan to reform elective care, Keir Starmer said that the country “needs an NHS reformed, from top to bottom”. 23 https://www.gov.uk/government/speeches/prime-ministers-remarks-on-the-nhs-6-january-2025 While that statement is likely true, it would be hard to argue that this is completely novel approach to managing the elective waiting list. Few of the headline policies in this document are new, with many either started or accelerated under the previous government.
They include expanded use of community diagnostic centres (CDCs), 24 https://www.gov.uk/government/news/40-community-diagnostic-centres-launching-across-england elective surgery hubs, 25 https://www.gov.uk/government/news/budget-and-spending-review-october-2021-what-you-need-to-know the independent sector, GPs seeking specialist advice from hospital colleagues before making a referral (the most common of which is advice and guidance, or A&G) and making follow-up outpatient appointments opt-in rather than opt-out (known as patient initiated follow up, or PIFU). 26 https://www.nuffieldtrust.org.uk/resource/patient-initiated-follow-up-does-it-work-why-it-matters-and-can-it-help-the-nhs-recover
It is positive that Labour is willing to pursue policies that work, regardless of their provenance: the Health Foundation shows expanded use of surgical hubs 27 https://www.health.org.uk/features-and-opinion/blogs/surgical-hubs-key-to-tackling-hospital-waiting-lists and the independent sector 28 https://www.health.org.uk/reports-and-analysis/analysis/waiting-for-nhs-hospital-care-the-role-of-the-independent-sector-in is an effective way to clear ‘high volume, low complexity’ elective cases such as cataract surgery, while CDCs seem to have increased diagnostic capacity.
The focus on specialist advice also shows that Labour learned a strong lesson from the last government: low referrals from general practice slows the growth of the elective waiting list. By our calculations, there were approximately 1.8 million fewer additions to the waiting list in 2023/24 than might have been expected if following pre-pandemic trends. That is 8.6% of the 20.5 million additions from 2023/24. The NHS estimates that specialist advice alone led to 1.2 million fewer referrals.
The government is using financial flows to incentivise activity
More interesting than some of those topline policies is that the government will rely heavily on financial incentives to encourage providers to deliver desired outputs.
In general practice, the NHS will pay GPs £20 per request for specialist advice with the goal of almost doubling the number of requests to four million in 2025/26 and avoiding two million referrals. GPs who have thus far conducted that work for free will almost certainly welcome that compensation, even if the implied total investment (£80 million) would represent a relatively small increase in overall funding for general practice.
Alongside that policy, the government will also provide additional capital funding for trusts that show the largest improvements in 18-week elective performance. This mimics a scheme that the previous government ran last year, in which it rewarded trusts that showed the largest improvement in A&E performance. 31 https://www.hsj.co.uk/emergency-care/trust-chiefs-criticise-divisive-capital-prizes-for-aande-performance/7036783.article
That scheme not only failed in its headline ambition – the NHS missed its A&E target – but it also allocated funding on poor criteria: the trusts that improved the most were often those had been performing poorly before the scheme was launched and therefore had the most room to improve. 32 https://x.com/CharlesTTHF/status/1797515920333795541 It is also somewhat perverse to reward well-performing trusts with additional capital funding, when a lack of capital investment could be a cause of under performance in the worst-performing trusts.
Regardless of these schemes’ relative merits, using financial flows to incentivise desired activity clearly mirrors the management philosophy of the last Labour government. During Tony Blair’s premiership, the NHS introduced ‘payment by results’ which compensates trusts according to how much elective activity they carry out. Most importantly, when combined with this government’s commitment to returning to the 18-week elective standard, it shows a clear alignment between targets and funding mechanisms, something which we have previously argued the government should do if it wants to improve performance in services.
Focusing on elective care puts more pressure on other parts of the health and care system
Despite these positive steps, there remain significant risks to the government achieving its elective goal. The ambition to return to the 18-week target is incredibly stretching, making this metric a headline milestone for measuring government success means the system will likely focus on elective activity above all else. That could make it difficult to achieve improvements in urgent and emergency care and other areas such as cancer treatment, at least in the short term.
Expanded use of specialist guidance will also push more patients into primary care and community care, with both systems already under intense pressure following years of underfunding relative to demand and increasingly complex demand. And while specialist advice clearly reduces additions to the elective waiting list, there has been little evaluation of the effect on health outcomes or GP workloads (at least that its publicly available). That makes the details of the government’s planned shift of care out of hospitals even more important. If done well, the upcoming 10-year plan could reduce pressure on hospitals, expand capacity and capability in the community and lead to better health outcomes. Done poorly, it risks overburdening a system that is already struggling, leaving patients unable to access sufficient care.
Lurking in the background of these reforms is a woefully underfunded adult social care system which will now remain largely unchanged throughout this parliament, adding demand to the elective waiting list and slowing activity in hospitals. It is a mistake for the government to delay action.
The government has made clear that bringing down elective waiting times is the north star of its health and care policy. This plan focuses on reforming systems that directly impact the elective waiting list; attention should now turn to how the government can support other parts of the system that will be indirectly affected by changing patterns of demand and care.
- Keywords
- NHS Health Government reform
- Publisher
- Institute for Government