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Performance Tracker 2022/23: Spring update - Hospitals

The NHS is still struggling with the effects of the pandemic, while factors outside of Covid continue to put hospitals under intense pressure.

A backlog of ambulances waiting outside an A&E department.

By any reasonable measure, hospitals are in crisis. The proportion of people waiting more than four hours at A&E was higher in 2022 than any year since records began, the mean response times for ambulances attending category 2 calls (which includes strokes and chest pain) was over an hour and a half in December 2022, the waiting list for elective care stands at over 7 million, and the number of outpatient appointments has still not returned to pre-pandemic levels.

The pandemic forced the NHS in England to suspend much of its normal hospital work and encourage people to actively stay away from hospitals except in an emergency. Beds that would have been used for routine activity were repurposed for Covid patients as hospitals struggled to meet the demands of each successive wave. As a result, the number of outpatient appointments, diagnostic tests and elective procedures all declined sharply in 2020/21. 

This winter is proving to be a difficult one for the NHS, as we predicted in last autumn’s Performance Tracker 2022. The yearly peak in demand – which has in effect become an ‘annual winter crisis’ – coincides with an ongoing and worsening staffing crisis with almost one in 10 NHS roles vacant at the end of September 2022 261 NHS Digital, NHS Vacancy Statistics England April 2015 – June 2022 Experimental Statistics, 1 September 2022,
retrieved 29 September 2022,
and a range of industrial action across nursing, ambulance workers and, most recently, junior doctors. 262 NHS Employers, ‘Confirmed industrial action strike days’, blog post, 20 January 2023, Covid has also not gone away and continues to divert NHS resources away from regular activity. In addition, this flu season is proving to be a particularly bad one, with over 6,000 people in hospital with flu at the beginning of January 2023. 263 NHS England, Urgent and emergency care daily situation reports 2022–23, 5 February 2023, retrieved 9 February

The NHS attempted to return to normal operations in 2021/22 and has become better at ramping up and down its Covid capacity as required. But it is still struggling with the effects of the pandemic, which continue to reduce hospital productivity. 264 Coyle D, Dreesbeimdieck K and Manley A, ‘Productivity in UK healthcare during and after the COVID-19
pandemic’, February 2021, The Productivity Institute, p.21,
However, factors outside of Covid – namely pre-pandemic trends of insufficient bed numbers, an overstretched workforce, increasing numbers of workforce vacancies and delays in discharging patients – all continue to contribute to the immense pressure that hospitals are under. 

The current crisis in the NHS was not inevitable. Instead, it has been driven by more than a decade of relative underinvestment in the service, which has led to too few, burnt-out staff working with too little, faulty, or out-of-date equipment in buildings that are often unsuitable for a modern health service. The level of investment in the NHS is ultimately a political decision, meaning the government cannot lay the blame for the critical state of the service on the pandemic or striking staff, though these have exacerbated underlying problems.

This chapter discusses NHS acute, ambulance and specialist trusts in England, which provide specific short-term treatments, including diagnostic services, outpatient treatment and services, emergency treatments – such as ambulances and A&E – and surgeries. As data relating solely to acute and specialist trusts is not always available, in some places we analyse corresponding data for all NHS trusts.

Spending has increased 13.4% since 2019/20, but much of this was Covid-related

Spending on NHS providers – which includes NHS acute trusts, ambulance, community and mental health services – increased by 13.4% in real terms between 2019/20 and 2021/22. After the biggest single-year spending increase since 2009/10 in 2020/21, spending grew a further 3.3% in 2021/22. This brings the total increase in spending since 2009/10 up to 42.7% in real terms. However, 2020/21 and 2021/22 were also the first two years of the pandemic and it should be expected that the NHS would increase spending to match the increased pressure imposed on hospitals. 

Unfortunately, it is not possible to determine how much of the spending in hospitals in those years was Covid-specific, but overall spending should either fall or grow less slowly in the coming years as Covid spending is rolled back, 293 The King’s Fund, The NHS budget and how it has changed, 3 February 2022, retrieved 28 April 2022,
though it is likely that there will be continuing Covid-related spending in the medium to long term. 

Another key area where spending increased was on staffing, which rose 11.4% between 2019/20 and 2021/22. This increase was driven by a mixture of higher spending on recruitment in line with ambitions in the NHS Long Term Plan (LTP) 294 NHS England, NHS Long Term Plan, 7 January 2019, NHS.UK, and emergency spending on staffing due to Covid. 

The increase in spending on hospitals since 2019/20 comes in the wake of a period of historically low spending increases for the service. Spending on hospitals increased by 1.6% per year in real terms between 2009/10 and 2014/15 – compared to an average of 6.3% per year in the decade to 2009/10. 295 The Health Foundation, How funding for the NHS in the UK has changed over a rolling ten year period, 31 October
2015, retrieved 28 April 2022,

Hospitals will continue to incur Covid costs 

Hospitals face continuing spending pressures from preventing the spread of Covid and responding to outbreaks of different variants. The National Audit Office (NAO) estimates that the government spent £89bn between March 2020 and June 2022 to support health and social care services through the pandemic. 296 National Audit Office, ‘COVID-19 cost tracker’, (no date), retrieved 22 June 2022, Estimating future cost, though, is more difficult. It is unclear how frequently Covid waves will occur and also difficult to accurately differentiate Covid costs from business-as-usual costs. 297 Institute for Government interview. Despite relative normality returning for the rest of the country, the average number of beds occupied by Covid patients per day* was almost a fifth (19.4%) higher in 2022 than in 2021 – at 9,179 in 2022 compared to 7,691 in 2021. 298 Hoddinott S, The NHS Crisis: Does the government have a plan?, Institute for Government, 26 January 2023,

In addition, the emergence of new variants might require the reintroduction of ‘mass vaccination and testing’ 299 Prime Minister’s Office, 10 Downing Street, ‘Prime Minister sets out plan for living with COVID’, press release,
21 February 2022,
measures that would entail an expansion of NHS spending. There are, however, reasons to believe that the emergence of another variant would not require the same extent of funding as previous variants. According to interviewees, the NHS has become more efficient at responding to Covid, taking less time – and therefore spending less money – to increase Covid capacity. Despite this, a joint report by NHS Confederation and NHS Providers, which uses survey data from 54% of NHS providers, estimates that the NHS will need to spend an additional £4–5bn per year on Covid-related costs “for some years to come”. 300 NHS Confederation and NHS Providers, A reckoning: the continuing cost of COVID-19, 2 September 2021,

The continuing high number of people in hospital with Covid also has implications for other areas of hospital performance. For instance, more people occupying beds with Covid makes it harder to admit urgent and emergency patients or conduct admitted elective activity. 

Hospitals found some efficiencies during the pandemic 

The pandemic encouraged the NHS to develop new ways of working. Some proved to be effective and could lead to longer-term – though not transformative – savings across the NHS. These innovations can be grouped into three categories. 

First, more efficient use of existing resources. For example, hospitals expanded the use of ‘mutual aid’ – the sharing of resources such as vaccines 301 NHS England, Mutual aid and the transfer of COVID-19 vaccines between NHS vaccination sites, 30 September
2021, retrieved 19 July 2022,…
and staff between different NHS providers – to reduce wastage and improve productivity.

Second, measures designed to keep people away from hospitals. Examples include the use of virtual wards 302 Institute for Government interview. , 303 Walton H and Fulop N, ‘Virtual wards and Covid-19: An explainer’, Nuffield Trust, 14 March 2022,
(in which hospital staff remotely monitor patients who stay in their own homes), increasing the number of virtual outpatient appointments 304 Nuffield Trust and the Health Foundation, The remote care revolution during Covid-19, (no date), retrieved
22 June 2022,
and carrying out acute services in the community. 305 NHS Cambridge University Hospitals, ‘Outpatient phlebotomy/blood tests’, (no date), retrieved 21 June 2022,
, 306 NHS Cambridge University Hospitals, ‘Outpatient phlebotomy/blood tests’, (no date), retrieved 21 June 2022,
There were 53 virtual wards providing 2,500 ‘virtual beds’ in February 2022 307 NHS England, 2022/23 priorities and operational planning guidance, 22 February 2022, p.22, and approximately 7,000 such beds by December 2022 308 Illman J, ‘Only half of new virtual beds occupied, internal figures reveal’, HSJ, 16 December 2022, – an increase of 180%. The NHS has an ambition to increase this capacity to “40–50 virtual beds per 100,000 population” 309 NHS England, 2022/23 priorities and operational planning guidance, 22 February 2022, p.22, by the end of December 2023. This would equate to approximately 23,000–28,000 virtual beds 310 Office for National Statistics, ‘England population mid-year estimate’, 25 June 2021, retrieved 20 May 2022,
– or around a quarter of the currently available general and acute beds.

Virtual wards are still, however, a relatively new innovation and there is not enough evidence to evaluate their effectiveness. 311 Walton H and Fulop N, ‘Virtual wards and Covid-19: An explainer’, Nuffield Trust,14 March 2022,
In addition, while not physically being in a hospital, staff still need to monitor the status of patients in virtual beds, 312 Best J, ‘The virtual wards aiming to ease hospital pressures’, the BMJ, 6 July 2022, which may prove difficult given current staffing issues (more on which below). Work by Nuffield Trust points out that virtual beds still require staff to interact with patients, and that those staff also often require additional training. 313 Walton H and Fulop N, ‘Virtual wards and Covid-19: An explainer’, Nuffield Trust,14 March 2022,

Finally, hospitals have attempted to reduce unnecessary activity. One lever for this is the introduction of ‘patient initiated follow-up’ (PIFU), 314 NHS England, ‘Patient initiated follow-up’, (no date), retrieved 27 June 2022, which places the onus on patients to arrange follow-up appointments only when they think they are necessary. This has the potential to free up capacity in the NHS; follow-up appointments accounted for 67.8%, 69.7% and 68.5% of attended outpatient appointments in 2019/20, 315 NHS Digital, Hospital Outpatient Activity 2019–20, ‘Main procedure or intervention’, 8 October 2020,
2020/21 316 NHS Digital, Hospital Outpatient Activity 2020–21, ‘Main procedure or intervention’, 23 September 2021,
and 2021/22 respectively. The NHS hopes that its target of “moving or discharging 5% of outpatient attendances to PIFU pathways by March 2023” 317 NHS England, 2022/23 priorities and operational planning guidance, 22 February 2022, p. 13, will help it to achieve its wider target of reducing outpatient follow-up appointments by 25% by March 2023. 318 NHS England, 2022/23 priorities and operational planning guidance, 22 February 2022, p. 13, There remain questions about this approach, however. The evidence that PIFU reduces unnecessary appointments remains mixed and there are some concerns that it could contribute to health inequalities. 319 Reed S and Crellin N, ‘Patient-initiated follow-up: will it free up capacity in outpatient care?’, Nuffield Trust,
4 August 2022,
, 320 Sherlaw-Johnson C, Georghiou T, Spencer J and others, Patient-initiated follow-up: findings from phase 1 of
a mixed-methods evaluation, Nuffield Trust, 2 December 2022,

* This includes ‘primary and secondary Covid patients’: those admitted for Covid and those admitted for something else but whose stay was prolonged due to their catching Covid in hospital respectively.

Hospital activity has not returned to pre-pandemic trend

Hospital activity dipped during the pandemic and has not returned to trend levels. This is despite the government spending more on the service, including employing 9.4% and 13.8% more doctors and nurses respectively between August 2019 and August 2022. The NHS conducted 23.7 million diagnostic tests (including tests carried out in non-hospital settings) in 2022 compared to 21.5 million in 2019 – a 10.3% increase. This comes after the NHS opened 91 community diagnostic centres (CDCs), 326 Department of Health and Social Care, ‘Government turbocharges efforts to tackle COVID-19 backlogs’, press
release, 7 December 2022,
remote locations designed to boost the number of tests carried out. The government claims that the previously opened 91 CDCs delivered 2.4 million tests between July 2021 and December 2022, 327 Department of Health and Social Care, ‘Government turbocharges efforts to tackle COVID-19 backlogs’, press
release, 7 December 2022,
which means that CDCs could be accounting for the majority of the 2.2 million increase in diagnostic tests between 2019 and 2022. 

Other areas of hospital activity, however, continue to operate below pre-pandemic levels. Hospitals carried out 125 million outpatient appointments in 2019. This fell to 122.7 million in 2022 – a 1.8% decline. Concerningly for the NHS’s ability to clear the elective backlog, the number of elective procedures fell from 17.1 million in 2019 to 16 million in 2022, a fall of 6.4%. 

This decline in output despite higher inputs indicates that the NHS is now less productive than it was before the pandemic, as other commentators have noted. 328 Warner M and Zaranko B, NHS funding, resources and treatment volumes, Institute for Fiscal Studies,
14 December 2022, retrieved 23 December 2022,
The reasons for this are complex and multifaceted and will therefore require further research to determine, but likely include: an historic underinvestment in capital, staffing issues (for example, poor retention of more experienced staff, or burnout or low morale among staff from working in unacceptable conditions, among others), under-management of the service, and the shock from Covid to a system that was designed to operate with little spare capacity. These trends and others are explored in more detail below.

High bed occupancy is limiting NHS capacity 

Patients are staying in beds longer than needed. 329 Curry N and Fisher E, ‘Chart of the week: What’s happening to hospital discharges?’, Nuffield Trust, 2 February
On average between 29 November 2021 and 12 February 2023 (the time period covered by the Daily SitRep data), 330 NHS England, ‘Urgent and emergency care daily situation reports 2021–22’, 7 April 2022, retrieved 1 July
21,728 patients per day no longer met the criteria to reside in hospital.* On average over half (58.3%, 12,672) of this number remained in hospital at the end of the day. With approximately 100,000 general & acute (G&A) beds available across the NHS at the end of January 2023, this means that 12.6% of G&A bed capacity on an average day was occupied by patients who were eligible for discharge.

The data for patients who no longer meet the criteria to reside, but whose length of stay is greater than 21 days, is worse. Between 14 November 2022 and 12 February 2023 (the time period for which this data is available), there was an average of 7,436 patients at the beginning of each day who had been in hospital for 21 days or more and were eligible for discharge. Of these the vast majority (6,613 patients, 88.9%) continued to occupy a bed at the end of the day, mostly due to a lack of appropriate support for discharge. Beyond the unnecessary occupancy of limited bed capacity, delayed discharge also uses up clinical resource, as staff have to care for patients who remain in hospital, diverting attention away from those more in need of care. 

After a decline at the beginning of the pandemic, occupancy of general and acute (G&A) beds has increased steadily and has been above 90% every month since August 2021, reaching a high of 94.4% in November 2022. 347 NHS England, ‘Critical care and general acute beds – urgent and emergency care daily situation reports’, (no
date), retrieved 1 July 2022,…
The situation is worse for adult G&A beds, where occupancy reached 95.7% in January 2023 – the most recent month for which we have data. This high occupancy is concerning for the performance of hospitals because, as noted, it makes it difficult to admit patients for urgent and emergency care and carry out planned elective care.

Unfortunately, following the suspension of the Delayed Transfer of Care dataset in February 2020, there is no longer official data on the cause of these delayed discharges. 348 NHS England, ‘Delayed transfers of care’, (no date), retrieved 1 July 2022, But interviews point to several reasons. First, limited staffing, both among social workers in local authorities who carry out assessments for care 349 Curry N and Fisher E, ‘Chart of the week: What’s happening to hospital discharges?’, Nuffield Trust , 2 February
and in care workers, reduces the supply of care into which hospitals can discharge patients. 

Second, there is a lack of available NHS community care that is preventing hospitals from discharging patients in a timely manner, increasing the reliance on social care 350 The Association of Directors of Adult Social Services, ADASS Spring Budget Survey 2022, 19 July 2022, p. 2,
– a service that is contending with its own workforce crisis. 351 Skills for Care, ‘Vacancy information – monthly tracking’, (no date), retrieved 24 January 2023,…
This was likely worsened at the beginning of 2022 by the redeployment of community care staff to the vaccination programme. 352 Limb M, ‘Delayed discharge: how are services and patients being affected?’, the BMJ, 17 January 2022,

Third, the NHS itself can cause delays due to a lack of intermediate care – for example, reablement and rehabilitation services – needed to facilitate a patient’s discharge from hospital. 353 The King’s Fund, Delayed transfers of care: a quick guide, 4 January 2018, retrieved 15 July 2022,
A Freedom of Information request carried out by Nuffield Trust confirms this view. Its research showed that in April 2022 almost two fifths (39%) of delayed discharges were due to patients awaiting either a permanent bed in a nursing or care home, or care in their own home. 354 Flinders S and Scobie S, ‘Hospitals at capacity: understanding delays in patient discharge’, Nuffield Trust,
3 October 2022,

The government seems to have recognised the importance of improving discharge from hospitals. In September 2022, Liz Truss’s government announced a £500m Adult Social Care Discharge Fund, with the aim of making it easier for hospitals to discharge patients into social care, 355 Department of Health and Social Care, Our plan for patients, 22 September 2022, retrieved 23 September
though it is not clear how much of that is new money. Rishi Sunak and Jeremy Hunt’s autumn statement went further still, providing an additional £2.3bn and £3.6bn for adult social care in 2023/24 and 2024/25 respectively, with the explicit goal that £500m of that should be used to improve discharge out of hospitals. 356 HM Treasury, Autumn statement, 17 November 2022, pp. 26–27,… The crisis in the winter of 2022/23 precipitated a further round of emergency funding, with the health secretary announcing an additional £250m as part of a ‘winter pressures and discharge’ fund. 357 Department of Health and Social Care, ‘Oral statement to parliament: New discharge funding and NHS winter
pressures’, GOV.UK, 9 January 2023,
While this funding is welcome, its short-term and haphazard nature makes it very difficult for the service to effectively plan and spend the money. 

While bed occupancy increased after an initial dip during the pandemic, the shortage of beds predates Covid. The number of overnight general and acute beds per 100,000 people has declined steadily since 2010/11, from a high of 210 beds per 100,000 people in the first quarter of 2010/11 to 181 by the second quarter of 2022/23 – a decline of 13.8%. It should be noted that this is a trend that predates 2010, with the number of G&A beds falling since the 1980s partly due to improved treatments that reduced length of stay and a shift to treating more people in the community. 358 Appleby J, Baird B, Thompson J and Jabbal J, The NHS under the coalition government. Part two: NHS performance,
The King’s Fund, March 2015, p. 16,
 But despite that longer term trend, there is evidence that in the 10 years before 2020 bed numbers were cut too far; bed occupancy was above 95% in one in six trusts by 2015 359 Appleby J, Baird B, Thompson J and Jabbal J, The NHS under the coalition government. Part two: NHS performance,
The King’s Fund, March 2015, p. 16,
– well above the recommended safe level of 85% 360 BMA, ‘NHS hospital beds data analysis’, 20 December 2022, retrieved 25 January 2023, – and the UK had the sixth lowest number of beds per capita compared to the 37 OECD countries by 2019 361 OECD, ‘Hospital beds’, OECD Data, (no date), retrieved 25 January 2023, – 2.4 beds per 1,000 people compared to the EU OECD average of 5. 362 BMA, ‘NHS hospital beds data analysis’, 20 December 2022, retrieved 25 January 2023,

Fewer open beds mean that the NHS is less well equipped to deal with urgent and emergency demand, elective activity and Covid surges. This worsens hospital performance in these areas, as explored below. However, increasing bed capacity by itself – as outlined in the operational resilience plan for the winter of 2021/22 364 NHS England, Next steps in increasing capacity and operational resilience in urgent and emergency care ahead
of the winter, 12 August 2022, retrieved 15 August 2022,
– is not sufficient to improve NHS performance; without extra staff to work on those beds, there is a risk of overburdening current staff.

Staff numbers are increasing, but poor retention is hampering performance

The number of nurses and doctors continued to increase over 2022, by 4.2% and 2.8% respectively, between October 2021 and October 2022. Since 2019/20, the number of nurses and doctors has increased by 4.2% and 3.4% per year respectively. This compares to a rate of 1.3% and 1.5% respectively between January 2010 and January 2019. This follows the launch of the LTP 367 NHS England, NHS Long Term Plan, 7 January 2019, in that year, which included ambitions to increase the number of nurses and doctors 368 NHS England, NHS Long Term Plan, 7 January 2019, p.79, through improved recruitment and retention.

After a decline in vacancies during the first year of the pandemic,* the proportion of unfilled roles in the NHS workforce has increased. In the quarter to the end of September 2022, nursing and total vacancies in NHS providers rose to 11.9% and 9.7% respectively, though medical vacancies dipped to 6.2%. This total figure is the highest level of vacancies since at least June 2017, when the time series started. 

However, these rates hide variation between specialities. For example, in February 2022 the Royal College of Anaesthetists estimated that there was a shortfall of 1,400 anaesthetists across the NHS 372 Royal College of Anaesthetists, ‘Stark figures show impact of shortage of anaesthetists on patients awaiting
surgery in the NHS’, press release, 23 February 2022,
– representing an 8.7% vacancy rate, well above the 5.6% given for ‘medical roles’ in that quarter (ending March). This is concerning for hospital productivity; anaesthetists are vital for carrying out operations and the same report puts the number of missed operations due to lack of anaesthetists at 1 million per year. 373 Royal College of Anaesthetists, The anaesthetic workforce: UK state of the nation report, February 2022,
retrieved 9 May 2022, p. 14,

Nursing vacancies are the highest among staff groups, despite increasing numbers of nurses across the service. After dipping before and during the early stages of the pandemic, vacancy rates rose above 10% in 2021/22, reaching a high of 11.9% in September 2022. Overall, the Health and Social Care Committee estimates that there is currently a shortage 50,000 nurses and midwives in England; its figure for doctors is 12,000. 374 House of Commons Committee of Health and Social Care, Workforce: recruitment, training and retention
in health and social care: Third report of the session 2022-23 (HC 115), The Stationery Office, p. 3,

Persistently high NHS vacancy rates are in part due to record levels of voluntary resignations. These grew to 148,640 in the year ending September 2022, up from 118,781 and 102,654 for the periods ending September 2021 and September 2020 respectively – increases of 25.1% and 44.8% respectively. Of these, the proportion of leavers citing ‘work-life balance’ as the reason for leaving has increased to its highest ever level, at close to a fifth (18.9%) of total voluntary resignations. It is also likely that as staff work under more stressful conditions this winter, we will see an increase in voluntary resignations for this reason. 

Elsewhere, the number of people resigning because they have been offered a better reward package (captured in the ’working conditions‘ category of our chart) saw the largest increase with 76.3% more people leaving in the 12 months to September 2022 than in the year before – though this still only accounted for roughly one quarter of the number of people who resigned for work-life balance reasons.

Worsening retention reflects the pressure that many staff experienced during and after the pandemic. The proportion of available FTE days lost to mental health reasons rose 22.3% in the first six months of 2022/23, compared to the same time in 2019/20 – 1.31% in the former compared to 1.07% in the latter. One interviewee described the mental health crisis in hospitals as a “vicious cycle”, wherein staff resign due to stress and burnout, which in turn applies more pressure to remaining staff. 381 Institute for Government interview. The NHS also continues to experience a high number of staff absences due to cold, cough, flu, chest and respiratory problems, and infectious diseases, showing the ongoing effect of Covid on the hospital workforce. This is likely to have worsened during the winter, as the flu season has been particularly bad. 382 Allegretti A, Booth R and Campbell D, ‘Flu season in England is worst for a decade, says health secretary’,
The Guardian, 9 January 2023,

The NHS is filling staffing gaps with agency staff and overseas recruitment, but both solutions come with problems. Agency staff are likely to be more inefficient as they work in unfamiliar teams, areas and roles, 383 Rocks S, ‘Why is the NHS really under ‘record pressure’?’, The Health Foundation, 12 March 2022, and also cost more per shift than regular staff. 384 Palmer B, Leone C and Appleby J, ‘Return on investment of overseas nurse recruitment: lessons for the NHS’,
Nuffield Trust, October 2021, p. 3,
The NHS is trying to reduce the amount spent on agency staff. 385 Anderson H, ‘NHSE tries to put £2.3bn cap on agency staff’, HSJ, 20 July 2022, Reliance on agency staff also risks cannibalising the workforce of other hospitals, shifting staffing problems to another part of the NHS. 386 Palmer B, Leone C and Appleby J, ‘Return on investment of overseas nurse recruitment: lessons for the NHS’,
Nuffield Trust, October 2021,

Since April 2021, more British nurses have left the NHS than have joined. In their place, the NHS hired more nurses than ever from outside the UK and the EU/EEA. Recruitment costs of foreign nurses are generally lower than those trained in the UK, 401 Palmer B, Leone C and Appleby J, ‘Return on investment of overseas nurse recruitment: lessons for the NHS’,
Nuffield Trust, October 2021,
but the government has no control over the number of nurses trained abroad and is likely to face greater competition for those nurses in the future as more OECD countries’ nursing workforces are increasingly staffed by foreign nurses. 402 Palmer B, Leone C and Appleby J, ‘Return on investment of overseas nurse recruitment: lessons for the NHS’,
Nuffield Trust, October 2021,

Uncompetitive pay in the NHS is also worsening retention. This has been exacerbated by two key factors. First, the UK’s tighter post-pandemic labour market has caused employers in competing sectors – such as retail and hospitality – to offer better pay deals, including welcome bonuses and higher hourly wages in an attempt to attract in-demand employees. 403 UNISON, ‘NHS facing stiff competition for staff from high street firms, says UNISON’, press release, 28 March
Second, high and rising inflation is eroding the real value of employees’ pay. 

In July 2022, the government accepted the NHS Pay Review Body’s recommendation for a pay uplift in full, 404 Department of Health and Social Care, ‘NHS staff to receive pay rise’, press release, 19 July 2022,
which will increase the NHS’ wage bill “by almost 5% in 2022/23”, with the highest uplifts going to the bottom of the wage distribution. 405 The Health Foundation, ‘Unfunded NHS staff pay increase could leave big hole in severely stretched NHS
budget’, press release, 19 July 2022,
The pay increase, however, is unfunded by central government, meaning that the money will have to come out of the existing NHS settlement. The DHSC claims that this could cost the NHS an extra £900m for every additional 1% pay increase. 406 Department of Health and Social Care, ‘The Department of Health and Social Care’s written evidence to the
NHS Pay Review Body (NHSPRB) for the 2022 to 2023 pay round’, GOV.UK, 28 February 2022, p. 19,…

Many NHS staff do not think this uplift is sufficient given the rising cost of living that has driven real salaries down, with nurses’ and consultants’ salaries both forecast to fall by more than 10% in real terms compared to 2010/11 by the end of 2022/23. 407 Dayan M and Palmer B, ‘What has happened to NHS staff pay since 2010?’, Nuffield Trust, 16 November 2022,
This was one factor that led to a number of staff groups voting to go on strike, most notably ambulance workers, 408 Sky News, ‘Ambulance workers stage mass strike – with public urged to use ‘common sense’ with activities’,
21 December 2022,
 junior doctors, 409 Williams H, ‘Junior doctors in England back strike action’, Independent, 20 January 2023, and nurses – the first time the Royal College of Nursing (RCN) has voted to go on strike. 410 Gregory A and Grierson J, ‘Nurses across UK to strike for first time on 15 and 20 December’, The Guardian,
25 November 2022,
At the time of writing, there has been no resolution to this dispute - though nurses have paused strikes for pay talks - and ongoing industrial action will make it harder for hospitals to clear backlogs and meet ongoing demand for urgent and emergency care.

* We use NHSE vacancy data for our analysis. This shows the difference between ’funded establishment posts’ and those filled by substantive staff. This does not show which posts are filled by temporary workforce. While we believe this is the best measure of vacancies in the service, it should be noted that there could be differences in how those reporting the data understand the requirements.

The NHS is undermanaged 

Despite hiring 30.3% more doctors and 31.6% more nurses between September 2009 and October 2022, the number of managers employed by the NHS has not kept pace. In the same time, the NHS hired only 6.8% more senior managers and now employs 6.7% fewer managers than at the beginning of the time period. 411 NHS Digital, ‘NHS Workforce statistics, staff group, care setting and level, August 2022’, 24 November 2022,
retrieved 23 December 2022,
The sharpest decline in the number of NHS managers occurred in 2013, in the wake of the coalition government’s Lansley reforms, which aimed to direct more funding towards “front-line care”, in part by cutting management costs. 412 Black S, ‘The politicians running the NHS hate management and would rather do without it. They’re wrong’,
blog, LinkedIn, 11 February 2019, retrieved 23 December 2022,
This seems to be an attitude that the current government maintains, with the health secretary declaring in September 2022 that “too much management can be a distraction to the front line”. 413 Donnelly L, ‘‘Too much management’ burdens the NHS front line, warns Steve Barclay’, The Telegraph,
1 September 2022,

The dismissive attitude to management in the NHS extends downwards into the service itself; the Messenger review found that “management lacks the status enjoyed by the established professions in health and social care” and also that managers do not receive the training and support needed to maximise their efficacy. 414 Department of Health and Social Care, ‘Leadership for a collaborative and inclusive future’, 8 June 2022,…

It could, however, be argued that the decline in the number of managers since 2009 was because the service was overmanaged before then. But when comparing NHS management to a range of benchmarks, it is clear that the service is remarkably understaffed with managers. Approximately 2% of the NHS workforce are managers, 428 Kirkpatrick I and Malby B, ‘Is the NHS overmanaged?’, NHS Confederation, 24 January 2022, retrieved
23 December 2022,
compared to 10.8% in the UK workforce. 429 Office for National Statistics, ‘EMP04: Employment by occupation – April to June 2018’, 11 September
2018, retrieved 23 December 2022,
The level of management in the NHS is also not typical of other health services: the average proportion of health care spending in OECD countries dedicated to administration was 3.1% in 2014, compared to 1.5% in the UK. 430 Dayan M, Ward D, Gardner T and Kelly E, How good is the NHS?, June 2018, The Health Foundation, p. 16,

Managers help to improve the NHS’s productivity in several ways. First, they play a co-ordination role, directing front-line staff and resources to where they are most needed. 431 Kirkpatrick I and Malby B, ‘What do NHS managers contribute?’, NHS Confederation, 11 February 2022,
retrieved 23 December 2022,
Second, they often take on administrative work, relieving front-line staff of those tasks, thereby allowing them to spend more time with patients. 432 Kirkpatrick I and Malby B, ‘What do NHS managers contribute?’, NHS Confederation, 11 February 2022,
retrieved 23 December 2022,
Third, they are able to take a system-wide view – be that across a single hospital, an integrated care system or the entire service – to identify inefficiencies and implement productivity-enhancing reform. 433 Kirkpatrick I and Malby B, ‘What do NHS managers contribute?’, NHS Confederation, 11 February 2022,
retrieved 23 December 2022,

These are not abstract benefits but rather directly contribute to improved outcomes in the NHS. Research shows that up to a certain point – when approximately 3% of hospital staff are managers, whereas current levels sit at around 1.8% 434 Veronesi G, Kirkpatrick I and Altanlar A, ‘Are public managers a bureaucratic burden? The case of English public
hospitals’, Journal of Public Administration and Theory, 2019, vol. 29, no. 2, pp. 193–209, p. 27,
– more managers resulted in higher patient satisfaction scores, improved efficiency and a reduction in infection rates. 435 Kirkpatrick I and Malby B, ‘What do NHS managers contribute?’, NHS Confederation, 11 February 2022,
retrieved 23 December 2022,

At a time when hospitals beds are scarce, more staff than ever are absent and vacancy rates are soaring, the role of managers has arguably never been more important. As an example of this, managers in Maidstone and Tunbridge Wells Trust created a ’Care co-ordination centre‘, which was better able to track available beds than clinical staff in the hospital. The result was a halving of bed turnaround times as the hospital admitted patients more quickly. 436 Downey A, ‘Maidstone and Tunbridge Wells go digital for bed management – and halve turnaround times’,
Digital Health News, 23 August 2021, retrieved 23 December 2022,
The NHS has also opened more than 40 ’traffic control centres‘ across England, designed to allow better monitoring of activity and planning of resource use. 437 NHS England, ‘NHS delivers on winter plan as system control centres go live’, press release, 1 December 2022,

The NHS has underinvested in capital 

The amount that the NHS spends on capital investment has long been below that of other OECD countries. Since 2000, the NHS exceeded the OECD average for amount spent on capital formation in only three years, from 2007–2009. 438 Charlesworth A, Failing to capitalise: Capital spending in the NHS, The Health Foundation, March 2019, p. 6,
Capital spending declined further in the years after 2010/11, with the average amount spent in the years until 2019/20 being 4.7% below the 2010/11 total. This was due to a combination of lower capital budgets, underspends on that budget (which amounted to £2.8bn, or 5.1% of budgeted capital spending), and transfers from the capital budget to day-to-day spending to cover gaps in that area of spending (which totalled £4.3bn, or 7.8% of budgeted capital spending). 

The capital budget is spent on a range of assets such as the NHS estate, diagnostic equipment, IT infrastructure, and research and development. 439 Charlesworth A, Failing to capitalise: Capital spending in the NHS, The Health Foundation, March 2019, p. 6,
The effects of underinvesting in these important areas can be seen in a range of indicators: the UK has the fifth lowest number of CT and PET scanners and MRI units per capita compared to the 37 OECD countries – 16.5 per million people, compared to the OECD average of 44.8. 440 Wickens C, Why do diagnostics matter?, The King’s Fund, October 2022, p. 24, As another indication of underinvestment in capital, the estates maintenance backlog is now at its highest ever level – £10.2bn, an increase of 81.2% since 2015/16 and 5.5% since 2020/21 in real terms.

Though difficult to draw direct causal links, it is likely that underinvesting in capital harms NHS productivity. For example, fewer diagnostic machines limits the service’s ability to carry out diagnostic tests – one of the key bottlenecks to reducing the elective waiting list 451 Mallorie S, ‘Waiting on the waiting list, but what for?’, blog, The King’s Fund, 28 November 2022, retrieved
25 January 2023,
and increasing the number of early cancer diagnoses. 452 NHS England, Delivery plan for tackling the COVID-19 backlog of elective care, February 2022, p.4, A poorly maintained estate means that staff may not be able to use faulty diagnostic equipment or a section of the hospital where the roof is at risk of collapse. 453 Campbell D, ‘Dangerous NHS England hospital roofs ‘will not be fixed until 2035’’, The Guardian, 28 September
Problems like these could be part of the reason why NHS activity has not yet returned to pre-pandemic levels. 

In its 2019 manifesto, the Conservative Party committed to building 40 new hospitals by 2030, 454 The Conservative and Unionist Party, The Conservative and Unionist Party Manifesto 2019, 24 November 2019,
retrieved 23 January 2023, p. 2,
thus providing hope that there would be a reversal in the trend of low capital spending. This commitment became the New Hospitals Programme, which came with a promise of £3.7bn of funding. 455 Kulakiewicz A and Powell T, Hospital building programme, House of Commons Library, 1 November 2021,
Since the launch of that programme, however, there has been little progress made against the target. The two hospitals that the government claims have been completed under the programme – the Northern Centre for Cancer Care 456 NHS England, ‘NHS England board meeting: New hospital programme update’, 6 October 2022, p. 5, and the Royal Liverpool Hospital 457 NHS Liverpool University Hospitals, ‘First patients welcomed at new Royal Liverpool University Hospital’,
4 October 2022,
– were both started before its 2019 announcement. 458 Comptroller and Auditor General, Investigation into the rescue of Carillion’s PFI hospital contracts, Session 2019-
20, HC 23, National Audit Office, 2020, p.6,
, 459 Newcastle University, ‘Northern Centre for Cancer Care (NCCC) at The Freeman Hospital’, (no date),
Even among the remaining projects, it seems that there were never 40 projects to begin with, they are not all hospitals, and they are not all new. 460 NHS England, ‘NHS England board meeting: New hospital programme update’, 6 October 2022,

The elective backlog has grown, but is smaller than expected

By December 2022, the elective backlog had grown to 7.2 million incomplete pathways,* its second highest level ever, behind only October 2022. People are also waiting longer for procedures. The proportion of the waiting list seen within 18 weeks of referral from a GP fell to 57.6%, its lowest level outside of the first months of the pandemic and far below the NHS’s target of 92%. 479 Department of Health, Referral to treatment consultant-led waiting times: rules suite, October 2015,
There are more people waiting longer, with 406,035 pathways waiting longer than 52 weeks at the end of December – a substantial increase from the 1,845 waiting that long in February 2020. But while Covid worsened wait times for elective procedures, it is not the root cause for them increasing. The last time that the NHS met the 18-week target was in February 2016. This is due to a combination of rising demand for services and underinvestment in the beds and staff that would have been needed to meet that demand. 480 Comptroller and Auditor General, NHS backlogs and waiting times in England, Session 2021–22, HC 859,
National Audit Office, 2021, p. 30,

Despite the record size of the waiting list, there is evidence that more people than are currently on waiting lists should have come forward for care. In December 2021, the Institute for Fiscal Studies (IFS) estimated that 7.6 million fewer people than expected joined a waiting list for hospital care during the pandemic. 481 Stoye G, Zaranko B and Warner M, ‘Could NHS waiting lists really reach 13 million?’, Institute for Fiscal Studies,
8 August 2021,

There are several possible explanations for this. First is a change in patient behaviour. 482 House of Commons Committee of Health and Social Care, Clearing the backlog caused by the pandemic: Ninth
report of the session 2021-22, (HC 599), The Stationery Office, p. 10,
While the NHS might have wanted to encourage people to come forward for care after the initial Covid wave, 483 NHS England, ‘Help us help you: NHS urges public to get care when they need it’, press release, 25 April 2020,
government messaging – for example, ‘Stay at home. Protect the NHS. Save lives’ – portrayed the NHS as under immense pressure. 484 Department of Health and Social Care, ‘New TV advert urges public to stay at home to protect the NHS’, press
release, 10 January 2021,
This might have led to fewer people coming forward for care. This messaging has since stopped, but the public still see stories in the media about the pressure the service is under, which might discourage them from coming forward.

Second, and most importantly, there are now higher barriers to care at each stage of the referral process than before the pandemic. Our ‘General practice’ chapter outlines the unprecedented demand for primary care services, which means that it is now more difficult to book a GP appointment than it was before the pandemic. The rate at which GPs refer patients through to secondary care has also dropped, in line with guidance from NHS England. 485 NHS England, ‘Advice and guidance’, (no date), retrieved 10 August 2022, Interviewees told us that, once referred, hospitals are now more likely to reject referrals they do not believe need treatment. 486 BMA, ‘NHS backlog data analysis’, (no date), retrieved 10 August 2022, , 487 Institute for Government interviews.  

The results of limiting access to the elective waiting list are mixed. On one hand, keeping people who do not need care away from an already overstretched system helps hospitals, freeing up capacity to meet emergency and Covid demand. The conditions that would have previously led to admission on to the waiting list, however, do not go away. Instead, patients seek care elsewhere, mainly in primary or social care. 488 BMA, ‘NHS backlog data analysis’, (no date), retrieved 10 August 2022, So while this protects hospitals it places a greater burden on services struggling with demand pressures and creates a ‘hidden backlog’ of care, while keeping the elective waiting list artificially low. This is despite a supposed increased focus on improving health outcomes through early intervention and prevention. 489 NHS England, NHS Long Term Plan, 7 January 2019, p. 33, There is also the risk that the longer would-be patients stay away the worse their condition becomes – meaning that when they do present, treatment is more complex and expensive.

* A pathway is a course of treatment that starts from the time a patient is referred and stops when it is either deemed that they do not need treatment, when they receive treatment, or if they do not respond to attempts to contact them. We refer to the size of the elective waiting list in terms of ‘pathways’ rather than ‘people’ because one person could simultaneously be on the waiting list for multiple pathways.

The NHS came close to meeting the first of its backlog recovery targets 

NHS England launched its Covid backlog recovery plan in February 2022. 490 NHS England, Delivery plan for tackling the COVID-19 backlog of elective care, February 2022, This plan includes measures such as the separation of elective from urgent activity to prevent surges in demand reducing elective activity, investing in community diagnostic centres and surgical hubs, increasing bed capacity, moving patients between trusts, and use of the independent sector, among others. 

The elective backlog recovery plan also lays out the NHS’s timetable for reducing the waiting list: 

•    Eliminate waits of more than two years by July 2022 
•    Eliminate waits of more than 18 months by April 2023 
•    Eliminate waits of more than one year by March 2025. 

According to NHS England, it nearly met the first – and most achievable – of these targets. By the end of July, 2,885 people who had been on the elective waiting list for more than two years were still awaiting treatment, down from 23,778 in January of the same year. 491 NHS England, ‘Consultant-led referral to treatment waiting times data 2022-23’, (no date), There are, however, some caveats that NHS England make to this outcome: of those 2,885 remaining on the waiting list, 1,579 opted to defer treatment and 1,030 were “very complex cases”. 492 NHS England, ‘NHS marks milestone in recovery plan as longest waits virtually eliminated’, press release,
9 August 2022,

The other targets will prove even harder to meet. There are far more people waiting 18 months or a year – and the NHS will not know who is in the latter group until April 2024. 493 NHS England, ‘Consultant-led referral to treatment waiting times data 2022-23’, (no date), This means it does not yet know the types of procedures that will be needed to meet the target, making it harder to plan resource use. 

In an attempt to meet the second of these targets, NHS England ordered all trusts to book those waiting more than 18 months at the beginning of January 2023. 494 Illman J, ‘Trusts given 20 days to book in all 78-week waiters’, HSJ, 12 January 2023, While understandable, this does show the risk of using these targets as performance metrics; the NHS is incentivised to prioritise patients on the basis of time spent on the waiting list as opposed to clinical need. 

It is not clear the planned measures to clear the backlog will work, as they are highly contingent on the extent to which Covid continues to impact the NHS. 495 Institute for Government interview. The NHS estimates that it needs to operate at 130% of pre-pandemic activity levels by 2024/25 to clear the elective backlog, 496 Gardner T and Fraser C, ‘Elective care: how has COVID-19 affected the waiting list?’, The Health Foundation, 27
September 2021,
but in 2022 it was not yet running at 100% of 2019 activity, with completed pathways (admitted and non-admitted) at only 93.6% of the amount carried out in that year. 

There has been some improvement since then – November 2022 saw the highest level of elective activity since the start of the pandemic, with 1.5 million completed admitted and non-admitted pathways. This is 4.8% higher than the amount carried out in November 2019, and the fourth highest level since records began. The results for December, however, show that the winter crisis in urgent and emergency care and ongoing industrial action will make it hard for the service to maintain November’s level of activity; the NHS completed 21.4% fewer elective pathways in December compared to November, a level that was also 4.2% lower than December 2019. 

Performance of emergency and acute services is the worst on record

After a slight improvement in A&E wait times during the pandemic (mostly because fewer people attended emergency departments), only 58% of people attending type 1 A&Es were seen within four hours in January 2023, against a target of 95%. This follows the worst performance on record in December 2022, which saw only 49.6% treated within four hours. The same decline in performance is evident in the ambulance service, where response times reached their highest recorded level in December 2022, before falling back to lower – though still relatively high – levels in January 2023. In December 2022, the mean response time for category 1 ambulance incidents – the most urgent category – rose to 10 minutes 57 seconds, the worst on record, before falling to 8 minutes 30 seconds in January 2023. The decline in performance is even worse for category 2 call-outs, which includes conditions such as strokes, 498 NHS North East Ambulance Service, ‘Understanding ambulance response categories’, (no date), retrieved
25 August 2022,
where the mean response time rose from 22 minutes 33 seconds in July 2018 to 1 hour 32 minutes and 54 seconds in December 2022, before improving to 32 minutes and 6 seconds in January 2023.

Worsening performance in urgent and emergency care cannot be attributed to a post-pandemic surge in demand for this service. There were only 0.2% more attendances at type 1 A&Es in 2022 compared to 2019 – 16.21 million compared to 16.18 million, a decline of 0.5%. This compares to an annual increase of 1.3% between 2011/12 and 2019/20. The difference is even more stark for A&E admissions. There were 4.8 million admissions in 2019, compared to 4.3 million in 2022, a decline of 10.2%.

Rather than increased demand, the major problems with urgent and emergency care relate to capacity elsewhere in hospital. Most importantly, poor patient flow through hospitals has a knock-on effect on the performance of urgent and emergency care. 504 The King’s Fund, ‘What’s going wrong with A&E waiting times?’, 26 May 2022, retrieved 25 August 2022,
When staff eventually see people, they find it difficult to admit patients due to the lack of unoccupied beds in hospitals, as noted above. This has resulted in 2022 having the lowest percentage of A&E attendances resulting in admissions since 2013 – 26.7%, compared to 29.9% in 2018 and 29.8% 2019. This difficulty in admitting patients pushes up the amount of time that people wait in A&Es. 

This also explains much of the delay in ambulance response times; ambulances cannot hand over patients for admission into hospitals because of a lack of available beds. This has resulted in the highest proportion of ambulance arrivals resulting in delayed handovers (more than 30 minutes) on record. 505 Nuffield Trust, ‘Ambulance handover delays’, 4 May 2022, retrieved 12 July 2022, This in turn prevents ambulances from responding to new calls, thereby increasing response times. 

All of this is compounded by the staffing issues, both related and unrelated to Covid, that A&E departments are still experiencing. 506 The King’s Fund, ‘What’s going wrong with A&E waiting times?’, 26 May 2022, retrieved 25 August 2022,

Declining performance in emergency care is extremely serious. Beyond the worsening experience for attendees, there is evidence that those who wait more than five hours are more likely to die within 30 days of attending A&E. 507 Jones S, Moulton C, Swift S and others, ‘Association between delays to patient admission from the emergency
department and all-cause 30-day mortality’, Emergency Medicine Journal, 2022, 39, pp. 168–173,

The NHS has recognised these issues and used the 2023/24 operational and planning guidance to outline targets for the coming year. The NHS is now aiming for improved performance such that 76% of A&E patients are seen within four hours by March 2024, that category 2 ambulance response times average 30 minutes across 2023/24, and that G&A bed occupancy is reduced to 92%. 508 NHS England, 2023/24 priorities and operational planning guidance, 23 December 2022, p. 7,  

While it is good that the NHS is targeting these improvements, it is striking how poor performance would still be if the NHS achieves these objectives. Improving the number of people waiting less than four hours to 78% would only return performance to 2019 levels, themselves some of the worst on record. The same is true for category 2 ambulance response times: a mean response time of 30 minutes would be two thirds longer than the current target of 18 minutes and would be higher than any month on record before March 2020. These targets in many ways show the long road that lies ahead for improvement in hospital performance.

More people are waiting longer for cancer treatment

The proportion of patients on a cancer referral pathway starting treatment within the targeted 62 days declined again in 2022 – from 70.9% in 2021 to 62.1%. As with other aspects of hospital performance, increasing cancer wait times predate the pandemic: the last month that the NHS exceeded the 85% target was December 2015.

Despite worsening wait times for treatment following a cancer referral, the NHS has run a successful campaign to encourage people to come forward for cancer care. 511 NHS England, ‘NHS chief urges people to come forward for life saving cancer checks ahead of new campaign’,
press release, 14 August 2021,
After a drop in the number of cancer referrals in 2020/21 – down to 2.1 million from 2.4 million in 2019/20 – GPs made 2.8 million urgent referrals in 2022. 512 NHS England, ‘Cancer waiting times’, (no date), retrieved 1 September 2022, This compares to an average of 2.7 million urgent referrals per year in 2021 and 2022, and is 13.5% higher than in 2019, implying that a good number of the people who did not come forward for care in the early months of the pandemic did so at a later date, and potentially due to the NHS’s awareness campaign. Despite this excellent recovery, the proportion of patients seen by a consultant within the targeted two weeks from an urgent referral fell in 2022 to 78.2%, down from 84.4% in 2021 and 91% in 2019. It is also substantially below the NHS’s operational target of 93%.

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