It wasn’t the sort of coverage Sajid Javid was hoping for. “Is that all we get for £12bn?” thundered the front page of Wednesday’s Daily Mail. The source of its frustration was the health secretary’s admission in the Commons 24 hours earlier that the length of the waiting list for hospital care in England, which now stands at a record 6.1 million people, would continue its relentless rise until March 2024. Javid’s candour came while he was launching NHS England’s “elective recovery plan”, its strategy – endorsed by the government – for addressing and, it is hoped, ultimately reducing that colossal backlog of care. The £12bn a year the forthcoming 1.25% rise in National Insurance will raise via the new health and social care levy will help fund the work involved.
The plan itself is a classically NHS document: 49 pages featuring a blizzard of statistics, examples of hospitals using innovative ways of reducing patients’ waiting times for care and a raft of detailed proposals aimed at “increasing health service capacity ... prioritising diagnosis and treatment ... [and] transforming the way we provide elective care”. However, the bits of most relevance – politically for ministers and practically for patients – are the targets setting out when indecently, sometimes dangerously long, and historically unprecedented, delays for treatment – for new hips and knees, cancer care, heart operations and much else besides – will finally end. Under the NHS constitution patients have a “right” – now often merely theoretical – to receive such care within 18 weeks.
The key targets – which are really just aspirations – include ensuring that by July no one has been waiting more than two years, 18-month waits are eradicated by March next year and one-year waits – 306,996 patients have recently faced a delay of that magnitude – banished by March 2025, and that the waiting list starts shrinking by March 2024, two months before the next election.
Javid gamely talked up the plan as embodying “a new national mission” to bust the backlog and offering “a bold and radical vision” for improving healthcare. He promised that hundreds of new “community diagnostic hubs” and “surgical hubs” would ensure speedier access to tests and treatment. All that may or may not prove to be the case over the next few years. Patients need it to happen.
But in the short- and medium-term the backlog is fraught with political danger, not just for Javid, but also for Boris Johnson, whose election win in 2019 was in part due to his eye-catching and oft-repeated NHS pledges. Commitments to hire 50,000 more nurses, build 40 new hospitals and recruit 6,000 extra GPs, which helped to neutralise the NHS as a negative for the Conservatives, played their part in the landslide.
A key determinant in the success of the plan is the known unknown of how many of the estimated 10 million people who avoided seeking NHS help during the Covid pandemic will belatedly do so. It could be 30% or it could be 80%, Javid told MPs. “Even if half these people come forward, this is going to place huge demand on the NHS” – that is, huge extra demand on a service that by its own performance metrics is increasingly unable to cope with the unceasing need for care it is already facing. That is why he made clear that delivering the plan’s key dates was an “ambition”, not a pledge. That realism was an implicit admission that he is not in control of events; that he cannot guarantee any fall in the headline number of people forced to wait by any set date.
There are serious doubts that the ambitions will be fulfilled. Privately, NHS bosses, health experts and doctors concur with what Max Warner of the Institute for Fiscal Studies said on Friday: that “there is almost no chance that the NHS will clear the Covid backlog and get the number of people on the waiting list back to pre-pandemic levels before the end of this parliament”. The NHS’s lack of staff, beds and equipment relative to EU and OECD countries, noted in a recent National Audit Office report on waiting times, will inhibit the plan’s ambitions being fulfilled.
The backlog “is one of the big challenges for the government. The scale of it is enormous,” said a source in Javid’s department. Ensuring that the waiting list is reducing by spring 2024 will be “really tough”. Projections prepared for ministers show that the backlog could reach 9.2 million by March 2024 under a best-case scenario and 10.7 million in the worst case. A tenth of England’s population is already on the list. Under the latter projection that would rise to one-sixth.
That could mean that every sixth voter Tory campaigners canvass in 2024 will be waiting for a procedure of some sort in hospital. While some may be sanguine about waiting, others will be frustrated, or even angry. Who will they blame: Covid, the government or the NHS itself? One Tory MP, an ex-health minister, observes that: “MPs are getting very little flak from constituents about long waits for surgery. People in general, for now at least, have accepted that Covid has been disruptive to aspects of NHS care.” That suggests Javid’s self-serving attempt to portray the waiting list as “the Covid-19 backlog” may be working. However, the MP adds ominously: “But if long delays are not addressed before the next election I suspect this will pose political risk for Boris Johnson and become a major issue for many MPs in marginal seats who wish to be re-elected.”
Delays will most affect, and most worry, a key Tory demographic – older people. As the Tory MP Edward Leigh said: “People of a certain age, of which unfortunately I am one, are terrified because they think that if something goes wrong, they may have to wait in pain for two years and we can’t wait until March 24 to join the back of a slightly shorter queue.”
The backlog could intensify tensions within the government, especially over the national insurance hike, and also between ministers and an NHS receiving record funding that they believe is guilty of backsliding on its part of the deal. But the greatest risk it poses for Johnson is the gift it hands to opposition parties. As the waiting list continues ever upward, a potentially growing mismatch between the public’s need for prompt care and the NHS’s ability to provide it could prove politically toxic. And the reality of NHS waits is not just undone surgery. It’s also delays in accessing all key types of NHS care – to see a GP, get A&E care, for an ambulance or to receive mental health help.
When Labour left office in May 2010, the waiting list stood at 2.6 million. It then rose slowly until 2015 and has been rising relentlessly ever since. Given it was at 4.4 million when Covid struck in March 2020, the pandemic is responsible for only 1.7 million – or 28% – of the 6.1 million total. Wes Streeting, Javid’s agile Labour shadow, stresses that “this isn’t a Covid backlog; it’s a Tory backlog”. It is a charge that he and Keir Starmer will doubtless hammer home regularly and one which, if supported by patients enduring the pain and fear of long waits, could help decide who wins in 2024.
