The road to recovery for elective care in the NHS: an uphill battle? - Thoughts from the Centre | Deloitte UK

By Emma Gould, Manager, and Scott Grainger, Manager, Deloitte Risk Advisory


When the first wave of COVID-19 hit the UK, the NHS had to prepare for worst-case scenarios. Plans for temporary hospitals and surge critical care capacity were rapidly drawn up, non-urgent services were significantly scaled down, and large numbers of staff were redeployed to ensure the NHS would be able to care for the impending rush of severely ill patients. More than a year on, and in the midst of another surge in positive cases, the true scale of the pandemic’s impact on wider health provision is starting to emerge as hospitals face an uphill battle to restore and recover elective services alongside increasing COVID-19 admissions.

The latest NHS performance data shows that the waiting list for consultant-led elective care stood at over 5.3 million patients by the end of May 2021, the highest number of patients waiting to begin treatment since records began in 2007. Of these patients, 336,733 have been waiting for more than a year, compared to less than 2,000 before the start of the pandemic.1 With waiting lists already at unprecedented levels, there is also a concern that a reduction in the number of people seeking medical advice during the pandemic could result in additional pressures further down the line. For example, Cancer Research UK estimates that between March 2020 and February 2021, urgent suspected cancer referrals were 15 per cent (total of 430,000) lower than the previous year.2

Whilst the clinical risk for patients already on the waiting list may be understood, patients presenting later with cancer symptoms could result in more complex treatments and poorer outcomes. There are early signs of improvement as urgent referrals for suspected cancers in May 2021 are 3.2 per cent higher than the same month two years ago, but this increase is not significant enough to make up for the overall shortfall.3

To add to the challenge, the NHS workforce is exhausted. Many staff have worked long hours in extremely difficult conditions for many months, particularly during the first wave, delaying annual leave to help tackle the crisis and some living away from their families in fear of passing on the virus. According to the ONS, at least 122,000 health service workers are suffering from long COVID and as a result, some staff have been on extended sickness leave, unable to provide care during subsequent waves.4 However, the physical health of staff is not the only cause for concern. Many of those working in critical care have been showing signs of anxiety and post-traumatic stress disorder (PTSD). Eighty per cent of nurses responding to the Nursing Standard survey in November 2020 reported that their mental health had been affected during the pandemic.5 It is therefore imperative that restoration plans continue to support the health and wellbeing of staff.

Support from NHS England

To support elective recovery, £1 billion of additional funding has been made available to Integrated Care Systems (ICSs), with allocations based on target activity (Table 1). ICSs must achieve 95 per cent of 2019-20 activity levels in July 2021 to access the funding, 10 per cent higher than was outlined in the original planning guidance in March.6

Table 1 – Performance targets for elective activity Picture1Source: NHS 2021/22 priorities and operational planning guidance

In order to access the funding, ICSs must also demonstrate how the following objectives are incorporated into their recovery plans:

  • Addressing health inequalities, including prioritising service delivery towards the bottom 20 per cent of the population by Index of Multiple Deprivation and black, Asian and minority ethnic populations.
  • Transforming outpatient services, including steps to avoid unnecessary outpatient attendances, deliver at least 25 per cent of consultations remotely, implement Patient Initiated Follow Ups, and improve collaboration with primary care to reduce referrals.
  • System-led recovery, including system level management of Patient Tracking Lists, risk stratification to support prioritisation by clinical urgency and waiting times, and maximising NHS and independent sector capacity available.
  • Clinical validation, waiting list data quality and reducing long waits, including robust, system level processes and governance for shared decision-making and treatment reviews.
  • People recovery, including a comprehensive set of staff experience measures to support monitoring and safeguarding of staff health and wellbeing. Workforce planning should aim to capitalise on the increase in applications to nursing courses in England, up by 34 per cent in February 2021 compared to the same time last year.8

Where to start?

How will NHS organisations be able to restore productivity, reduce the backlog and treat long waiters whilst adhering to ongoing infection prevention measures and dealing with ongoing workforce challenges? We have identified four crucial steps:

4 steps

Given the scale of the problem, traditional approaches to optimising efficiency within providers alone are unlikely to be enough. Some examples which have already been shown to be effective in parts of the country are:

  • designation of COVID-free hospitals and “green pathways” to support the delivery of uninterrupted services and to allow a return to higher levels productivity
  • ICS-wide collaborative approaches to referral management, demand and capacity planning, pathway redesign and supporting smooth discharges
  • development of “focus factories” whereby priority conditions with long waiting lists are delivered on a single hospital site, pooling resources across the system to maximise the number of patients treated
  • creation of diagnostic imaging networks and community diagnostic hubs to ringfence capacity and reduce waiting times for scans
  • review and enhance the use of digital tools implemented during the pandemic.


Collaborations across health systems have been accelerated during the pandemic as NHS organisations established partnerships to provide patients with the care they need in a more efficient and effective way. Embracing and building upon this momentum of collaboration and a continued focus on developing and sharing innovative ways of working will be key to recovering waiting times as quickly as possible and minimising the risk of further harm to patients. While the road ahead may be bumpy and at times feel like an uphill battle, by following the above steps and embracing innovative solutions, it’s a battle the NHS can win.

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Emma Gould - Manager, Deloitte Risk Advisory

Emma is a Manager in Deloitte’s Risk Advisory (Health) team. For the last 6 years, she has worked with a range of NHS Trusts to deliver transformation and operational improvement programmes, with a particular focus on increasing productivity and redesigning patient pathways across outpatients and theatres. More recently, she has been working with the leadership teams of Integrated Care Systems to develop the culture, behaviours and governance required for successful partnership working.

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Scott Grainger

Scott Grainger - Manager, Deloitte Risk Advisory

Scott is a Manager in Deloitte’s Health Analytics Practice. He has a range of experience in supporting healthcare organisations analyse their data and design their strategies to become insight driven organisations. Scott has used data science techniques across a range of challenges such as: supporting national programmes looking at outpatient optimisation; and supporting healthcare organisations in assessing the impact of new patient pathways, including changes in expected patient outcomes, operational impacts, and financial implications.

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1 Referral to Treatment (RTT) Waiting Times, England – April 2007 – May 2021, NHS England and NHS Improvement,
2 Evidence of the impact of COVID-19 across the cancer pathway: Key Stats, Cancer Intelligence Team (Cancer Research UK), last updated 15/04/2021,
3 Cancer Waiting Times, Monthly Provider Based Data and Summaries, NHS England and NHS Improvement,
4 Prevalence of ongoing symptoms following coronavirus (COVID-19) infection in the UK: 1 April 2021,
5 How COVID-19 is affecting nurses’ mental health, and what to do about it, Royal College of Nurses,
6 NHS 2021/22 priorities and operational planning guidance,
7 Four key points on the elective recovery fund,
8 Press Release: Nursing applications in England up by over a third to 48,830,


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