Hospital of the future: what’s the Government’s plan for secondary care?
Research Manager and Head of Health
There is no public service that operates like a hospital. Schools and prisons are not straightforward organisations, but they have a clear core pathway. They exist to teach children and to house criminals, respectively, and that main purpose defines most of their operating model.
Hospitals co-locate numerous specialist functions, and need to be a symphony of efficiency and prioritisation to juggle very different kinds of cases with limited resources. Crises of corridor care and unacceptably long waits for cancer treatment consistently demonstrate that this system has broken down, at great cost both to patients and the taxpayer.
It’s now been 10 months since the Government came into power, so what are they doing about the most expensive part of their most expensive public service?
In short, the Government are throwing the kitchen sink at fixing elective care, and this will naturally come at the expense of progress on other areas of healthcare reform. Many will have questioned the decision to tie themselves to the mast of elective care backlogs, the most expensive, resource intensive target they could have chosen. But to govern is to choose, and Labour have chosen a popular goal which will be salient with the public.
But given emergency care performance will be deprioritised as a result, the question is whether it actively gets worse over the next four years or simply stays very bad. In January 2025, 159,582 waited longer than four hours in A&E. In January 2024, this number was 158,735. While 61,529 people waited more than 12 hours, higher than the 54,312 in January 2024. And in 2016 this number was as low as 957.
Wes Streeting has openly acknowledged that it cannot meet every target all at once within one Parliament, and it would be impressive to see a dramatic improvement in just 10 months. But longer term, Downing Street said in December it could not guarantee the A&E target – for 95 per cent of patients to be seen in four hours – would be met within this Parliament. Rather, they plan to increase four-hour A&E performance to 78 per cent. Even so, it’s not clear what money is budgeted for improving emergency care performance, and the upcoming recovery plan was even labelled as “lacking ambition” by NHS England.
It is good that leaders are recognising the trade-off that a focus on electives will have for worse A&E performance. Leaks of the recovery plan do show it repeats well-trodden ground on hospital reform, including triage, tackling unwarranted variation and “delivering care closer to home”. Anyone that has worked in health policy for more than ten minutes will know the latter is a constant yet elusive ambition in healthcare, and unlikely to lead to any substantive change in A&E performance without significant investment outside of hospitals.
In summary: there has been little progress on emergency care, it does not look like there will be any time soon, and if there was, the proposed policy solutions would be more of the same.
In that case, given the Government are targeting elective care, can we expect to see improvements there? Progress here has been slightly more positive, with the total waiting list for consultant-led elective care slowly creeping down. But it has received significantly more investment and attention in recent years. Elective care has received £3.2 billion in capital investment since 2022, and £1.5 billion in capital investment in the 2024 Autumn Budget. This has mostly been spent on building surgical hubs and new diagnostic equipment.
But the return on that investment is not yet clear. Elective care is multifaceted – there are targets within targets and these various targets oscillate between met and unmet. The main target to keep in mind are that the Government want 92 per cent of patients to be seen within 18 weeks of referral by July 2029, and 65 per cent by March 2026. Currently performance is 59 per cent.
To succeed, the rate at which patients are removed from the waiting list needs to significantly exceed the number of new referrals on to it. NHS England thus aimed to deliver 129% of 2019-20 levels of activity by 2024-25, and they are currently at 116%. This means fewer people are leaving the waiting list than anticipated, leading to validation drives (when those on the waiting list are re-confirmed or eliminated depending on whether they still need treatment.)
There is one clear win – the NHS has eliminated 104 week and 78 week waits for treatment. But pretty much every target NHS England set itself has not been met, as this report from the National Audit Office demonstrates.
Policymakers might point to wins in additional capacity such as more Community Diagnostic Centres and surgical hubs. While these are positive, simply adding more capacity does not automatically generate improved outcomes. For example, the latest data on activity level targets above demonstrates they’ve struggled to create the activity boost they desired by focusing largely on increasing equipment.
The other major face – and cash drain – of the Government’s hospital agenda is the New Hospital Programme (inherited from the previous Government), which should be scrapped (you can read why here).
Hospitals will remain the Achilles heel for the Government’s NHS agenda if they cannot get the reform right (with more from us on this soon). There are some signs of progress but much – almost too much – hinges on new policy in the upcoming Ten Year Plan. Let’s hope it delivers.