Nowcasting waiting lists for elective procedures and surgery in England: a modelling study

Lancet. 2023 Nov:402 Suppl 1:S74. doi: 10.1016/S0140-6736(23)02073-1.


Background: The COVID-19 pandemic resulted in extensive disruption to the delivery of elective health services. Official figures of NHS waiting lists in England do not account for patients on the hidden waiting list (ie, patients who have symptoms or disease requiring elective procedures who have not been placed on the waiting list due to pandemic-related disruption). The aim of this study was to model the elective procedure backlog in England, including the hidden waiting list.

Methods: We used publicly available activity data from NHS Digital to estimate procedure-level backlogs in England for the pandemic period (from Jan 1, 2020, to Dec 31, 2022) compared with expected population need for elective procedures based on pre-pandemic trends, adjusting for population growth and ageing, as well as patient deaths while on the waiting list. The primary outcome was the elective procedure backlog. Elective procedures were defined as including surgery, endoscopy, interventional radiology, and interventional cardiology. The secondary outcome was the procedural hidden waiting list. The elective procedure backlog was reported by specialty and procedure.

Findings: The total elective procedure backlog in England on Dec 31, 2022, was modelled to be 4 519 467 procedures. The hidden waiting list was 3 621 423, comprising 80·3% of the total backlog. Half the total backlog (2 228 348, 49·3%) was in people aged 16-59 years. The largest backlogs were in general surgery (1 463 423, 32·4%), orthopaedics (1 001 850, 22·2%), and urology (510 649, 11·3%). Overall, 84·7% (3 827 687 procedures) of the backlog were for day-case procedures. The procedures with the greatest total backlog were sigmoidoscopy and colonoscopy (546 930, 12·1%), gastroscopy (376 089, 8·3%), cataract surgery (238 912, 5·3%), and lower limb joint replacement (209 976, 4·6%).

Interpretation: NHS waiting lists are an unreliable guide to the true population need for elective procedures. Initiatives are needed to identify and prioritise patients requiring urgent treatment. Most need is for low-complexity high-volume day-case surgery. Sustained, ring-fenced funding is required to invest in scaling up the operative workforce and facilities, and to increase the resilience of surgical services to avoid existing backlogs being compounded by future external pressures. This modelling study is based on an assumption that over the course of the pandemic the incidence of surgical disease did not change.

Funding: None.

MeSH terms

  • COVID-19* / epidemiology
  • Cataract Extraction*
  • Elective Surgical Procedures
  • England / epidemiology
  • Humans
  • Pandemics
  • Waiting Lists