The NHS Waiting List in Numbers: How 7.5 Million People Are Waiting for Treatment

The Scale of the Waiting List

The NHS England Referral to Treatment (RTT) waiting list — a measure of the number of incomplete elective treatment pathways — stood at approximately 7.5 million in late 2024. This is the number of pathways, not strictly the number of unique individuals: a patient waiting for a hip replacement and separately for a cataract operation would appear twice. NHS England estimates the number of unique patients is somewhat lower than the headline pathway figure, but the scale remains historically unprecedented.

To understand what 7.5 million means: the entire population of London is approximately 9 million. The NHS elective waiting list is roughly equivalent to waiting for every single resident of Greater London — plus every resident of Birmingham and Manchester combined. It represents approximately one in eight of England's population of 56 million.

The waiting list has fluctuated significantly over the past decade. Before the COVID-19 pandemic, the list stood at around 4.4 million — already the highest it had been for many years, and a figure that represented a sustained failure to meet the 18-week standard. The pandemic then caused it to surge dramatically. Between March 2020 and July 2020, the NHS effectively halted elective activity to protect capacity for COVID-19 patients. An estimated 10 million planned procedures and outpatient appointments were cancelled or postponed during this period, and the backlog they created has proven extremely difficult to clear.

How the Waiting List Grew: From Crisis to Catastrophe

The story of the NHS waiting list is not simply a COVID story. The pressures that allowed the list to reach 7.5 million were present long before the pandemic — COVID accelerated and amplified trends that were already well-established.

Pre-pandemic pressures (2010–2019)

The NHS 18-week Referral to Treatment standard — requiring 92% of patients to start treatment within 18 weeks of referral — was consistently met in the years following its introduction in 2008. However, from 2016 onward, performance began to slip. The list grew from around 3 million to 4.4 million between 2012 and 2019, even before the pandemic. Demand for elective care was rising as the population aged and as improved diagnostic technology identified more treatable conditions. But funding constraints, staff shortages, and bed capacity limits prevented supply from keeping pace.

The NHS workforce was under particular pressure. By 2019, NHS England had approximately 100,000 vacancies across all staff groups, including around 44,000 nursing vacancies. International recruitment was supplementing domestic training, but the long lead time for training doctors and nurses (7 years for a consultant, 3–4 years for a registered nurse) meant that the workforce pipeline could not respond quickly to rising demand.

The COVID-19 shock (2020–2021)

When the pandemic hit in March 2020, NHS England took the decision to stand down elective activity almost entirely to protect intensive care capacity and staff for COVID-19 patients. Approximately 350,000 elective operations were cancelled in April 2020 alone. During the first lockdown, the waiting list continued to grow because new referrals still occurred (general practice continued operating) but treatment almost stopped.

The economic concept that helps explain the waiting list growth during this period is "hidden demand." Patients who would normally have been referred but weren't — because they stayed away from GP surgeries during lockdown, or because GPs were managing COVID demand — represent a latent pool of need that surfaced as restrictions eased. When primary care and referral activity resumed at full capacity in 2021, the referral rate exceeded pre-pandemic levels, accelerating waiting list growth even as treatment activity recovered.

Post-pandemic recovery (2022–present)

NHS England's recovery from the pandemic backlog has been slower than initially planned. The Elective Recovery Plan, published in 2022, set targets to eliminate waits of over two years by July 2022, over 18 months by April 2023, and over a year by March 2025. The over-two-year waiters were largely cleared by mid-2022, and over-18-month waiters were largely cleared by 2023. However, the target for eliminating waits over 52 weeks has proven much harder to achieve, partly because the pool of patients with shorter waits is constantly being replenished by new referrals.

Who Is Waiting — and for What?

The waiting list is not evenly distributed across medical specialties. The longest waits and the largest volumes are concentrated in a small number of areas where demand is high and capacity is most constrained.

Highest-volume specialties

Orthopaedic surgery (joint replacements, spinal surgery) consistently has one of the largest waits, with around 700,000–800,000 patients waiting at any given time. Hip and knee replacements are particularly affected — they are high-volume, elective procedures where the conditions are painful and disabling but not life-threatening, meaning they are frequently deferred when capacity is under pressure.

Ophthalmology (eye conditions including cataracts) is the highest-volume specialty by number of outpatient appointments, with several million appointments per year. Cataract surgery — a routine procedure that restores vision in around 30 minutes — has faced significant backlogs, with waits in some areas exceeding two years. For older patients, waiting two years for a cataract operation can mean the difference between independent living and loss of driving licence, mobility, and quality of life.

Gastroenterology (endoscopy, colonoscopy) has faced severe pressures related to the push to diagnose bowel cancer earlier. Colonoscopies require specialist equipment and trained endoscopists; both were in short supply before the pandemic and COVID accelerated the backlog. Waits for diagnostic endoscopy in some trusts extended beyond 12 months, with clinical consequences for patients where early detection of cancer can be decisive.

Diagnostic waiting times

The waiting list for diagnostic tests — MRI scans, CT scans, endoscopy, echocardiography — is tracked separately from the RTT waiting list but is a critical bottleneck. NHS England's diagnostic waiting times data shows that approximately 1.5 million patients are waiting for a diagnostic test at any given time, with a significant proportion waiting beyond 6 weeks — the standard that applies to diagnostics.

Mental health

The RTT waiting list applies primarily to physical health (elective surgery and outpatient services). Mental health waiting times are tracked separately and present an additional dimension of the crisis. As of 2024, approximately 1.6 million people are waiting for NHS mental health services. Waiting times for Child and Adolescent Mental Health Services (CAMHS) are particularly long in many areas, with children waiting 12–18 months for an autism assessment and similar periods for eating disorder treatment in some trusts.

The 18-Week Standard: A Target Not Met Since 2016

The NHS Referral to Treatment standard requires that 92% of patients on an incomplete pathway should have been waiting 18 weeks or fewer. This standard was last met nationally in February 2016. In the years since, performance has deteriorated progressively, with the pandemic driving a collapse in compliance.

As of late 2024, approximately 58% of patients on the waiting list have been waiting 18 weeks or fewer — substantially below the 92% standard. Around 42% have been waiting longer than 18 weeks, and of those, approximately 300,000 have been waiting over 52 weeks (one year).

The political and clinical significance of the 18-week standard goes beyond a performance metric. For patients, waiting longer than 18 weeks for a hip replacement means months of pain, reduced mobility, and likely deterioration. For patients awaiting cancer surgery or treatment for serious cardiac conditions, delays can have direct consequences for outcomes. NHS England does not apply the 18-week standard to cancer pathways (which have separate, more stringent targets) or to urgent and emergency care — but for the large volume of patients with serious but non-urgent conditions, the wait can be clinically significant.

A&E: A Separate But Related Crisis

The elective waiting list is only one dimension of NHS pressure. Accident and Emergency departments have faced their own sustained crisis, and the two problems are connected: when patients cannot access timely elective or primary care, they often present to A&E as a point of last resort, increasing emergency demand and displacing resources from planned care.

NHS England recorded approximately 25 million A&E attendances in 2023/24, a figure that has grown year on year. The four-hour target — under which 95% of patients should be admitted, transferred, or discharged within four hours of arrival — has not been met since 2015. Performance has fallen to around 70–75% in recent years, with patients in some trusts spending 8, 12, or more hours in A&E awaiting a bed, assessment, or clinician.

Ambulance handover delays — time spent waiting outside A&E for a hospital bay to become available so a patient can be handed over from the ambulance crew — represent a particular systemic failure. In 2022 and 2023, some trusts recorded aggregate ambulance handover delays of hundreds of thousands of hours per year. Each hour an ambulance crew spends waiting to hand over a patient is an hour in which that crew cannot respond to new 999 calls.

Discharge delays

A significant driver of A&E pressure and bed shortages is delayed hospital discharge. Patients who are clinically well enough to leave hospital but cannot do so because social care, home care, or appropriate housing is unavailable occupy acute hospital beds that are needed for emergency and surgical patients. NHS England estimates that at any given time, approximately 10,000–13,000 hospital beds are occupied by patients who are medically fit for discharge but cannot leave. This is equivalent to around 10% of the total acute bed base in England, and it has a cascading effect on waiting times throughout the system.

The Workforce Crisis Behind the Numbers

The waiting list cannot be understood in isolation from the NHS workforce. You cannot treat more patients without more staff — and the NHS has faced significant workforce pressures that have constrained its ability to expand elective capacity, regardless of investment levels.

As of 2023/24, NHS England has approximately 40,000 nursing vacancies and around 10,000 medical vacancies. The nursing vacancy rate of around 9% means that roughly one in eleven nursing posts is unfilled. This has significant operational consequences: wards with unfilled nursing posts cannot safely run at full capacity, theatres cannot operate at full volume, and community services cannot discharge patients promptly.

NHS Improvement data shows that in 2023/24, NHS trusts spent approximately £3 billion on agency and bank staff — temporary workers who command premium rates and who provide no continuity of care. This expenditure represents a significant additional cost above the substantive workforce pay bill, diverting funds that might otherwise be invested in capital, equipment, or service development.

International recruitment

The NHS has significantly expanded international recruitment in recent years to fill workforce gaps. The number of internationally trained nurses joining the NMC register from overseas increased substantially after Brexit, as freedom of movement from the EU ended and international recruitment from India, the Philippines, and other countries intensified. By 2023, internationally educated nurses made up a significant proportion of new NMC registrations. This has helped to reduce the nursing vacancy rate from its peak, but it raises ethical questions about recruitment from countries that can ill afford to lose their own trained healthcare workers.

The Recovery Plan: What Is Being Done?

NHS England's Elective Recovery Plan sets out a programme to progressively reduce waiting times, eliminate long waits, and restore performance against the 18-week standard. Key elements include:

• Independent sector capacity: NHS England has significantly expanded use of independent sector (private hospital) capacity to treat NHS patients at NHS cost. Independent sector providers typically operate in less complex elective areas — cataracts, hip and knee replacements, hernias — where they can treat patients more quickly than NHS trusts dealing with the full spectrum of complexity.
• Surgical hubs: NHS England has invested in dedicated elective surgical hubs — facilities ring-fenced for planned surgery and protected from emergency demand. These operate on a "green pathway" model, separating elective care from the acute hospital flow that can disrupt planned lists.
• Patient-initiated follow-up (PIFU): PIFU allows patients to contact the NHS directly when they need a follow-up, rather than being given automatic follow-up appointments. This reduces outpatient demand from patients who are stable and do not need regular clinical review, freeing capacity for new referrals.
• Community diagnostic centres: Over 100 community diagnostic centres have been established across England, providing MRI, CT, ultrasound, and other diagnostic tests in community settings, separate from acute hospitals. These aim to reduce diagnostic backlogs and free acute hospital capacity.
• Productivity improvement: NHS England and the government have set expectations for trusts to increase elective productivity — treating more patients per session, reducing cancellations, and optimising theatre utilisation.

Progress has been made on the longest waits. The number of patients waiting over two years fell to near zero by 2022, and over-18-month waiters were largely eliminated by 2023. The harder challenge is the total volume of 7.5 million pathways, which requires sustained activity at levels above historical norms to make a material dent.

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