What were we trying to do?
We set out to investigate how and why elective care waiting times and backlogs vary across England following the COVID-19 pandemic. While national policy has focused on reducing waiting lists, we wanted to look beneath the headline figures to understand the referral and treatment dynamics that drive differences between regions.

 

Why was this important?
Elective care backlogs have been a major concern since the pandemic, but national averages often hide local pressures. Some areas face higher demand, others struggle with treatment capacity, and some are still seeing ‘missing patients’ return after delays in seeking care. Without recognising these differences, national recovery policies risk being unrealistic or unfair, and may worsen existing inequalities.

 

How did we do it?
We analysed NHS Referral to Treatment (RTT) data from 2017 to 2024 at the sub-Integrated Care Board (ICB) level. This allowed us to track monthly flows of patients being referred, treated, or waiting for care, adjusting for local population size and demographics.

We then compared recovery trajectories across regions against their pre-pandemic baselines, identifying whether changes in waiting lists were mainly driven by new referrals, completed treatments, or both. 

 

Findings

• Regional variation: All areas were affected by the pandemic, but recovery patterns look very different across regions. Some saw referrals return faster than treatments, leading to growing waiting lists. Others saw the opposite, limiting backlog growth despite slower treatment recovery.
• Uneven return of ‘missing patients’: Some populations have been slower to re-enter the system, affecting demand pressures in different ways.
• Limits of waiting list metrics: Areas with similar waiting list sizes may face very different underlying challenges—capacity bottlenecks in some, hidden demand in others.
• Inequalities: Early evidence suggests deprived populations have faced slower recovery of referrals, raising the risk of widening health inequalities.

 

Interpretation of findings
Our research highlights that a “one-size-fits-all” approach to elective recovery is not effective. National targets should be supplemented with regional data on referral inflows and treatment outflows, to give a fuller picture of system pressures. This would help identify where backlogs are driven by constrained capacity versus unmet demand, and support fairer, more realistic oversight.

 

 

Who did we work with?
This work was led by the Health Organisation, Policy and Economics (HOPE) group at The University of Manchester, supported by Policy@Manchester.

 

 

More information

 

 

Senior Programme Lead
Mike Spence
michael.spence@manchester.ac.uk