• Overall, NHSE has made progress towards reducing waiting times, but more slowly than planned, with around 6.3m people (as of Jan 2025) waiting for elective care across 7.4m pathways.
  • While the diagnostic transformation programme met objectives to increase diagnostic tests, the surgical and outpatients’ transformation programmes have not achieved their targets.
  • There are signs NHS England has learned lessons from the programmes and there is scope for stronger governance arrangements, performance tracking and clinical leadership to improve the management of the programmes

NHS England’s (NHSE) three elective care transformation programmes have not fully met their goals to help reduce how long people spend waiting for elective care. A better understanding is required of the outcomes for patients and whether NHSE is spending in the right places to secure value for money, as stated by a new National Audit Office (NAO) report.

In February 2022, NHSE published its elective care recovery plan to see more patients sooner and prioritise patients waiting the longest. The NHS last met its elective care waiting standard, for patients to begin treatment within 18 weeks from referral, in 2015.

So far in 2024-25 the NHS has delivered a 116% increase in activity, compared to 19/20 baseline levels, but fell short of its 129% target. NHSE has broadly achieved its aim of eliminating waits of more than 2 years and more than 18 months but it will not achieve its target to eliminate waits of more than a year by March 2025.

NHSE told the NAO that there were several factors that weren’t included in their planning assumptions that reduced its ability to deliver the targets, including industrial action, lower than expected productivity, and higher than expected levels of COVID-19 infection, demand for urgent care and inflation during 2023 and 2024.

The independent public spending watchdog’s latest report takes a closer look at NHSE’s management of the three transformation programmes – diagnostic, surgical and outpatient:

  • Diagnostic transformation: Since 2022-23, an estimated £2.2 billion of funding has been spent on building new community diagnostic centres (CDCs) and buying equipment to move patients through diagnostic services more quickly. 141 out of a planned 170 CDCs will be operational at their permanent sites by March 2025 and waiting list diagnostic tests by CDCs have increased as planned, growing from 7% in 2023 to 13% in 2024. NHS England has improved diagnostic waiting times, but not by as much as it wanted. As of the end of January 2025, 22% of patients waiting for a diagnostic test waited more than 6 weeks, against a recovery target of 5% by March 2025.
  • Surgical transformation: Since 2022-23 an estimated £1 billion has been spent on surgical hubs to carry out low complexity procedures more efficiently. 19 of 37 new surgical hubs were complete by December 2024 but 11 of the remaining hubs are behind schedule. NHS trusts with surgical hubs are delivering 48% less additional elective activity than they planned to.
  • Outpatients’ transformation: 80% of elective activity is completed in outpatient settings. NHSE spent £52 million between 2021-22 and 2023-24, aiming to free up capacity in outpatients’ services by, for example, reducing referrals and follow-up appointments. However, it has struggled to deliver the programme. It set a target to reduce outpatient follow-up appointments by 25% compared with 2019-20 levels, but NHSE’s reporting showed that appointments reduced by 0.1% between June 2022 and July 2023.

NHSE’s management and oversight of the programmes could be improved. Governance arrangements for the programmes have not been effective, with gaps in data reported, inconsistent reporting of key indicators and a lack of reporting of progress against milestones.

NHSE’s oversight board for elective recovery does not assess whether NHSE has the right balance of investment across the programmes to reduce waiting lists and NHSE was slow to make significant changes to the outpatients’ programme when it was not delivering.

NHSE’s new 2025 elective care reform plan has taken on board lessons learned to date from the transformation programmes, although there is still scope for further improvement. The NAO report recommends:

  • As NHSE establishes its new national level oversight Board for the transformation programmes it should ensure that performance information is prioritised, clear and consistent so that the board has a clear view of trends over time and issues arising, including the programme costs and risk information is up to date.
  • When a programme is not delivering, as the outpatients transformation programme was not, highlight this in reports to the board.
  • The board should also assess the level of investment across the programmes and should play an active role in ensuring that lessons are learned on and between the transformation programmes.
  • NHSE should do more to secure buy-in from clinicians across its programmes, continuing to build support and endorsement nationally by strengthening its work with Royal Colleges and through national clinical directors embedded in the elective recovery programme.

"To achieve its aims on elective reform NHSE will need to make sure all its transformation programmes are delivering quicker access to treatment for patients as planned. This has not consistently been the case so far.

"With its reset of how it manages its programmes NHSE has an opportunity to ensure that it learns from its experience in the first phase of the programmes – particularly where it has failed to meet its targets – and there is some evidence that it has started to apply these lessons."

Gareth Davies, head of the NAO

Read the full report

NHS England’s management of elective care transformation programmes

Notes for editors

  1. Press notices and reports are available from the date of publication on the NAO website. Hard copies can be obtained by using the relevant links on our website.
  2. In broad terms, ‘elective care’ means non-emergency treatment that is under the care of a consultant.
  3. NHSE reports the number of ongoing elective referral-to-treatment (RTT) pathways monthly and this is referred to as the elective care waiting list. As of January 2025, patients had been on the waiting list for elective care on 7.4 million pathways. Some people are on more than one pathway and NHSE estimates that 6.3 million individuals were waiting for treatment in January 2025.
  4. This report was based on work completed in early March 2025. On 13 March 2025, the Government announced that NHSE would be abolished within two years. All references to future actions of NHSE in this report should be read as encompassing whatever arrangements the DHSC puts in place to deliver the responsibilities currently delivered by NHSE.
  5. The government plans to continue to run the elective care transformation programme for several more years, and in January 2025 set out further plans to reform elective care and reduce waiting lists. This includes a further £1.5 billion of capital funding for new surgical hubs and diagnostic scanners in 2025-26.

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