Widening variation in waiting times for elective care

Our analysis shows that elective care waiting times worsened substantially between 2019 and 2025, and they varied across ICBs far more in 2025 than in 2019. These findings highlight that where people live has become a bigger factor in shaping how long they wait for elective care since the COVID-19 pandemic. The government’s pledge to restore the 18-week standard by 2029 is unlikely to be met nationally unless all ICBs can deliver substantial improvements. With the operational standard set at 92% (to allow for clinical exceptions and patient choice), the scope for ICBs that exceed the standard to offset underperformance elsewhere is fundamentally limited. The government simply cannot afford for any ICBs to be left behind. 

Changes in referrals and elective care activity across ICBs

The volume of referrals increased in most ICBs in 2025 compared with 2019, although eight ICBs saw referrals decrease by 1–13%. Lower referral volumes may be partly due to service changes, though they do not appear to be due to higher use of A&G before referrals in these ICBs. It is hard to know the true contribution of A&G in limiting inappropriate referrals, as there are incentives for GPs to use A&G, and some may use A&G when no referral would have been made in its absence. 

Our previous projections show elective health care demand is likely to increase by 1.4% annually between 2024/25 and 2034/35 due to increases in population, comorbidities and age. Therefore, further work is needed to understand whether the decline in referrals in some ICBs represents an appropriate use of alternative services or a growing unmet need for elective care.

While it is encouraging that the volume of total completed pathways has increased in most parts of England, there are major differences between ICBs. Some have substantially exceeded 2019 activity levels, while others have only just met the 2019 volume. Several factors may have shaped these disparities. Prior to COVID-19, inequalities in access to elective care were already growing, and the impact of the pandemic was not evenly distributed across England. Other factors likely played a role, such as the ‘financial reset’ initiated by NHS England for 2025/26, differences in access to local independent sector health care services and the extent to which ICBs could take advantage of financial incentives. Further analysis is needed to understand whether some of the policies introduced to support elective care recovery may have boosted national performance while contributing to widening differences between ICBs.   

System changes and recovery challenges

There have been even bigger differences between ICBs in terms of unreported removals. Nationally, the volume of unreported removals in 2025 was lower than in 2019 (unlike referrals and completed pathways) – this may be due to more timely reporting of completed pathways. Variation in changes to unreported removals across ICBs was likely partially due to different approaches to the validation of waiting lists and temporary disruptions caused by the adoption of new electronic patient record systems. However, the lack of information on unreported removals within publicly available data makes it difficult to know, for example, how unreported removals resulting from validation exercises compare with previous years. NHS England needs to routinely report the breakdown of unreported removals to enable the more effective monitoring of changes in total elective care activity. 

This month, planned ICB mergers and clustering arrangements have reduced the number of ICBs from 42 to 26. As some ICBs’ population sizes increase, our ability to identify inequalities between areas of England at a granular level using ICB data will be limited. This will make it harder to identify areas lagging behind that would benefit from additional support. A forthcoming Health Foundation analysis will explore demographic inequalities in elective care waits and how ICB changes will affect how we understand these inequalities.

With reduced visibility of place-based inequalities, it will become even more important to address variation across ICBs. As this variation is driven by unequal performance across the trusts delivering care within each integrated care system, action is needed at the trust level. The government’s recently announced NHS intensive recovery programme – focusing on five trusts with ‘structural challenges’ – is a welcome recognition that some parts of the country need additional support to meet performance targets. However, the type of support provided will be key – for example, the proposal to make leadership changes in these trusts may not have the desired effect without the inclusion of additional resources.   

The widening variation in elective care waiting times highlights the scale of the challenge to return to the 18-week standard and deliver equitable recovery of elective care. The government must ensure it reduces inequalities in access to health care as part of elective care recovery so that where you live doesn’t affect how long you have to wait for care. 

Acknowledgements

We are grateful to the Elective Recovery Analysis and Modelling team at NHS England for their feedback on our analysis.