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NHS: evidence and policy appraisals

Detailed research records, alternatives, costs and provisional assessments. These records preserve different scopes and historical reviews; they are not an additional ranked action plan.

What would it take to improve this?

Detailed policy appraisal

The outcome we want: Timely, safe planned care in England, with fewer people waiting longer than 18 weeks.

The main constraint: Trained staff, beds and theatres are shared between emergency and planned care, so extra planned capacity needs staff and running budgets that NHS trusts and integrated care boards must find — capital alone does not provide them.

Constraint type: workforce, infrastructure, money.

The options on the table

What is funded now, and the changes assessed against it — the current baseline and the alternatives, before the position today and the actions.

Provisional single-reviewer assessments from the 6 October 2026 review; not approved business cases, and not government policy.

  • Cut treatment waits and improve patients’ healthDelivery risk: Red

    Funded now
    Baseline: the Elective Reform Plan (65% within 18 weeks by March 2026, met narrowly at 65.3%; 92% by March 2029), the planning framework’s 70% by March 2027, surgical hubs and £2.0bn of elective capital in 2026–27. Choosing specialties by binding constraint and adding capacity beyond funded plans is a UK Facts proposal, not government policy.
    The change assessed
    Not yet defined.

    Range if completed: 13.0–22.0 out of 30 (equal weights; not yet assessed: increment beyond baseline (Ad), expected incremental benefit (Bn), incremental affordability (Co))

  • Fix NHS equipment and estate bottlenecks that cancel careDelivery risk: Red

    Funded now
    Not yet stated in the record.
    The change assessed
    Select named maintenance/equipment projects with logged downtime and funded staff to use restored capacity.

    Range if completed: 15.0–21.0 out of 30 (equal weights; not yet assessed: expected incremental benefit (Bn), incremental affordability (Co))

Assessed with another page as home

These options also bear on this topic. The full assessment sits on the home page named under each.

  • A costed social-care capacity planDelivery risk: Red

    Home: Social care.

    Funded now
    Baseline: a £500m first-year envelope agreed for the Fair Pay Agreement, with negotiations from about April 2027 and the first agreement in April 2028; an adult social care workforce plan promised by the end of 2026 (30 September 2026); the Casey Commission reports by summer 2027; the Prime Minister has proposed a National Care Service for the next Parliament. Making the workforce plan a costed capacity plan tied to the pay agreed is a UK Facts proposal, not government policy.
    The change assessed
    Not yet defined.

    Range if completed: 10.0–19.0 out of 30 (equal weights; not yet assessed: increment beyond baseline (Ad), expected incremental benefit (Bn), incremental affordability (Co))

  • Get effective depression treatment to adults missing outDelivery risk: Amber

    Home: Health.

    Funded now
    Funded baseline: NHS Talking Therapies (1.81m referrals and 674,683 finished courses in England in 2025–26), with ring-fenced funding and a planning target of 805,000 courses by the end of 2026/27 and 915,000 by 2028/29. Targeting extra capacity at the areas with the lowest completion and recovery is a UK Facts proposal, not government policy.
    The change assessed
    Close a verified access gap for clinically appropriate NICE-recommended adult depression treatment, with supervision and an escalation route.

    Range if completed: 19.0–22.0 out of 30 (equal weights; not yet assessed: incremental affordability (Co))

Alternatives already on record: 26 options listed under the points in the position today (16 without an action record), and 3 earlier options under other options compared. They have not been scored in the review.

The position today

  • What we can build on (2)
  • What is holding us back (7)Mental-health access needs its own recovery test. CQC reports pressure on community and crisis services and a workforce that has not kept pace with demand. Hospital elective waiting-time improvements cannot establish that mental-health access or quality has improved. (2024/25 regulator assessment · England)
  • What could improve things (1)Protecting planned surgery where cancellations are the constraint, and integrating employment support with care for people who want to work, address different parts of the same pressure.
  • What could make it worse (3)

Which quadrant a point sits in is our analytical judgement, not a statistical category. Each point says whether it is a measured fact, our synthesis or a risk.

What we can build on Strengths

What is holding us back Weaknesses

What could improve things Opportunities

What could make it worse Threats

  • The NAO found the reset hospital programme had a more stable long-term basis, but construction schedules remained challenging. Slippage could push work and budget pressure into later funding periods. A programme announcement is not evidence that replacement hospitals are operational.

    Risk, not a certaintyConfidence: High· January 2026 audit· England

    Source: National Audit Office, Update on the New Hospital Programme (Conclusion)

  • Hubs can move work rather than add it: total elective surgery at trusts that opened hubs did not rise significantly, and staff may be drawn from emergency care.

    Risk, not a certaintyConfidence: Moderate

    Source: Health Foundation, Surgical hubs: key to tackling hospital waiting lists? (blog) and The impact of elective surgical hubs on elective surgery in acute hospital trusts in England (Nature Communications, 2025) (Paper Results “New hubs”)

    What government has committed to

    Funding: NHS England capital for 2026/27 includes a separate urgent and emergency care allocation targeted at bed capacity and same-day emergency care, alongside elective capital, so expansion of planned capacity is not meant to come from emergency beds.

    Who and when:
    NHS England (England) (regulator or independent body), 17 November 2025.
    Since 20 July 2026:
    No Burnham-era statement on protecting emergency capacity from hub expansion found. Estates Safety Fund round (9 Sep 2026) mentions protecting capacity over winter but is not elective-specific.
    Source:
    NHS England, Capital guidance 2026/27 to 2029/30 ("Overview of the NHS capital settlement for 2026/27" (around £2.0bn in 2026/27 of a £5bn 4-year programme to deliver the March 2029 92% RTT standard); "Constitutional standards and hospital to community shift" > Elective recovery ("capital in 2026/27 will be targeted at completing delivery of elective hub and surgical schemes commenced in 2025/26"); UEC allocation for bed capacity)

    Checked 4 October 2026. A commitment is not delivery.

    Options (3)

    • Protect elective surgery from emergency disruption (ring-fenced surgical hubs, staffed and evaluated on waits)

      Separating planned operations from emergency beds cuts on-the-day cancellations so more routine operations are done, which is the route by which the 18-week share could rise; hub business cases must fund staff and measure waits.

      Who: NHS trusts and integrated care boards (delivery); NHS England/DHSC (capital approval) · Evidence: Experimental or quasi-experimental evaluation · Status: Established

      Source: Nature Communications, The impact of elective surgical hubs on elective surgery in acute hospital trusts in England (Co, Marks, Tracey, Conti, Clarke) (Abstract and Results "New hubs" (21.9% higher high-volume low-complexity surgery, 95% CI 11.7% to 32.2%))

    • Fund emergency bed capacity and same-day emergency care alongside hubs

      Separate UEC capital adds beds so staff and beds moved into hubs do not leave emergency care short.

      Who: NHS England regions and integrated care boards · Evidence: Expert or audit recommendation · Status: Funded programme

      Source: NHS England, Capital guidance 2026/27 to 2029/30 ("Overview of the NHS capital settlement for 2026/27" (around £2.0bn in 2026/27 of a £5bn 4-year programme to deliver the March 2029 92% RTT standard); "Constitutional standards and hospital to community shift" > Elective recovery ("capital in 2026/27 will be targeted at completing delivery of elective hub and surgical schemes commenced in 2025/26"); UEC allocation for bed capacity)

    • Fund social care to unblock hospital discharge

      Fewer delayed discharges free beds for both emergency and planned work, so hubs need not draw on emergency capacity.

      Who: DHSC, MHCLG, councils, NHS trusts · Evidence: Observational analysis · Status: Established · Works through Social care: Fewer delayed discharges free beds for both emergency and planned work, so hubs need not draw on emergency capacity.

      Source: NHS England, Discharge delays (acute) statistics (Statistical work area landing page)

  • Capital for elective recovery in 2026/27 is aimed at finishing schemes already started, leaving little for new hubs without a further decision.

    Risk, not a certaintyConfidence: Moderate

    Source: NHS England, Capital guidance 2026/27 to 2029/30 (“Constitutional standards and hospital to community shift”)

    What government has committed to

    Funding: NHS capital for elective recovery in 2026/27 will be targeted at completing elective hub and surgical schemes commenced in 2025/26; around £2.0bn in 2026/27 is part of a £5bn four-year programme to deliver the March 2029 92% standard.

    Who and when:
    NHS England (England) (regulator or independent body), 17 November 2025.
    Since 20 July 2026:
    No new elective-hub capital announcement found since 20 Jul 2026. HL2447 (25 Aug 2026) says the government is 'committed to expanding the number of surgical hubs' without new funding; the 9 Sep 2026 £1.5bn round is Estates Safety Fund money (safety and maintenance) and cites a 10 Year Capital Plan.
    Source:
    NHS England, Capital guidance 2026/27 to 2029/30 ("Overview of the NHS capital settlement for 2026/27" (around £2.0bn in 2026/27 of a £5bn 4-year programme to deliver the March 2029 92% RTT standard); "Constitutional standards and hospital to community shift" > Elective recovery ("capital in 2026/27 will be targeted at completing delivery of elective hub and surgical schemes commenced in 2025/26"); UEC allocation for bed capacity)

    Checked 4 October 2026. A commitment is not delivery.

    Options (3)

    • Protect elective surgery from emergency disruption (ring-fenced surgical hubs, staffed and evaluated on waits)

      Separating planned operations from emergency beds cuts on-the-day cancellations so more routine operations are done, which is the route by which the 18-week share could rise; hub business cases must fund staff and measure waits.

      Who: NHS trusts and integrated care boards (delivery); NHS England/DHSC (capital approval) · Evidence: Experimental or quasi-experimental evaluation · Status: Established

      Source: Nature Communications, The impact of elective surgical hubs on elective surgery in acute hospital trusts in England (Co, Marks, Tracey, Conti, Clarke) (Abstract and Results "New hubs" (21.9% higher high-volume low-complexity surgery, 95% CI 11.7% to 32.2%))

    • Invest in buildings, equipment and IT through a multi-year capital plan

      A 10-year capital plan would let trusts plan new theatres beyond completing current schemes.

      Who: DHSC and HM Treasury · Evidence: Observational analysis · Status: Announced proposal

      Source: DHSC, Over £1.5 billion to help NHS withstand year-round pressure (Body and background: £6.75bn Estates Safety Fund; 10 major projects incl. new theatres at Bristol Royal Infirmary and Royal Free; capital budget rising to £15bn in 2029-30; 10 Year Capital Plan)

    • Use existing estate for protected planned-care days before building new hubs

      Ring-fencing existing theatres for planned lists adds protected capacity without new capital.

      Who: Integrated care boards and trusts · Evidence: Expert or audit recommendation · Status: Announced proposal

      Source: NHS England, Medium term planning framework – delivering change together 2026/27 to 2028/29 (Elective care success-measure table (2026/27: every trust +7 points or 65%, national 70%; 2028/29: 92%); mental health table (MHST 77% coverage 2026/27, 94% 2028/29, 100% by 2029; IPS 63,500 by end 2026/27, 73,500 by 2028/29); UEC section on discharge delays)

The actions worth examining

Our shortlist for this page. Research quality, policy status, cost and funding are judged separately; none of these is government policy unless its status says so.Our shortlist. None is government policy unless its status says so.

  1. Protect elective surgery from emergency disruption — not yet costed / funding not identified
  2. Offer evidence-based employment support alongside healthcare — indicative costing / partial funding
  3. Cut treatment waits and improve patients’ health — not yet costed / funding not identified

  • Action 1A04Policy status: established

    Protect elective surgery from emergency disruption

    Ring-fenced surgical hubs keep theatres and beds for planned operations, so routine lists run even when emergency pressure is high.

    The thread: issue, evidence, action

    1. Issue Weakness: 65.2% of waiting pathways were within 18 weeks, against the 92% standard, last met in September 2015 on the figures including estimates for missing trusts (February 2016 on reported figures). Also: weakness, strength
    2. Evidence Waiting pathways within 18 weeks; Treatment pathways waiting
    3. Action A04, this action

    Assessment (draft, 6 October review)

    Not assessed in the 6 October review; this action stays in the topic plan with its own evidence.

    Who decides:
    NHS commissioners and provider trusts, with DHSC and NHS England (England)
    Evidence:
    Experimental or quasi-experimental evaluation. A national quasi-experimental study found more of one category of surgery; it did not measure waiting lists.
    Expected effect:
    +21.9%: high-volume, low-complexity operations at trusts that opened a hub (31 English acute trusts). Activity, not the waiting list: total elective surgery at these trusts did not change significantly, and the study did not measure waits.
    Cost and funding

    Not yet costed

    Funding: Not yet costed / funding not identified

    Why it is shortlisted here: Protected theatres and beds are an evaluated way to do more routine operations: trusts that opened a hub did 21.9% more of them. That study did not measure waiting times, so any effect on the 18-week standard is untested — the first step is to measure cancellations locally and the case for a hub must include a wait-time evaluation, with staff and beds funded alongside the building.

    What it takes
    The problem

    Planned operations are cancelled when emergency demand takes the beds, theatres and staff they depend on.

    Who is affected, and where

    Patients waiting for routine planned surgery in England. Territory: England. Health is devolved; NHS Scotland, Wales and Northern Ireland plan elective capacity separately.

    Policy status

    Already in place. Surgical hubs already operate; NHS capital in 2026/27 targets completing hub schemes begun in 2025/26. Expanding further depends on local business cases.

    The evidence
    What the research found:
    High-volume, low-complexity surgery was 21.9% higher (95% CI 11.7% to 32.2%) in the first year at trusts that opened hubs; total elective surgery did not change significantly; no effect on length of stay at new hubs.
    Evaluated on:
    31 acute trusts that opened hubs, compared with a synthetic group of trusts without hubs; English NHS, 2018–2022
    Transfer to this case:
    Effects depend on hub design and case mix.
    Our recommendation (separate from the research):
    Expand only where a local business case shows cancellations and theatre time are the constraint, and fund staff and recovery beds, not just buildings.
    Strongest counter-evidence:
    More routine operations did not raise total elective activity at these trusts, so hubs may shift work rather than add it; staff may be drawn from emergency care.
    Effects on record
    • High-volume, low-complexity operations at trusts that opened a hub: +21.9% (a synthetic comparison built from trusts without hubs; first year after opening, 2018–2022 data; 95% CI 11.7% to 32.2%). evaluated, moderate confidence; 31 English acute trusts. Activity, not the waiting list: total elective surgery at these trusts did not change significantly, and the study did not measure waits.
    Cost and funding

    Cost completeness: Not yet costed. Funding: Not yet costed / funding not identified.

    • Site capital, theatre staff, equipment and running costs for a hub (capital; paid by NHS): Not yet costed. Past programme spending is not a price for a new hub. NHS capital guidance names no separate amount for hubs; staff and running costs are recurring and outside capital budgets.
    Who pays:
    The NHS: capital from national allocations; staff and running costs from trust and commissioner budgets.
    Financing proposed:
    NHS capital routes for elective recovery (about £2.0bn in 2026/27 across diagnostics, elective and urgent care); no allocation identified for a new hub.
    Gap remaining:
    Unknown: no site has been costed here.
    What delivery needs
    Skills:
    Anaesthetists, theatre staff and recovery nurses.
    Operational capacity:
    Recovery beds and pre-operative assessment.
    Infrastructure:
    Theatres and beds protected from emergency use.
    Permissions:
    Commissioner approval and capital business case.
    Law:
    No new law.
    Public consent:
    Patients may travel further to a hub.
    First step and stages

    First step: Measure cancellations, theatre use and staffing constraints before choosing a hub or an operational change. (owner: Trusts and integrated care boards)

    1. Assess the local constraint — Trusts and integrated care boards (proposed stage, not an official timetable)
    2. Staff and commission the hub — Trusts; NHS England capital (proposed stage, not an official timetable)
    3. Evaluate activity, safety and access before expanding — NHS England (proposed stage, not an official timetable)

    Depends on: Workforce supply; Discharge capacity

    Trade-offs
    Who gains and who loses:
    Gains for patients needing routine operations; risk to emergency patients if staff are diverted; travel burdens for some.
    What else the money or effort could do:
    Capital and staff could go to diagnostics, discharge or emergency care instead.
    Strongest counterargument:
    The queue depends on referrals and total capacity; protecting one category of surgery can leave the overall list unchanged.
    Risks:
    Selecting easier cases, diverting staff and increasing activity without reducing the total queue.
    How we would judge it
    Baseline:
    Share of waiting pathways under 18 weeks (NHS England RTT).
    Leading indicator:
    Completed procedures and on-the-day cancellations at the hub.
    Outcome:
    Waiting-time distribution, complications and equitable access.
    Continue, adapt or stop:
    Expand where activity rises without harm to emergency care; stop where activity rises but waits for the same procedures do not fall.
    Earlier option on this page

    This card replaces the option “Ring-fenced planned-care and diagnostic capacity” (operating: Elective reform plan published January 2025; 92% target by March 2029 in the medium term planning framework.). Its evidence: Separating elective from emergency capacity is supported by professional bodies and NHS England’s elective reform plan; robust evaluations of the effect on national waiting times are limited, and extra activity has partly been absorbed by rising referrals. NHS England, Reforming elective care for patients (January 2025)

    Sources

    Source published September 2024 (blog); July 2025 (paper); November 2025 (capital guidance); evidence reviewed 2026-10-04. Reconsider if: A study measuring waits at hub trusts; New capital guidance; The 18-week share moves towards 92%.

  • Action 2A09Policy status: funded programme

    Offer evidence-based employment support alongside healthcare

    Individual Placement and Support puts an employment specialist alongside health services to find matched work quickly and keep supporting the person once they start.

    The thread: issue, evidence, action

    1. Issue Weakness (Jobs & pay): 2.74 million people aged 16–64 were economically inactive because of long-term sickness, against 2.08 million at the end of 2019. Also: opportunity, strengthHow acting here reaches it: Health services meet people who are out of work through ill health; offering evidence-based employment support alongside care is meant to move some of them back into work, which the long-term sickness inactivity count records.
    2. Evidence Economically inactive because of long-term sickness, aged 16–64
    3. Action A09, this action

    Assessment (draft, 6 October review)

    Who decides:
    DWP and local authority delivery areas (Connect to Work), with NHS commissioners (England and Wales)
    Evidence:
    Experimental or quasi-experimental evaluation. Randomised trials of an adapted model found modest effects that varied by place; evidence is strongest for severe mental illness, a different group.
    Expected effect:
    +4 percentage points (22% vs 18%): working 13 or more weeks in the year after joining (out-of-work participants) (West Midlands Combined Authority). No effect for out-of-work participants in Sheffield City Region, and no effect on earnings at 12 months. 2 more results in “What it takes”.
    Cost and funding

    £1.03bn in total, 2025–26 to 2028–29, cash (nominal) prices; 2 further cost lines, some not yet costed

    Funding: Indicative costing / partial funding

    Why it is shortlisted here: Health services meet many people who are out of work through ill health; integrated support is already funded and needs to be held to fidelity.

    What it takes
    The problem

    People with health conditions who want to work often get employment help that is separate from their care and does not stay with them in work.

    Who is affected, and where

    Adults with health conditions or disabilities who want to work, in England and Wales. Territory: England and Wales. Connect to Work covers England and Wales; Scotland and Northern Ireland run their own employment support.

    Policy status

    A funded programme already exists. Connect to Work has taken referrals since April 2025 and aims to support about 300,000 people by 2029/30; IPS also operates in NHS mental health services. The proposal here is to hold it to fidelity and integrate it with care, not to start something new.

    The evidence
    What the research found:
    Working 13+ weeks in a year: +4 percentage points for out-of-work participants in the West Midlands; +3 points for people in work in Sheffield City Region (weaker evidence); no effect for out-of-work participants there; no earnings effect at 12 months; small health gains in Sheffield City Region only.
    Evaluated on:
    9,785 adults with mild to moderate health conditions, in or out of work; Sheffield City Region and West Midlands, 2018–2020
    Transfer to this case:
    Results for severe mental illness or for one area should not be assumed for all economically inactive people.
    Our recommendation (separate from the research):
    Keep delivery at fidelity, integrate it with NHS care, and judge it by sustained work and health, not referrals or starts.
    Strongest counter-evidence:
    One of three trial groups saw no employment effect and the Exchequer return within a year was 1–2p per £1; benefits were mainly in health and wellbeing, and only in one area.
    Effects on record
    • Working 13 or more weeks in the year after joining (out-of-work participants): +4 percentage points (22% vs 18%) (randomised control group receiving usual support; 12 months after randomisation, 2018–2020; significant at the 99% level; no interval published). evaluated, moderate confidence; West Midlands Combined Authority. No effect for out-of-work participants in Sheffield City Region, and no effect on earnings at 12 months.
    • Working 13 or more weeks in the year after joining (people in work but struggling): +3 percentage points (randomised control group; 12 months after randomisation, 2018–2020; significant only at the 90% level; no interval published). evaluated, limited confidence; Sheffield City Region. Weaker evidence than the West Midlands result.
    • Self-reported health (EQ-5D-5L) at 12 months: +0.10 standard deviations (randomised control group; 12 months after randomisation; significant at the 90% level (99% when Sheffield groups are pooled); no effect in the West Midlands). evaluated, limited confidence; Sheffield City Region. Small; not found in the West Midlands. Not evidence of reduced NHS demand.
    Cost and funding

    Cost completeness: Partly costed. Funding: Indicative costing / partial funding.

    • Connect to Work grant and programme costs, 2025–26 to 2028–29 (recurring spending; paid by central government): £1.03bn in total, 2025–26 to 2028–29, cash (nominal) prices. Sum of the four years in the revised business case. Excludes £15.5m spent in 2023–24 and 2024–25.
    • Connect to Work costs, 2029–30 to 2031–32 (recurring spending; paid by central government): £134.4m in total, 2029–30 to 2031–32, cash (nominal) prices. Sum of the last three years in the revised business case.
    • NHS clinical integration, referral and supervision for IPS (recurring spending; paid by NHS): Not yet costed. Not in the DWP business case. An older national IPS price is not a current rollout budget.
    • Autumn Budget 2024 and Spending Review 2025 settlements for Connect to Work: £1.09bn, 2025–26 to 2028–29 — committed (allocated to this scope). £114m for 2025–26 plus £978m for 2026–27 to 2028–29. The business case says funding and costs differ because volume forecasts changed.
    • Connect to Work funding to be requested at a future Spending Review: £138m, 2029–30 to 2031–32 — not committed (no allocation). “Will be requested in a future Spending Review.”
    Who pays:
    DWP for Connect to Work grants; the NHS for clinical integration and IPS in mental health services.
    Financing proposed:
    £138m for 2029–30 onwards is to be requested at a future Spending Review.
    Gap remaining:
    Connect to Work is funded to 2028–29; the later years are not committed and the NHS-side integration cost is not established.
    What delivery needs
    Skills:
    Trained employment specialists and supervisors.
    Operational capacity:
    NHS referral routes and fidelity reviews.
    Infrastructure:
    None beyond services.
    Permissions:
    Data sharing between health and employment services.
    Law:
    No new law.
    Public consent:
    Voluntary for participants.
    First step and stages

    First step: Select the eligible group, service standard and an existing capacity gap in one area. (owner: DWP delivery areas and NHS commissioners)

    1. Recruit and train to fidelity — Connect to Work delivery areas (proposed stage, not an official timetable)
    2. Refer and support into work — Providers with NHS teams (proposed stage, not an official timetable)
    3. Measure sustained work and health from payroll and survey data — DWP (proposed stage, not an official timetable)

    Depends on: NHS capacity to refer and integrate; Employer vacancies

    Trade-offs
    Who gains and who loses:
    Gains for participants who find suitable work; intensive support per person means fewer people reached.
    What else the money or effort could do:
    The same money could fund less intensive support for more people, or health services directly.
    Strongest counterargument:
    Trial effects were modest and inconsistent; scaling may dilute fidelity further.
    Risks:
    Unsuitable jobs, pressure on people who are not ready, and over-claiming benefit savings.
    How we would judge it
    Baseline:
    Economic inactivity due to long-term sickness (ONS Labour Force Survey).
    Leading indicator:
    Programme starts and the share in paid work within 12 months.
    Outcome:
    Employment sustained 6–12 months later (HMRC payroll data), job quality and health.
    Continue, adapt or stop:
    Continue where sustained work beats a matched comparison; adapt or stop where it does not.
    Sources

    Source published April 2023 (trials); July 2026 (business case); evidence reviewed 2026-10-04. Reconsider if: Connect to Work impact evaluation results; The next Spending Review; New trials in different populations.

    Also on: Economy, Jobs and pay, Benefits — one shared record, so its cost is counted once.

  • Action 3A61Policy status: external proposal

    Cut treatment waits and improve patients’ health

    Mapping diagnostic, theatre, staffing and discharge constraints by specialty and adding capacity where one constraint binds — starting with trauma and orthopaedics, the largest list — turns extra resources into treatments and shorter waits.

    The thread: issue, evidence, action

    1. Issue Weakness: 65.2% of waiting pathways were within 18 weeks, against the 92% standard, last met in September 2015 on the figures including estimates for missing trusts (February 2016 on reported figures). Also: weakness
    2. Evidence Waiting pathways within 18 weeks; Patients waiting six weeks or more for a diagnostic test
    3. Action A61, this action

    Assessment (draft, 6 October review)

    Who decides:
    NHS England, integrated care boards and NHS trusts (England)
    Evidence:
    Experimental or quasi-experimental evaluation. A synthetic-control study found surgical hubs raised routine operations; descriptive analysis shows staff growth outpaced activity; no study links a specialty-targeted increment to waiting times.
    Expected effect:
    Direction plausible; size not established.
    Cost and funding

    Not yet costed

    Funding: Not yet costed / funding not identified

    Why it is shortlisted here: The national waiting-list option (Wellbeing list): it is a different intervention from surgical hubs — choose the specialties where diagnostics or theatre time hold waits back and add capacity there, measured against other specialties.

    What it takes
    The problem

    Fewer than two-thirds of waiting pathways are within 18 weeks, against 92% by March 2029, and almost a quarter of patients wait six weeks or more for a diagnostic test; extra staff since 2019 have not produced proportionate extra activity.

    Who is affected, and where

    Patients waiting for planned hospital treatment in England, starting with trauma and orthopaedics (840,967 pathways, 60.9% within 18 weeks in July 2026) and specialties with the lowest 18-week shares. Territory: England. Scotland, Wales and Northern Ireland run separate systems with different waiting standards; not assessed.

    Policy status

    Proposed by researchers or others, not government policy. Baseline: the Elective Reform Plan (65% within 18 weeks by March 2026, met narrowly at 65.3%; 92% by March 2029), the planning framework’s 70% by March 2027, surgical hubs and £2.0bn of elective capital in 2026–27. Choosing specialties by binding constraint and adding capacity beyond funded plans is a UK Facts proposal, not government policy.

    The evidence
    What the research found:
    Trusts opening a surgical hub did 21.9% (11.7–32.2) more routine high-volume operations in the first year; from 2019 to 2024 consultants rose 18.2% and nurses 22.9% while elective admissions rose 9.1%.
    Evaluated on:
    English acute trusts, 2018–2022 (hubs); NHS hospital activity 2019–2024; England
    Transfer to this case:
    The hub study did not measure waiting times and could not separate hub activity from the rest of the trust.
    Our recommendation (separate from the research):
    Publish constraint maps by specialty and trust, and fund extra diagnostics or theatre time only where it is the binding constraint, measuring 18-week performance in that specialty against others.
    Strongest counter-evidence:
    More capacity has not reliably meant shorter waits; the March 2026 rise may partly reflect waiting-list validation rather than treatment.
    Cost and funding

    Cost completeness: Not yet costed. Funding: Not yet costed / funding not identified.

      Who pays:
      The NHS.
      Financing proposed:
      Not identified beyond existing elective capital.
      Gap remaining:
      Unknown: the revenue, staffing and diagnostics costs of an increment beyond funded plans.
      What delivery needs
      Skills:
      Surgeons, anaesthetists, radiographers and theatre staff.
      Operational capacity:
      Diagnostic and theatre capacity; discharge.
      Infrastructure:
      Hubs and community diagnostic centres.
      Permissions:
      None.
      Law:
      None.
      Public consent:
      Patient choice of provider.
      First step and stages

      First step: NHS England publishes, for trauma and orthopaedics and the three specialties with the lowest 18-week shares, which constraint binds in each trust, and selects trusts for added capacity with others as comparisons. (owner: NHS England)

      1. Publish constraint maps by specialty — NHS England (proposed stage, not an official timetable)
      2. Add capacity where one constraint binds — Trusts and integrated care boards (proposed stage, not an official timetable)
      3. Compare 18-week performance — NHS England (proposed stage, not an official timetable)

      Depends on: Workforce supply; Diagnostic capacity

      Trade-offs
      Who gains and who loses:
      Patients on the longest lists, including older people waiting for joint replacement.
      What else the money or effort could do:
      Capacity added to one specialty is not available to others.
      Strongest counterargument:
      System-wide productivity and discharge may matter more than specialty targeting.
      Risks:
      Displacement between specialties; counting validation as progress.
      How we would judge it
      Baseline:
      July 2026: 65.4% of pathways within 18 weeks; 23.1% waiting six weeks or more for a diagnostic test (target at most 14% for 2026/27).
      Leading indicator:
      Diagnostic waits and theatre utilisation in selected specialties.
      Outcome:
      18-week performance in selected specialties against comparisons.
      Continue, adapt or stop:
      Continue where 18-week performance improves faster than in comparison specialties.
      Sources

      Source published 10 September 2026 (RTT and DM01); 4 July 2025 (hub study); 12 November 2024 (IFS); evidence reviewed 2026-10-07. Reconsider if: RTT and DM01 for August 2026 (8 October 2026); The mental health and elective plans for 2027/28.

    Considered but not shortlisted here: A05 — A framework rather than an intervention: it needs a named local need and intervention with its own effect evidence before it can be costed or measured. Kept for the national assessment.

    How the options are assessed

    One shared record per option — the same one the national plan reads. Delivery risk, gate and list membership are separate judgements.

    • Cut treatment waits and improve patients’ health — Red delivery RAG; gate pending
    • Fix NHS equipment and estate bottlenecks that cancel care — Red delivery RAG; gate pending

    Provisional single-reviewer assessments from the 6 October 2026 review; not approved business cases, and not government policy.

    • A61Delivery risk: RedGate: pending

      Cut treatment waits and improve patients’ health

      Existing action A61, assessed at the same scope.

      Provisional single-reviewer assessment; not an approved business case.

      Who and where
      Patients waiting for planned hospital treatment in England, starting with trauma and orthopaedics (840,967 pathways, 60.9% within 18 weeks in July 2026) and specialties with the lowest 18-week shares. (from the action record) Jurisdiction: England.
      Result so far
      Range if completed: 13.0–22.0 out of 30 (equal weights; not yet assessed: increment beyond baseline (Ad), expected incremental benefit (Bn), incremental affordability (Co))
      Funded now (baseline)
      Baseline: the Elective Reform Plan (65% within 18 weeks by March 2026, met narrowly at 65.3%; 92% by March 2029), the planning framework’s 70% by March 2027, surgical hubs and £2.0bn of elective capital in 2026–27. Choosing specialties by binding constraint and adding capacity beyond funded plans is a UK Facts proposal, not government policy. (from the action record)
      The change assessed (marginal)
      Marginal change not yet defined
      What the evidence supports—and the next decision

      The waiting list is a stock of pathways; reducing it is not a specified treatment intervention and can conceal changes in access.

      AI-assisted analytical follow-up · 8 October 2026. Proposed appraisal design; the attributed scores below are unchanged. No funding or delivery agreement is implied.

      Define the change
      Choose a specialty and bottleneck, with eligible patients and a funded workforce plan. Compare diagnostics, treatment capacity and pathway redesign.
      Test whether it works
      Wait distribution, completed treatment, clinical outcomes and unmet referrals; retain emergency and community-service balancing measures.
      Establish the cost
      Staff, diagnostics, theatre time, capital, maintenance and follow-up, including the opportunity cost of moving staff from another service.
      Protect against harm
      Do not improve the metric by rejecting or administratively removing patients without appropriate care.

      Read with the outcome evidence and sources in the full assessment. Monitoring proposals are not existing baseline measurements. A numerical benefit or cost score needs evidence for the defined increment, not just the scale of the problem.

      Full assessment of Cut treatment waits and improve patients’ health: ten criteria, scenarios, delivery, costs and monitoring
      The ten criteria (0–3)

      Each criterion is scored 0 to 3 by the reviewer. “Not yet assessed” means unknown: it is never counted as zero.

      1. Scale and severity (Sc)3 of 3 — Severe harm across a broad population

        Reviewer’s reason: Provisional problem-importance judgement from linked site pages; not the scale of achievable benefit.

      2. Increment beyond baseline (Ad)Not yet assessed

        Reviewer’s reason: Map diagnostic, theatre, staffing and discharge constraints; select a specialty/locality; demonstrate addition beyond funded plans. A missing rating requires a defined marginal change.

      3. Confidence in the proposed action (Ev)2 of 3 — Relevant evaluated evidence with limitations

        Reviewer’s reason: Hub evidence concerns activity; the artifact notes no total activity gain. The proposed increment and effect on waits are unresolved.

      4. Expected incremental benefit (Bn)Not yet assessed

        Reviewer’s reason: Unknown unless a reasonably defined target-population benefit can be judged; no bonus merely for spanning domains.

      5. Residual harms (Hm)1 of 3 — Material harm/unresolved mitigation

        Reviewer’s reason: Binding workforce capacity; displacement of urgent or other elective care.

      6. Incremental affordability (Co)Not yet assessed

        Reviewer’s reason: Capital, staff, diagnostics, maintenance, displaced activity and recurring running costs.

      7. Delivery capacity (Ca)1 of 3 — Binding scarce resource

        Reviewer’s reason: Map diagnostic, theatre, staffing and discharge constraints; select a specialty/locality; demonstrate addition beyond funded plans.

      8. Distribution (Fa)2 of 3 — Mixed or broadly neutral with safeguards

        Reviewer’s reason: Provisional distribution judgement for the stated target; verify who pays, who gains and excluded groups.

      9. Meaningful first outcome (Ti)2 of 3 — More than one and up to three years

        Reviewer’s reason: First meaningful outcome, not announcement: Patient waits and health outcomes, not hub throughput alone.

      10. Readiness (Rd)2 of 3 — Named commissioning/allocation/coordination step

        Reviewer’s reason: NHS commissioners/providers; nation-specific systems; Identify marginal bottleneck and appraise

      Four weightings

      Normalised as 10 × weighted sum ÷ sum of weights, on a 0–30 scale. Where a criterion is not yet assessed, the range is the lowest and highest result if it were later scored 0 or 3 — not a score, a confidence interval or a rank.

      • Equal weights: Range if completed: 13.0–22.0 out of 30. Not yet assessed: increment beyond baseline (Ad), expected incremental benefit (Bn), incremental affordability (Co). Funding gate: not passed.
      • Evidence doubled: Range if completed: 13.6–21.8 out of 30. Not yet assessed: increment beyond baseline (Ad), expected incremental benefit (Bn), incremental affordability (Co). Funding gate: not passed.
      • Scale doubled: Range if completed: 14.5–22.7 out of 30. Not yet assessed: increment beyond baseline (Ad), expected incremental benefit (Bn), incremental affordability (Co). Funding gate: not passed.
      • Cost ignored (the funding gate still applies): Range if completed: 14.4–21.1 out of 30. Not yet assessed: increment beyond baseline (Ad), expected incremental benefit (Bn), incremental affordability (Co). Funding gate: not passed.

      Funding gate: Not passed — the cost is not yet assessed or no allocation is committed for this scope. Ignoring cost in a weighting never removes the gate.

      Delivery risk and gate

      Delivery risk shown: RedReview’s claim: Red. Best the recorded evidence allows: Red.

      Review’s reason: Binding workforce capacity; displacement of urgent or other elective care.

      Why it is not Green yet

      • Delivery obstacle: Binding workforce capacity; displacement of urgent or other elective care..
      • Scope (population, place and increment) not verified against the delivery baseline.
      • No verified owner with the powers in place.
      • Delivery capacity not verified.
      • Lifetime incremental costs not complete.
      • No credible funding (a committed allocation for the scope).
      • Safeguards not specified.
      • Monitoring lacks a metric, a data source or a baseline.

      Green needs verified scope, a verified owner with the powers, verified capacity, complete lifetime costs with credible funding, specified safeguards and monitoring with a metric, source and baseline. Amber means appraisal gaps remain; Red means a material delivery obstacle. Red does not mean unimportant.

      Gate: Pending — appraisal incomplete (review label: “Pending: incomplete appraisal”).

      Why: Scores incomplete; Funding gate not passed (cost unknown or no credible funding).

      The gate is separate from national list membership: being listed does not make an option eligible, and an eligible option need not be listed.

      Cost and funding

      Lifetime costing: Not established. Review: “Full incremental costing not established in reviewed material”.

      Still to cost: Capital, staff, diagnostics, maintenance, displaced activity and recurring running costs.

      Funding status: not identified.

      Owner, powers and capacity

      Proposed owner: NHS commissioners/providers; nation-specific systems (proposed, unverified).

      Powers: needs a decision or allocation. Capacity: binding constraint.

      Powers and capacity read from the review’s Rd and Ca anchors; no proposed owner has agreed to act (the review: “Proposed owners have not agreed to act”).

      England:
      NHS England, integrated care boards and NHS trusts (action record)
      Scotland:
      not assessed
      Wales:
      not assessed
      Northern Ireland:
      not assessed

      Scotland, Wales and Northern Ireland run separate systems with different waiting standards; not assessed.

      Dependencies, safeguards and risks

      Depends on: None recorded.

      Safeguards

      None specified yet.

      Risks and residual harms: Binding workforce capacity; displacement of urgent or other elective care.

      Monitoring and measured results

      Metric: Patient waits and health outcomes, not hub throughput alone.

      Data source: Not yet named. Baseline: Not yet established.

      Measures already on the domain page

      A page measure is not necessarily the review’s metric; linking the two is an editorial decision still to be made.

      Evidence for the outcome

      Outcome: Patient waits and health outcomes, not hub throughput alone.

      Hub evidence concerns activity; the artifact notes no total activity gain. The proposed increment and effect on waits are unresolved.

      Review record

      Assessment status: Provisional single-reviewer assessment; not an approved business case.

      Reviewer: Original assessment author (name not supplied). Reviewed: 6 October 2026.

      Scored in the working review of 6 October 2026 on the shared ten-criterion scale (one reviewer); not independently calibrated.

      First 90 days (review): Produce a signed scope and current-delivery baseline; Map diagnostic, theatre, staffing and discharge constraints; select a specialty/locality; demonstrate addition beyond funded plans. Obtain incremental costs and an accountable decision before expansion.

      Decision route: Identify marginal bottleneck and appraise

      An editorial screening framework by one reviewer, not a formal appraisal or business case. Proposed owners have not agreed to act.

    • A75Delivery risk: RedGate: pending

      Fix NHS equipment and estate bottlenecks that cancel care

      Proposed new action A75; sourced research home and appraisal design; scope and funding remain provisional.

      Provisional single-reviewer desk assessment, 6 October 2026.

      Who and where
      Select named maintenance/equipment projects with logged downtime and funded staff to use restored capacity. (from the 6 October review) Jurisdiction: England.
      Result so far
      Range if completed: 15.0–21.0 out of 30 (equal weights; not yet assessed: expected incremental benefit (Bn), incremental affordability (Co))
      Funded now (baseline)
      Funded baseline not yet stated
      The change assessed (marginal)
      Select named maintenance/equipment projects with logged downtime and funded staff to use restored capacity. (from the 6 October review)
      • Domain home: NHS
      What the evidence supports—and the next decision

      The maintenance backlog measures estimated repair needs; it is not a forecast of cancelled care avoided by spending the same sum.

      AI-assisted analytical follow-up · 8 October 2026. Proposed appraisal design; the attributed scores below are unchanged. No funding or delivery agreement is implied.

      Define the change
      Select named equipment or estate failures linked to service downtime, with a funded workforce able to use restored capacity.
      Test whether it works
      Downtime, cancellations, usable sessions and patient outcomes before and after repair, allowing for demand and staffing changes.
      Establish the cost
      Survey, repair or replacement, decanting, maintenance, training and running costs; assess lifecycle alternatives and construction disruption.
      Protect against harm
      Prioritise safety and clinical need; avoid buying capacity that cannot be staffed.

      Read with the outcome evidence and sources in the full assessment. Monitoring proposals are not existing baseline measurements. A numerical benefit or cost score needs evidence for the defined increment, not just the scale of the problem.

      Full assessment of Fix NHS equipment and estate bottlenecks that cancel care: ten criteria, scenarios, delivery, costs and monitoring
      The ten criteria (0–3)

      Each criterion is scored 0 to 3 by the reviewer. “Not yet assessed” means unknown: it is never counted as zero.

      1. Scale and severity (Sc)3 of 3 — Severe harm across a broad population

        Reviewer’s reason: Problem scale judged from the linked domain evidence; not a population estimate of those helped.

      2. Increment beyond baseline (Ad)2 of 3 — Specific material change to existing delivery

        Reviewer’s reason: Select named maintenance/equipment projects with logged downtime and funded staff to use restored capacity. This is a provisional marginal-change judgement, to confirm against commissioned delivery.

      3. Confidence in the proposed action (Ev)1 of 3 — Indirect, mixed, modelled or weak causal support

        Reviewer’s reason: Site records a large backlog; it does not establish a national return per pound of repair.

      4. Expected incremental benefit (Bn)Not yet assessed

        Reviewer’s reason: Unknown: no sufficiently supported magnitude for this exact change.

      5. Residual harms (Hm)2 of 3 — Manageable harm with specified safeguards

        Reviewer’s reason: Capital without operating staff; shifting maintenance from other critical sites.

      6. Incremental affordability (Co)Not yet assessed

        Reviewer’s reason: Unknown: the proposed increment has not been costed and matched to an approved affordable allocation in this review. Existing programme envelopes are not that allocation.

      7. Delivery capacity (Ca)1 of 3 — Binding scarce resource

        Reviewer’s reason: Scheme costs and staff capacity must be established before approving expansion.

      8. Distribution (Fa)2 of 3 — Mixed or broadly neutral with safeguards

        Reviewer’s reason: Distribution assessed against the target group and the burdens described here: Capital without operating staff; shifting maintenance from other critical sites.

      9. Meaningful first outcome (Ti)2 of 3 — More than one and up to three years

        Reviewer’s reason: Timing judgement concerns the first meaningful outcome in: Cancelled lists due to estate/equipment; usable theatre hours and completed care, adjusted for staffing. It does not imply all long-term benefits arrive then.

      10. Readiness (Rd)2 of 3 — Named commissioning/allocation/coordination step

        Reviewer’s reason: Prioritise safety-critical work separately; appraise operational fixes using downtime and completed-care data. Owner: NHS trusts and capital commissioners in England.

      Four weightings

      Normalised as 10 × weighted sum ÷ sum of weights, on a 0–30 scale. Where a criterion is not yet assessed, the range is the lowest and highest result if it were later scored 0 or 3 — not a score, a confidence interval or a rank.

      • Equal weights: Range if completed: 15.0–21.0 out of 30. Not yet assessed: expected incremental benefit (Bn), incremental affordability (Co). Funding gate: not passed.
      • Evidence doubled: Range if completed: 14.5–20.0 out of 30. Not yet assessed: expected incremental benefit (Bn), incremental affordability (Co). Funding gate: not passed.
      • Scale doubled: Range if completed: 16.4–21.8 out of 30. Not yet assessed: expected incremental benefit (Bn), incremental affordability (Co). Funding gate: not passed.
      • Cost ignored (the funding gate still applies): Range if completed: 16.7–20.0 out of 30. Not yet assessed: expected incremental benefit (Bn), incremental affordability (Co). Funding gate: not passed.

      Funding gate: Not passed — the cost is not yet assessed or no allocation is committed for this scope. Ignoring cost in a weighting never removes the gate.

      Delivery risk and gate

      Delivery risk shown: RedReview’s claim: Red. Best the recorded evidence allows: Red.

      Review’s reason: Capital without operating staff; shifting maintenance from other critical sites. Scheme costs and staff capacity must be established before approving expansion.

      Why it is not Green yet

      • Delivery obstacle: Capital without operating staff; shifting maintenance from other critical sites. Scheme costs and staff capacity must be established before approving expansion..
      • Scope (population, place and increment) not verified against the delivery baseline.
      • No verified owner with the powers in place.
      • Delivery capacity not verified.
      • Lifetime incremental costs not complete.
      • No credible funding (a committed allocation for the scope).
      • Safeguards not specified.
      • Monitoring lacks a metric, a data source or a baseline.

      Green needs verified scope, a verified owner with the powers, verified capacity, complete lifetime costs with credible funding, specified safeguards and monitoring with a metric, source and baseline. Amber means appraisal gaps remain; Red means a material delivery obstacle. Red does not mean unimportant.

      Gate: Pending — appraisal incomplete (review label: “Pending cost, funding, scope and capacity appraisal”).

      Why: Scores incomplete; Funding gate not passed (cost unknown or no credible funding).

      The gate is separate from national list membership: being listed does not make an option eligible, and an eligible option need not be listed.

      Cost and funding

      Lifetime costing: Not established.

      Still to cost: Incremental lifetime costs and funding not established. Scheme costs and staff capacity must be established before approving expansion.

      Funding status: not established in review.

      Owner, powers and capacity

      Proposed owner: NHS trusts and capital commissioners in England. (proposed, unverified).

      Powers: needs a decision or allocation. Capacity: binding constraint.

      Powers and capacity read from the review’s Rd and Ca anchors; no proposed owner has agreed to act (the review: “Proposed owners have not agreed to act”).

      England:
      NHS trusts and capital commissioners in England. (review)
      Scotland:
      not assessed
      Wales:
      not assessed
      Northern Ireland:
      not assessed

      Read from the review’s owner and scope text; not verified against the powers held.

      Dependencies, safeguards and risks

      Depends on: Scheme costs and staff capacity must be established before approving expansion.

      Safeguards

      None specified yet.

      Risks and residual harms: Capital without operating staff; shifting maintenance from other critical sites.

      Monitoring and measured results

      Metric: Cancelled lists due to estate/equipment; usable theatre hours and completed care, adjusted for staffing.

      Data source: Not yet named. Baseline: Not yet established.

      Evidence for the outcome

      Outcome: Cancelled lists due to estate/equipment; usable theatre hours and completed care, adjusted for staffing.

      Site records a large backlog; it does not establish a national return per pound of repair.

      Review record

      Assessment status: Provisional single-reviewer desk assessment, 6 October 2026.

      Reviewer: Original assessment author (name not supplied). Reviewed: 6 October 2026.

      Carried from the earlier domain review (C record): must be calibrated jointly with the G/W/E/NG/NW/NE records before any combined comparison.

      Decision route: Prioritise safety-critical work separately; appraise operational fixes using downtime and completed-care data.

      An editorial screening framework by one reviewer, not a formal appraisal or business case. Proposed owners have not agreed to act.

    Decision brief

    • Protect staffed theatre sessions for routine operations where emergencies cancel them — and test whether waits for those operations fall

    The leading option set out as a decision someone could take: who decides, who benefits, the best evidence, cost and funding, and the main trade-off. The full research record is one click away.

    Decision briefPublic-policy proposalReviewed 2026-10-04

    Protect staffed theatre sessions for routine operations where emergencies cancel them — and test whether waits for those operations fall

    The thread: issue, evidence, action

    1. Issue Weakness: 65.2% of waiting pathways were within 18 weeks, against the 92% standard, last met in September 2015 on the figures including estimates for missing trusts (February 2016 on reported figures). Also: weakness, strength
    2. Evidence Waiting pathways within 18 weeks; Treatment pathways waiting
    3. Action Protect elective surgery from emergency disruption
    Decision required
    An integrated care board and its hospital trusts choose two or three specialties where planned operations are being cancelled by emergency pressure, and fund protected theatre lists with the staff and recovery beds to run them, under a business case that sets out the cost per extra completed operation and a waiting-time evaluation.
    Who and where
    Adults on referral-to-treatment pathways in the chosen specialties at the participating trusts, starting with high-volume, low-complexity procedures. Applies in: England.
    Accountable body
    Integrated care board (commissioner) and the provider trust boards; NHS England regional team for capital and Getting It Right First Time (GIRFT) surgical-hub accreditation
    Intervention
    Ring-fence staffed theatre sessions and recovery beds for planned lists in the chosen specialties.
    Best evidence, and where it applies
    An England-wide evaluation found 21.9% more routine, high-volume operations in the first year at 31 trusts that opened surgical hubs (95% CI 11.7% to 32.2%). Total planned surgery at those trusts did not change significantly, and waiting times were not measured.Studied in: 8.08 million elective operations at 31 trusts that opened hubs, 23 with established hubs and 54 without (April 2018 to December 2022, excluding April 2020 to March 2021).How closely the comparison transfers to this decision: Denmark (national) and Portugal (national surgical waiting-list system) — partial.
    Extra cost of this change
    Capital: none identified in the brief.Recurring: Staffed theatre sessions (anaesthetist, theatre team, recovery nursing) — not yet established; Cost per additional completed case — not yet established.One-off or mixed: Site capital, theatre staff, equipment and running costs for a hub — Not yet costed; Independent evaluation of waits, activity, displacement and emergency performance — not yet established.
    Funding
    Not funded yet: a possible funding route exists, but nothing is allocated to this change.Committed to this change: none.Possible source, not an award: none identified.Unfunded: Unknown until a site is chosen and costed; the whole cost is unfunded at project level.
    Savings and wider benefits
    Not yet specified: no cashable saving or avoided cost has been costed for this change. Expected outcomes are listed one by one in the research appendix and are never added together or counted as money available.
    First 90-day step
    Publish the site’s cancellation and theatre-utilisation audit and the shortlist of specialties, with the procedures, staffed sessions and comparison group named.The proposed first milestone; a 90-day date is not yet specified. Owner: Provider trust with the integrated care board. Proposed by UK Facts, not an official deadline.
    Twelve-month milestone
    Not yet specified.Time to a first useful result: Activity and cancellations within months of opening (the national study saw effects after about three months); waits for the chosen procedures need roughly a year of pathway data.
    Outcome, and when to scale or stop
    Measure: Protected sessions actually run as planned, and on-the-day cancellations for non-clinical reasons.Scale if: Completed operations and waits for the chosen procedures both improve against the comparison without a measurable worsening of emergency care or safety, at a cost per additional case the business case judged acceptable.Stop if: Protected sessions cannot be staffed without drawing on emergency rotas, or emergency performance or safety worsens attributably.
    Main trade-off
    Staff and beds ring-fenced for planned lists are not available to emergency care, and more of one kind of operation can leave the overall queue unchanged.
    Source and review date
    Surgical hubs: key to tackling hospital waiting lists? (blog) and The impact of elective surgical hubs on elective surgery in acute hospital trusts in England (Nature Communications, 2025) (4 July 2025 (paper); 5 September 2024 (blog)). Reviewed 2026-10-04.

    An editorial proposal by UK Facts for discussion, not government policy. Records: A04 · effects E-A04-ACTIVITY · costs C-A04-HUB

    Research appendix: study design, effect sizes and limits, alternatives, full costing, international comparisons and how we would know

    1.The change, in plain words

    Protect staffed theatre sessions for routine operations where emergencies cancel them — and test whether waits for those operations fall

    2.The decision requested

    Decision
    Approve, for one integrated care board area, a costed business case to protect a defined number of staffed theatre sessions a week for two or three named specialties, chosen because local data show on-the-day cancellations or lost theatre time from emergency pressure; and commission an evaluation of waits for those procedures before any wider roll-out.
    Accountable institution
    Integrated care board (commissioner) and the provider trust boards; NHS England regional team for capital and Getting It Right First Time (GIRFT) surgical-hub accreditation
    Geography
    England
    Powers
    Existing NHS commissioning and trust powers under the National Health Service Act 2006 (as amended by the Health and Care Act 2022); capital through NHS England’s capital allocations and business-case process. No new law.
    Delivery partners
    Provider trusts’ surgical, anaesthetic and theatre teams; NHS England regional elective team and GIRFT; Local authority adult social care (discharge); Independent-sector providers already contracted for NHS work, where they form part of the option

    3.Who it is for, and what changes beyond today

    Target population
    Adults on referral-to-treatment pathways in the chosen specialties at the participating trusts, starting with high-volume, low-complexity procedures.
    Eligibility
    Patients clinically suitable for a protected planned list (the case mix the hub is designed and accredited for); complex or high-risk cases stay on main-site lists.
    Scale
    Set by the local business case from measured cancellations, theatre utilisation and the staff who can be recruited — not a national number. A first phase of two or three specialties at one site lets the effect on waits be measured against comparable specialties or trusts.
    Baseline
    65.2% of waiting pathways in England were within 18 weeks in August 2026, against the 92% standard, last met in September 2015 on the figures including estimates for missing trusts (February 2016 on reported figures); 7.37 million pathways were waiting. No national series records how many planned operations are lost to emergency pressure at a given site, so the local baseline must be measured first.

    Source: NHS England, Referral to treatment (RTT) waiting times: overview time series including estimates for missing trusts (Overview time series)

    Change beyond existing law or funding
    Surgical hubs already exist and NHS capital for 2026/27 targets finishing schemes begun in 2025/26. The added change is not another building: it is protected, fully staffed sessions (anaesthetists, theatre staff, recovery beds) chosen where cancellations are the measured constraint, priced as cost per extra completed case, with a pre-specified waiting-time evaluation and a check on what capacity was displaced.

    4.How it would work

    Do: Ring-fence staffed theatre sessions and recovery beds for planned lists in the chosen specialties Changing: fewer planned operations lost to emergency pressure, so more routine operations are completed each week

    • More high-volume, low-complexity operations at the participating trusts

      Measured for this interventionEffect record E-A04-ACTIVITY

      Measured at 31 English trusts that opened hubs (first year, 2018–2022 data). Whether a new site repeats it depends on design, staffing and case mix.

    • Shorter waits for the same procedures

      Hypothesis to test

      Not measured by any study we found. Activity can rise without waits falling if referrals rise or work moves from other lists; this is the main thing the pilot must test.

    • No worse emergency performance or patient safety at the same trusts

      Hypothesis to test

      A risk to monitor, not an expected benefit: staff drawn into protected lists may come from emergency care.

    Outcomes are kept separate and never added into one impact figure.

    5.Best evidence

    • Surgical hubs: key to tackling hospital waiting lists? (blog) and The impact of elective surgical hubs on elective surgery in acute hospital trusts in England (Nature Communications, 2025)

      Author or institution:
      Melissa Co, Tatjana Marks, Freya Tracey, Stefano Conti, Geraldine M. Clarke (Improvement Analytics Unit, Health Foundation and NHS England); commissioned by NHS England’s GIRFT team
      Published:
      4 July 2025 (paper); 5 September 2024 (blog)
      Evaluation period:
      April 2018 to December 2022, excluding April 2020 to March 2021
      Design:
      Generalised synthetic control on a trust-level panel of Hospital Episode Statistics
      Sample or population:
      8.08 million elective operations at 31 trusts that opened hubs, 23 with established hubs and 54 without
      Effect and uncertainty:
      High-volume, low-complexity surgery 21.9% higher in the first year at new-hub trusts (95% CI 11.7% to 32.2%), about 29,000 extra procedures a year; total elective surgery not significantly different; no length-of-stay effect at new hubs.
      Limits:
      Did not measure waiting times, quality, safety, emergency care or inequalities; could not separate hub activity from wider trust activity or shifts to private providers; trusts that opened hubs may have been better placed financially.

      Where: Nature Communications paper: Results “New hubs”, Table 3, Fig. 3; Discussion (limitations). Affiliation is provenance, not proof of quality.

    6.Alternatives, counter-evidence and who loses

    Closest feasible alternative
    Buy the same operations from independent-sector providers already contracted for NHS work, or spend the money on discharge capacity so that beds stop being the reason lists are cancelled.
    Strongest counter-evidence
    At the trusts that opened hubs, total planned surgery did not rise significantly: more routine operations may have displaced other work rather than adding to it. The waiting list depends on referrals and total capacity, which a protected list does not change.

    Source: Health Foundation, Surgical hubs: key to tackling hospital waiting lists? (blog) and The impact of elective surgical hubs on elective surgery in acute hospital trusts in England (Nature Communications, 2025) (Results “New hubs”; Discussion)

    Distributional effects
    Gains go to patients needing routine operations at the participating sites; patients with complex conditions, emergency patients and people who cannot travel to a hub could lose out if staff and beds move. Waits differ by deprivation, so the evaluation should report who was treated.
    Main downside
    Staff are the scarce resource: protecting planned sessions without new anaesthetists, theatre staff and recovery nurses moves the shortage to emergency care.

    The options compared, including current policy

    • The proposal

      Protected, fully staffed sessions in named specialties with a waiting-time evaluation (this brief)

      Who is reached
      Patients needing routine operations in the chosen specialties at the participating sites
      Evidence
      Evaluated: more routine operations at hub trusts; effect on waits not measured
      Likely outcome and timing
      More operations within months; any change in waits measurable after about a year
      Cost and funding
      Not costed; capital route exists, staff costs recurring, nothing allocated
      Main trade-off
      Staff and beds unavailable to emergency care; may move rather than add work

    • Current policy

      Current policy: finish hub schemes already under way, with activity targets

      Who is reached
      Patients at trusts with hub schemes begun in 2025/26
      Evidence
      Same evaluation; no wait-time measurement built in
      Likely outcome and timing
      More routine activity where staffed; effect on waits unknown
      Cost and funding
      NHS capital for elective recovery in 2026/27; scheme-level amounts not published here
      Main trade-off
      Buildings can be completed without the staff to run them

    • Alternative

      Buy more operations from contracted independent-sector providers

      Who is reached
      Patients willing and able to travel to a private provider for NHS-funded care
      Evidence
      Activity is countable; effect on overall waits depends on whether NHS staff move to the private sector
      Likely outcome and timing
      Fast where capacity exists
      Cost and funding
      Paid per case from NHS budgets; not costed here
      Main trade-off
      Same staff pool; complex cases stay in NHS hospitals

    • Alternative

      Spend on discharge capacity so beds stop cancelling lists

      Who is reached
      Patients delayed in hospital and those whose operations need a bed
      Evidence
      Not evaluated here for its effect on elective cancellations
      Likely outcome and timing
      Depends on social-care workforce
      Cost and funding
      Shared NHS and council budgets; not costed here
      Main trade-off
      Not every delayed discharge is a social-care delay

    • Alternative

      A waiting-time guarantee with a right to go elsewhere (Denmark, Portugal)

      Who is reached
      Everyone who passes the maximum wait
      Evidence
      Descriptive reviews only; in Portugal most vouchers went unused
      Likely outcome and timing
      Moves patients if spare capacity exists elsewhere
      Cost and funding
      Not established
      Main trade-off
      England already has an 18-week standard and choice; a guarantee does not add staffed capacity

    7.What other countries or the devolved nations show

    Country lesson · Denmark (national) and Portugal (national surgical waiting-list system), Denmark: guarantee in place for several years, described in 2024; Portugal: SIGIC from 2004, maximum times reset in 2015 and 2017

    Waiting-time guarantees with a right to go elsewhere in Denmark and Portugal

    Evidence: Expert or audit recommendationPartial match: some conditions differ

    What was changed
    A legal maximum wait, published waiting-time information and, when the maximum is missed, a right to treatment at another public or a private hospital paid for by the home system. Denmark: diagnosis within 30 days, treatment within a further 30. Portugal: a surgery voucher generated automatically at 75% of the maximum time for the patient’s priority (maximums from 15 to 270 days in 2015).
    Study design and population
    Descriptive health-system reviews (European Observatory) and administrative voucher data reported in a news fact-check. No causal evaluation of either guarantee’s effect on waits was found in these sources. All patients referred for planned hospital diagnosis and treatment (Denmark); patients listed for planned surgery in the Portuguese NHS.
    Measured outcome there
    No measured effect on waiting times is available from these sources. What is recorded: in Portugal in 2022 only 21% of 165,079 vouchers were used; in 2017 the review found no effective mechanism to enforce the maximum times and waits still very high. In Denmark in 2022 about 4,700 nursing posts were unfilled and staff shortages cancelled operations.
    Cost status
    Not established. The Danish review expects capacity limits to raise public spending on private hospitals; no cost per additional case was found for either country.
    What failed or remains uncertain
    A guarantee without spare capacity moves patients and money rather than adding operations: most Portuguese patients did not take up the voucher, and Danish shortages of nurses cancelled planned surgery and put the guarantee itself under review.
    Why the UK differs
    England already has a legal 18-week standard and a right to choose provider, and independent-sector capacity is already used; the binding constraint is staffed theatre and bed capacity, not a missing entitlement. Danish and Portuguese case mix, private capacity and payment rules differ.
    First change required here
    Before adding any guarantee or choice right, measure where staffed theatre sessions are lost to emergency pressure and fund the staff and beds that protect them; track whether patients offered another provider actually move.

    Not a UK forecast: the effect above was measured in that place and population. Source: European Observatory on Health Systems and Policies (WHO Regional Office for Europe), Denmark: Health system review 2024 (Health Systems in Transition, vol. 26 no. 1) (pp.xxiii, 29–31, 115; section 7.2.3); European Observatory on Health Systems and Policies (WHO Regional Office for Europe), Portugal: Health system review 2017 (Health Systems in Transition, vol. 19 no. 2) (pp.110–111, 159); Rádio Renascença (rr.pt), Fact Check: “80% dos cheques-cirurgia ficam por utilizar”. Verdade ou mentira? (Paragraphs 2–4). Reviewed 2026-10-04.

    8.What delivery needs first

    • staff — Anaesthetists, theatre practitioners and recovery nurses to staff the protected sessions without taking them from emergency rotas. (Genuine veto: nothing proceeds without it; owner: Provider trusts (workforce plans), NHS England regional workforce team)
    • infrastructure — Theatres and recovery or day-case beds that can physically be kept separate from emergency flow. (Scarce resource shared with other priorities; owner: Provider trust estates; NHS England capital)
    • data — Site-level data on on-the-day cancellations, their reasons and theatre utilisation, plus pathway-level waiting times by procedure, to pick specialties and evaluate. (Requirement; owner: Trust business intelligence; integrated care board analytics)
    • dependency — Discharge capacity, so recovery beds are free for the next list. (Scarce resource shared with other priorities; owner: Integrated care board with local authority adult social care)
    • procurement — A capital business case through NHS England’s process if any building or equipment is needed. (Requirement; owner: Provider trust with NHS England)

    9.What it would cost

    How the cost is built up: Capital (if any) + staffed sessions a week × cost per session × weeks + recovery-bed costs + evaluation; divided by additional completed operations net of displaced work = cost per additional completed case.

    • Site capital, theatre staff, equipment and running costs for a hub

      One trust or system where a local business case supports protected capacity

      Not yet costed (ledger C-A04-HUB)

      mixed; price year not stated; Capital up front; staff and running costs every year; Not yet established

      Read from the ledger record, which has no amount: past programme spending is not a price for a new scheme.

      Source: NHS England, Capital guidance 2026/27 to 2029/30 (“Constitutional standards and hospital to community shift”)

    • Staffed theatre sessions (anaesthetist, theatre team, recovery nursing)

      Protected sessions a week in the chosen specialties

      Not yet established per staffed session

      recurring; price year not stated; Each year of operation; Not yet established

      The largest recurring cost and the true constraint; it must be priced from the trust’s own pay costs and vacancy position.

    • Cost per additional completed case

      Extra operations completed in the chosen specialties, net of work displaced from other lists

      Not yet established per additional completed case

      recurring; price year not stated; Each year of operation; Not yet established

      The decision metric: total added cost divided by operations that would not otherwise have happened. National tariff prices are payments, not the marginal cost of an extra case.

    • Independent evaluation of waits, activity, displacement and emergency performance

      Participating specialties against comparable specialties or trusts

      Not yet established per evaluation

      one-off revenue; price year not stated; First two years; Not yet established

    10.Who pays, and what is missing

    Programme envelope (a possible route, not an award)
    None identified
    Allocation committed to this change
    None
    Remaining gap
    Unknown until a site is chosen and costed; the whole cost is unfunded at project level.
    Proposed financing
    NHS capital for elective recovery (about £2.0bn in 2026/27 across diagnostics, elective and urgent care, within a £5bn four-year programme) could pay for any building; staff and running costs would come from the integrated care board’s allocation and elective activity payments. Nothing is allocated to this scheme.
    Responsible payer
    NHS
    Budget displaced
    Capital not spent on diagnostics, discharge or urgent and emergency care; staff time not available to emergency rotas.

    11.First milestone and time to a useful result

    Publish the site’s cancellation and theatre-utilisation audit and the shortlist of specialties, with the procedures, staffed sessions and comparison group named. (Owner: Provider trust with the integrated care board. Proposed by UK Facts, not an official deadline.)

    Time to first useful result: Activity and cancellations within months of opening (the national study saw effects after about three months); waits for the chosen procedures need roughly a year of pathway data.

    What could delay it: Staff can be recruited rather than moved from emergency care Recovery beds are freed by discharge capacity Capital approval, if needed, is timely Pathway-level waiting data are available by procedure

    12.How we would know

    Baseline
    For each chosen procedure: waiting-time distribution, completed operations a week, on-the-day cancellations and their reasons, theatre utilisation, and emergency performance at the same trust, over the year before the change.
    Comparison
    Comparable specialties at the same trust and matched trusts without protected lists (a synthetic control, as in the national study), with a phased start if more than one site joins.
    Leading indicator
    Protected sessions actually run as planned, and on-the-day cancellations for non-clinical reasons.
    Follow-up
    Twelve and 24 months: waits for the chosen procedures, total planned activity at the trust (to detect displacement), complications and readmissions, emergency performance, and who was treated by deprivation and age.
    Continue if
    Completed operations and waits for the chosen procedures both improve against the comparison without a measurable worsening of emergency care or safety, at a cost per additional case the business case judged acceptable.
    Adapt if
    Activity rises but waits do not: check for displaced work and rising referrals, and change the specialty mix or the staffing model before expanding.
    Stop if
    Protected sessions cannot be staffed without drawing on emergency rotas, or emergency performance or safety worsens attributably.
    Thresholds
    Not yet set: Numerical success and stop levels need the local baseline, the business case and a power calculation for the comparison; none exists yet.

    What is not yet known, and how to find out

    • What does one protected, fully staffed session cost, and what is the cost per additional completed case? (cost)Next step: Price the staffing model and any capital in the local business case, net of displaced activity.Scope: Protected sessions a week in two or three specialties at one site, for two years · Data or quotes needed: Trust pay costs and vacancy rates, theatre and bed running costs, National Cost Collection unit costs for the procedures, any capital quotes · Who can estimate it: Provider trust finance team with the integrated care board; NHS England regional finance for capital
    • Do protected lists shorten waits for the same procedures, or only raise activity? (effect)Next step: Run the first phase as a bounded pilot with a matched comparison and pre-registered waiting-time outcomes.Defensible route: bounded pilot
    • Which specialties at which site lose most planned operations to emergency pressure? (data)Next step: Audit on-the-day cancellations by reason and theatre utilisation over the last 12 months.
    • Can the sessions be staffed without drawing on emergency rotas? (delivery)Next step: Test recruitment and rota plans in the business case before capital is committed.

    Sources last checked 4 October 2026 · Owner: Evidence editor (James Harris) · Next check: the first trigger: NHS England monthly referral-to-treatment and cancelled-operations statistics.

    More decision briefs on other pages

    What it would take

    The order things have to happen in, who pays, and the effects and appraisals on record.

    The order things have to happen in

    1. First, the prerequisite

      Measure cancellations, theatre use and staffing at candidate sites

      Owner: Trusts and integrated care boards

      No date: the timing depends on the steps before it.

    2. Then, the decision

      Approve a costed business case with staff and running budget

      Owner: Integrated care boards with NHS England (capital)

      No date: the timing depends on the steps before it.

    3. Then, delivery

      Open protected capacity; build IPS referral routes from clinical teams

      Owner: Trusts; Connect to Work delivery areas

      No date: the timing depends on the steps before it.

    4. Finally, the measured outcome

      92% of pathways within 18 weeks

      Owner: NHS England

      March 2029 (official milestone; restated 25 August 2026) — source

    5. First, the prerequisite

      Publish the binding constraint by specialty and trust (diagnostics, theatres, staff, discharge)

      Owner: NHS England

      No date: the timing depends on the steps before it.

    Who pays, and what is still missing

    Cost, committed funding and the remaining gap for the same scope and years. A programme envelope is not an award to a project; a proposal is not committed money. No total is shown because these costs are on different bases or periods and cannot be added.

    Connect to Work (A09): cost and funding by period

    £ in total, cash (nominal) prices. Outline = cost; solid = committed; hatched = proposed, not committed; empty = no funding identified.

    • Connect to Work grant and programme costs, 2025–26 to 2028–29: cost £1.03bn; committed £1.09bn

    • Connect to Work costs, 2029–30 to 2031–32: cost £134.4m; nothing committed; proposed £138m

    Committed funding for 2025–26 to 2028–29 is slightly above the revised cost because volume forecasts changed. The later years are costed but not funded. NHS integration costs are not included because they are not established.

    Cost and funding ledger

    • Site capital, theatre staff, equipment and running costs for a hub

      A04 · capital · not costed

      Amount
      Not yet costed
      Who pays
      NHS
      Committed
      None identified
      Proposed, not committed
      —
      Gap
      Not established

    • Connect to Work grant and programme costs, 2025–26 to 2028–29

      A09 · recurring spending · complete for scope

      Amount
      £1.03bn in total, 2025–26 to 2028–29, cash (nominal) prices
      Who pays
      central government
      Committed
      £1.09bn
      Proposed, not committed
      —
      Gap
      None for this scope

    • Connect to Work costs, 2029–30 to 2031–32

      A09 · recurring spending · complete for scope

      Amount
      £134.4m in total, 2029–30 to 2031–32, cash (nominal) prices
      Who pays
      central government
      Committed
      None identified
      Proposed, not committed
      £138m (Connect to Work funding to be requested at a future Spending Review)
      Gap
      £134.4m

    • NHS clinical integration, referral and supervision for IPS

      A09 · recurring spending · not costed

      Amount
      Not yet costed
      Who pays
      NHS
      Committed
      None identified
      Proposed, not committed
      —
      Gap
      Not established

    “Not yet costed” means no defensible cost has been found — not that the action is free. Lifetime benefits, benefit-cost ratios and forecast savings are never shown here as money available to spend.

    Effects on record, with evidence ratings (4 records)

    What the evidence says each action changes

    Effects on record — these measure different outcomes, so they are not drawn on one scale
    ActionOutcome and areaEffectCompared withEvidence
    Protect elective surgery from emergency disruptionHigh-volume, low-complexity operations at trusts that opened a hub Health and care+21.9%95% CI 11.7% to 32.2%a synthetic comparison built from trusts without hubs; first year after opening, 2018–2022 dataevaluated; moderate confidence; 31 English acute trustsActivity, not the waiting list: total elective surgery at these trusts did not change significantly, and the study did not measure waits.
    Offer evidence-based employment support alongside healthcareWorking 13 or more weeks in the year after joining (out-of-work participants) Work and pay+4 percentage points (22% vs 18%)significant at the 99% level; no interval publishedrandomised control group receiving usual support; 12 months after randomisation, 2018–2020evaluated; moderate confidence; West Midlands Combined AuthorityNo effect for out-of-work participants in Sheffield City Region, and no effect on earnings at 12 months.
    Offer evidence-based employment support alongside healthcareWorking 13 or more weeks in the year after joining (people in work but struggling) Work and pay+3 percentage pointssignificant only at the 90% level; no interval publishedrandomised control group; 12 months after randomisation, 2018–2020evaluated; limited confidence; Sheffield City RegionWeaker evidence than the West Midlands result.
    Offer evidence-based employment support alongside healthcareSelf-reported health (EQ-5D-5L) at 12 months Health and care+0.10 standard deviationssignificant at the 90% level (99% when Sheffield groups are pooled); no effect in the West Midlandsrandomised control group; 12 months after randomisationevaluated; limited confidence; Sheffield City RegionSmall; not found in the West Midlands. Not evidence of reduced NHS demand.

    How we would know

    Waiting pathways within 18 weeks; Treatment pathways waiting; Economically inactive because of long-term sickness, aged 16–64; and 1 more.

    The outcome measures to watch. A baseline is where we start, not a target; where there is no official target we say so.

    Measured results

    What each option would be judged on, and the latest value of the measures already on this page. A measure moving is not proof that an option caused it.

    Where the ideas come from

    Research, counter-evidence and methods (16 sources; 2 claims held back)
    • Surgical hubs: key to tackling hospital waiting lists? (blog) and The impact of elective surgical hubs on elective surgery in acute hospital trusts in England (Nature Communications, 2025) — Health Foundation (Geraldine Clarke (blog); Melissa Co, Tatjana Marks, Freya Tracey, Stefano Conti, Geraldine M. Clarke (paper)), 2024-09-05 (blog); 2025-07-04 (paper).Generalised synthetic control method on a trust-level panel (not difference-in-differences); 8.08 million elective operations in Hospital Episode Statistics at 31 new-hub, 23 established-hub and 54 non-hub acute trusts, April 2018 to December 2022 (excluding April 2020 to March 2021); England. Full text checked (read from an Internet Archive copy), 2026-10-04. Limits: Neither the blog nor the paper measures the waiting list. Activity is not the same as a shorter queue; the effect is for one category of surgery at the trusts that opened hubs.
    • Connect to Work: Programme Business Case 2 summary — Department for Work and Pensions, 2026-07-30.Programme business case; England and Wales. Full text checked, 2026-10-04.
    • State of Care 2024/25: Mental health — Care Quality Commission, date not stated.Regulator assessment; England. Relevant passages checked, 2026-10-10. Limits: Dated regulator findings; not a 2026 national prevalence estimate or hospital RTT statistic.
    • ERIC 2024/25: summary and dataset — NHS England, 2025-10-16.Official statistics; England. Relevant passages checked, 2026-10-08. Limits: Supports the stated problem or design consideration, not the causal effect or cost of the proposed action.
    • Community health services waiting times: actions to meet Medium term planning framework targets — NHS England, date not stated.Operational guidance; England. Relevant passages checked, 2026-10-08. Limits: Separate community-service standards and pathway guidance; not an estimate of the causal effect of additional capacity and not additive to hospital RTT waits.
    • Referral to treatment (RTT) waiting times: overview time series including estimates for missing trusts — NHS England, date not stated.Official statistics; England. Relevant passages checked, 2026-10-04.
    • Monthly diagnostic waiting times: national time series — NHS England, date not stated.Official statistics; England. Relevant passages checked, 2026-10-10. Limits: Latest national percentage comes from the existing validated registry. Covers 15 diagnostic tests; not all tests or unique people across NHS pathways. Historical revisions may change earlier observations.
    • Diagnostic waiting times and activity (DM01), July 2026 — NHS England, 2026-09-10.Official statistics; England. Relevant passages checked, 2026-10-07.
    • Referral to treatment waiting times statistics: July 2026 press notice — NHS England, 2026-09-10.Official statistics; England. Relevant passages checked, 2026-10-07. Limits: Three trusts and one independent provider did not submit; their figures are estimated. August 2026 data are due 8 October 2026.
    • Investigation into the NHS dental recovery plan — National Audit Office, 2024-11-27.Audit report; England. Relevant passages checked, 2026-10-07. Limits: Historical assessment of the 2024 plan; not current dental access statistics or a measured impact of later contract reforms.
    • Health-led Employment Trials: evaluation synthesis report — Department for Work and Pensions, 2023-04.Randomised controlled trials of an adapted IPS service with economic and process evaluations; 9,785 people randomised in Sheffield City Region and the West Midlands, May 2018 to October 2019; people with mild to moderate physical or mental health conditions, in or out of work; Two English combined authorities. Relevant passages checked, 2026-10-04. Limits: Adapted IPS for mild to moderate conditions; results differ sharply by site and group. Not evidence about severe mental illness or all economically inactive people.
    • Update on the New Hospital Programme — National Audit Office, date not stated.Independent audit; England. Relevant passages checked, 2026-10-10. Limits: January 2026 delivery-risk assessment; not a current count of completed hospitals.
    • Capital guidance 2026/27 to 2029/30 — NHS England, 2025-11-17.Official capital funding guidance; England. Relevant passages checked, 2026-10-04. Limits: No separate amount for surgical hubs; a later section gives “circa £6.0bn” for a related total. Capital eligibility does not fund staff or running costs.
    • Investment priorities for mental health 2025 — Centre for Mental Health, 2025-05-07.Evidence review and policy proposals. Full text checked, 2026-10-04. Limits: Supports examining Individual Placement and Support for appropriate populations. Check original trials, service fidelity and the vintage of any national costing before reuse.
    • NHS hospital productivity: some positive news — Institute for Fiscal Studies (Harvey-Rich M, Warner M, Zaranko B), 2024-11-12.Independent analysis; England. Relevant passages checked (The live IFS page returned HTTP 403; read through the Wayback Machine copy of 18 February 2026.), 2026-10-07. Limits: Descriptive, not causal.
    • Labour Force Survey: economically inactive because of long-term sickness, 16–64 — Office for National Statistics, 15 September 2026.Official statistics (Labour Force Survey); United Kingdom. Relevant passages checked, 2026-10-04.

    Counter-evidence and criticism

    • Protect elective surgery from emergency disruption: More routine operations did not raise total elective activity at these trusts, so hubs may shift work rather than add it; staff may be drawn from emergency care. (Health Foundation)
    • Offer evidence-based employment support alongside healthcare: One of three trial groups saw no employment effect and the Exchequer return within a year was 1–2p per £1; benefits were mainly in health and wellbeing, and only in one area. (Department for Work and Pensions)
    • Cut treatment waits and improve patients’ health: More capacity has not reliably meant shorter waits; the March 2026 rise may partly reflect waiting-list validation rather than treatment. (Institute for Fiscal Studies)

    Claims held back

    • Surgical hubs reduced (or did not reduce) the overall waiting list — Neither the blog nor the paper measured the waiting list. Needed: A study of waits at hub trusts against comparators.
    • IPS saves NHS money or benefit spending — The trials found health gains in one area and a 1–2p Exchequer return per £1 within a year; no cashable NHS saving was measured. Needed: Longer follow-up with service-use data.

    “Full text checked” means we read the report itself; “relevant passages” means the sections behind each figure; “summary or abstract only” means we could not read the full study, so no number from it is published here without another source.

    Other options compared — not on the shortlist (3)

    Other options compared

    Options from earlier work on this page that are not on the shortlist. They remain valid choices; their evidence is shown as before.

    • capacityStatus: operating

      Keep and grow the workforce

      Aims to:
      Fewer staff leaving and more trained staff in the professions with the longest queues.
      How:
      Better retention (flexible working, pay, pensions, workload), more training places and fewer vacancies raise capacity at every step of the journey.
      Who decides:
      DHSC, NHS England, NHS trusts; HM Treasury (pay); universities and medical schools (training).
      Main constraint:
      New doctors take five to ten years to train; international recruitment is ethically and politically constrained.
      Evidence:
      Moderate evidence — evaluated, with limits on scope or transfer
      See the trade-offs and evidence
      What the evidence shows
      The 2023 Long Term Workforce Plan projected shortfalls without action and set training expansions; staff numbers have grown fast since 2019 while measured productivity has not kept pace, so headcount alone is not enough.
      Policy status
      A refreshed workforce plan is due; training expansion takes years to deliver.
      Resources
      Pay settlements; training places and supervisors; housing and childcare support in some areas.
      Consent and decisions needed
      Pay disputes and industrial action in recent years show the cost of disagreement.
      Time
      Retention can change within a year or two; training expansion takes five years or more.
      Cost and yield
      No single costing for a retention package is cited here; pay settlements are the largest cost.
      Trade-offs and who pays
      Pay rises compete with spending on equipment and buildings within the same budget.
      How we would know it worked
      Leading indicator: Leaver rates and vacancy rates by profession. Outcome: Activity per member of staff rising, and waits falling. It would not be working if: Headcount grows but activity and waits do not improve.
    • capacityStatus: operating

      Discharge support and social care capacity

      Aims to:
      Patients who are medically ready leave hospital the same day, freeing beds for A&E and planned care.
      How:
      Funding for home care, reablement and care-home places, plus joined-up NHS and council discharge teams, lets hospitals discharge patients on time.
      Who decides:
      DHSC and MHCLG (funding), councils (social care), NHS trusts and ICBs (discharge), care providers.
      Main constraint:
      Care-sector vacancies and low pay; councils’ budgets are under separate pressure.
      Evidence:
      Limited evidence — plausible mechanism, little direct evaluation
      See the trade-offs and evidence
      What the evidence shows
      Delayed discharges are consistently linked to bed pressure, but evaluations of past discharge funds found effects that were modest or hard to separate from other changes. Care reform does not free beds without the staff and places to receive patients.
      Policy status
      Better Care Fund continues; an independent commission on adult social care is due to report in stages.
      Resources
      Care workers, care-home and home-care capacity, council budgets.
      Consent and decisions needed
      Long-term social care funding reform has been deferred by successive governments.
      Time
      Short-term funding acts within months; workforce capacity takes years.
      Cost and yield
      Depends on the package; no single costing is cited here.
      Trade-offs and who pays
      Money for discharge competes with prevention and with longer-term care reform.
      How we would know it worked
      Leading indicator: Patients in hospital who no longer meet the criteria to reside. Outcome: 12-hour A&E waits and bed occupancy falling. It would not be working if: Funding rises but delayed discharges do not fall.
    • capacityStatus: funded

      Invest in buildings, equipment and IT

      Aims to:
      Fewer beds and theatres out of action, faster diagnostics and more productive staff.
      How:
      Clearing the repair backlog and replacing old equipment and IT removes physical limits on activity and lets staff spend more time with patients.
      Who decides:
      DHSC and HM Treasury (capital budgets), NHS England and trusts.
      Main constraint:
      Capital has often been raided to fund day-to-day spending in the past.
      Evidence:
      Moderate evidence — evaluated, with limits on scope or transfer
      See the trade-offs and evidence
      What the evidence shows
      The repair backlog stood at about £15.9bn in 2024/25, and lack of capital is widely cited as one reason NHS productivity has lagged staff growth. The link from capital spending to output is plausible but not precisely measured.
      Policy status
      Capital budgets set at the 2025 Spending Review; the new hospital programme has been re-phased.
      Resources
      Capital funding; construction and IT capacity.
      Consent and decisions needed
      Generally supported; specific hospital schemes are locally contested.
      Time
      Equipment within a year; buildings over five to ten years.
      Cost and yield
      Backlog estimate about £15.9bn (2024/25); total need depends on choices about new hospitals.
      Trade-offs and who pays
      Capital spending competes with day-to-day pay and services in the same health budget.
      How we would know it worked
      Leading indicator: Backlog value and high-risk backlog falling; scanner numbers. Outcome: Diagnostic waits and cancelled operations falling. It would not be working if: Capital rises while activity per bed and per scanner does not.
    The options side by side
    OptionResourcesTimeEvidenceOutcome to watch
    Keep and grow the workforcePay settlements; training places and supervisors; housing and childcare support in some areas.Retention can change within a year or two; training expansion takes five years or more.moderateActivity per member of staff rising, and waits falling.
    Discharge support and social care capacityCare workers, care-home and home-care capacity, council budgets.Short-term funding acts within months; workforce capacity takes years.limited12-hour A&E waits and bed occupancy falling.
    Invest in buildings, equipment and ITCapital funding; construction and IT capacity.Equipment within a year; buildings over five to ten years.moderateDiagnostic waits and cancelled operations falling.

    Plan reviewed 2026-10-07. How we judge evidence.