“It’s all about more staff!”

No, it’s not. It’s about the task you ask staff to do and the support you give them to do it.

The next couple of posts use material from the annual performance tracker for 2023 published by the partnership between the Institute for Government and the Chartered Institute of Public Finance and Accounting (CIPFA).

What is significant about this analysis is that it is presented by two organisations that work to understand all public services and how they could work better. With the NHS they use data to understand the service, but they are not OF the NHS. These are ‘different eyes with a broader perspective on what needs to be done.

This is what the NHS desperately needs.

Let’s start with the money. The truth is that in the next few years there won’t be much more (if any).

“Whoever wins the next election will have difficult decisions to make. Current spending plans to which both the Conservatives and Labour are committed are incredibly tight and imply spending cuts for some services already performing far worse than on the eve of the pandemic……. In this year’s performance tracker, we analysed spending performance, staffing and demand for nine public services,”

(Foreword by Dr Hannah White OBE, Director, Institute for Government – page 4.)

… continuing with the nature of planning and policy.

Whoever takes the keys to number 10 needs to be prepared to make some difficult decisions with a focus on a shift to longer term planning instead of the short termism that has characterised much of recent policy making”

(Foreword by Rob Whiteman, Chief Executive, CIPFA – page 5.)

The report discusses public services since Covid and much of the two chapters on the NHS (One on GPs, one on hospitals) is about the number and nature of new staff that have joined the NHS, and how demand for care has developed.

In hospitals the increased numbers are startling.

“in July 2023 there were 20.1% more nurses and 19.9% more doctors working in hospitals and community settings than in March 2019.”

(Page 78)

This is a colossal increase in staff over such a short period of time. And whilst I can understand many hospitals saying that they still have high vacancy levels; it is very difficult to imagine how any organisation could cope with taking on a more than 20% increase in staff over 4 years.

In terms of demand for hospital care the expectation during and immediately after Covid was that there would be some form of ‘big bounce’ in referrals after the end of the most infectious part of the pandemic. What is interesting is that in general medicine this has not happened. Whilst cancer referrals have increased, the number of additional referrals joining waiting lists every month have not.

Average monthly additions to hospital waiting lists in 2019/20 was 1,687,243. In 2022/23 it was 1,662,878.

This is a really important figure.

(But first of all, let’s just stand back and look at their size.  We often forget, when we talk about the NHS, the enormous size of the enterprise. Every month more than one a half million people get referred, usually by their GP, to a hospital for some form of diagnosis or treatment. This is an enormous number. of anxious individuals. Add their family to that and it’s 5-6 million worried people. Every.single.month.

We may think other parts of our society are large, but this is an enormous enterprise working with so many millions of people and their loved ones – all in some form of distress).

Apart from their size what’s significant about these monthly figures is that they are about the same. The numbers joining hospital waiting lists in 2022/3 is about the same as pre-pandemic.

But hospital waiting lists have gone up. And keep going up.

Despite the additional 20% more nurses and doctors.

Perhaps this is being caused by the numbers of beds being still occupied by Covid patients?

But by the end of September 2023 there were 54% fewer admissions than in the same month in 2022.


And yet still numbers have increased.

And it’s completely true that all those extra staff are not hanging around doing nothing. They are all – everyone – working hard all of the time.

More staff, the same number of people entering the waiting list, staff all working hard…

If the answer to cutting waiting lists was simply more staff it has to be said that we have tried this recently and, on its own, it hasn’t worked.

The IfG CIPFA report argues,

“Despite more spending on the service and large increase in numbers of nurses and doctors, overall hospital activity has not returned to the level that hospitals achieved directly before the pandemic in a range of key areas. This is caused by underinvestment in capital and lack of management capacity, poor retention of experienced staff high vacancies at critical points of patient flow and poorly aligned incentives across the service”.

(Page 98)

This is a really important diagnosis. (And it’s such a pity that only a week or two ago one of Steven Barclay’s last acts as Health Secretary was to raid the capital budget (again!) making it even less likely that there will be sufficient investment to reduce hospital waits year in the future.)

So, if we want to bring down the waiting lists, the lessons to learn from this report would appear to be,

    • It will take time and some longer term (more than 3 months!) investment in capital.
    • We need more and better management capacity.
    • If we have resource for staffing, we should spend it on retaining existing staff even more than on employing new ones.
    • We need to develop staff to make decisions themselves at the critical points of patient flow through the system.


    • We need to get the whole system incentives right.

If we do these five things consistently over 4-5 years, we will bring waiting lists down.