Short waits for planned care

3.107. Low back and neck pain is the greatest cause of years lost to disability [154], with chronic joint pain or osteoarthritis affecting over 8.75 million people in the UK. Over 30 million working days are lost due to musculoskeletal (MSK) conditions every year in the UK [155] and they account for 30% of GP consultations in England [156]. We will build on work already undertaken to ensure patients will have direct access to MSK First Contact Practitioners (FCP). 98% of STPs have confirmed pilot sites for FCP and 55% of pilots are already underway. We will expand the number of physiotherapists working in primary care networks, enabling people to see the right professional first time, without needing a GP referral. We will also expand access to support such as the online version of ESCAPE-pain (Enabling Self-management and Coping with Arthritic Pain through Exercise), a digital version of the well-established, face-to-face group programme [157].

3.108. For those patients that do need an  operation, whether for MSK or any other condition, short waits are important. Cataract extraction, joint replacements and other planned surgery all help people stay independent and yield important quality of life gains. In the 1990s and 2000s the NHS made large investments in reducing waiting times for planned surgery. Waiting times remain low by historic standards, and GP referrals are flat, but in recent years treatment capacity has not grown fast enough to keep up with patient need, and the number of patients waiting longer than 18 weeks has been steadily increasing. Under the Long Term Plan, the local NHS is being allocated sufficient funds over the next five years to grow the amount of planned surgery year-on-year, to cut long waits, and reduce the waiting list. The phasing of this improvement will partly be shaped by the availability of staff to expand treatment capacity in hospitals, and will be determined annually through the planning guidance process.

3.109. The ability of patients to choose where they have their treatment remains a powerful tool for delivering improved waiting times and patient experiences of care. The NHS will continue to provide patients with a wide choice of options for quick elective care, including making use of available Independent Sector capacity. This will be supported by continued roll out of Capacity Alerts as a tool for CCGs to use to support GPs and patients to make informed decisions about where to have their treatment. Patients will continue to have choice at point of referral and anyone who has been waiting for six months will be reviewed and given the option of faster treatment at an alternative provider, with money following the patient to fund their care.

3.110. Given that two thirds of referral to treatment (RTT) ‘clock stops’ are outpatient appointments, the effect of removing up to a third of these (as set out in Chapter One) will be to distort how RTT waiting times performance is calculated. This is something the NHS National Medical Director’s Clinical Standards Review will take into account in its recommendations in the spring. In the meantime, given that there will now, over the coming years, be sufficient funding available to CCGs and hospitals to eliminate long waits, we will reintroduce the incentive system under which hospitals and CCGs will both be fined for any patient who breaches 12 months.

3.111. Although inpatient elective admissions (as against day-cases or outpatients) constitute under 5% of RTT ‘clock stops’, separating urgent from planned services can make it easier for NHS hospitals to run efficient surgical services. Planned services are provided from a ’cold‘ site where capacity can be protected to reduce the risk of operations being postponed at the last minute if more urgent cases come in. Managing complex, urgent care on a separate ’hot’ site allows trusts to provide improved trauma assessment and better access to specialist care, so that patients have better access to the right expertise at the right time. So we will continue to back hospitals that wish to pursue this model. In those locations where a complete site shift to ‘cold’ elective services is not feasible, we will also introduce a new option of ‘A&E locals’.

Case study: Gloucestershire Hospital

Gloucestershire Hospitals NHS Foundation Trust faced significant challenges, with poor A&E performance and high numbers of cancellations and delays to planned operations. The Getting it Right First Time (GIRFT) programme supported the trust to split its ‘hot’ emergency work and ‘cold’ planned trauma and orthopaedics work onto two separate sites. Senior clinical decision makers were introduced at the A&E ‘front door’ to help ensure patients were managed more effectively. During the first six months the trust was able to achieve its 4-hour A&E target for the first time since 2010 and had halved the number of cancelled operations. There was a reduction in waiting times for surgeries, including for hip or knee replacements, and an 8% increase in the amount of elective surgery performed.


154. Steel, N., Ford, J., Newton, J., Davis, A., Vos, T. & Naghavi, M. et al. (2018) Changes in health in the countries of the UK and 150 English Local Authority areas 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. The Lancet. 392: 1647–61. DOI

155. Office for National Statistics (2017) Sickness absence in the UK labour market: 2016. Available from:

156. Department of Health (2006) The Musculoskeletal Services Framework. A joint responsibility: doing it differently. Available from:

157. NHS Innovation Accelerator (2018) Award-winning ESCAPE-pain programme now online. Available from: