The NHS Confederation has warned that the NHS in England could face a hidden waiting list of nearly six million people who have not come forward or been referred for treatment yet.

The organisation has said that, following the failure of the Budget to invest appropriately in the NHS, urgent action is needed to support the sector, including to manage the treatment backlog in a realistic, fair and safe way. This should support different parts of the NHS, including primary care, to work together to decide what is best for their local communities rather than individual services being assessed on standards that will be impossible to deliver because of the pandemic and within current resources.

Despite the NHS performing more than six million elective treatments in 2020 and while its hospitals cared for nearly a quarter of a million people with coronavirus, the treatment backlog for non-urgent procedures stood at 4.52 million by the end of last year.

The NHS Confederation wrote to the Prime Minister last month about these and other issues and is now calling for a comprehensive plan to help ensure people can get the treatment they need.

Now, new analysis suggests that the true demand for elective care could be much larger when referrals for treatment, such as from GPs, begin to increase again, following a 30 per cent drop last year. It says that 5.9 million fewer referrals for elective treatment were made in 2020 compared to 2019, with the difference believed to be due to the disruption of the pandemic and the public not coming forward despite the NHS being ‘open for business’.

The exact size of this hidden list is not known currently as some people may have sought care elsewhere, while others may never come forward. However, if a sizeable majority did present, it could significantly add to the total. One of the modelling projections in the analysis suggests the backlog could therefore reach 6.9 million by the end of 2021.

The NHS Confederation is calling on the government to be honest with the public about the scale of the challenge facing the NHS, to work with local leaders to agree manageable plans, and to give the services the resources they need to respond to what will be serious and long-term problems.

Danny Mortimer, chief executive of the NHS Confederation, said: “The NHS has worked tirelessly to support the country in response to the pandemic and while it has never been a Covid-only service, the disruption has been enormous, leading to a considerable number of people waiting far longer for treatment than the NHS would ever want.

“Health leaders are concerned that we may be scratching the surface of this waiting list if further referrals come through at a time when coronavirus pressures are still high, the workforce is in a very fragile state, and when capacity is still so constrained.

“For their part NHS organisations are making substantial changes to how they work to improve access and maximise the capacity that is available to them. They are working together to organise treatment between different organisations and they are applying best practice at a scale and pace that have not been seen before. But this will not be enough to address the problems our patients face.

“It was therefore something of a shock that the Chancellor did not even start to remedy this in the Budget. The Government now needs to level with the public on the scale of the challenge facing the NHS and step up with a strategy that will work with all parts of the service to tackle the waiting list in a safe, fair and patient-focused way.

“As we have made clear to the Prime Minister, we need similar support to address the impact of increased demand for mental health services and the care of patients with Long Covid in our communities. Also, we need urgent action to address under investment in our infrastructure, workforce and the health of the population, which has been lacking for far too long. Our colleagues in social care face even greater challenges and have experienced an even weaker response.

“Despite everything the NHS is doing, without a comprehensive new plan, the government faces the politically unacceptable legacy of hundreds of thousands of patients left with deteriorating conditions for the remainder of the parliament.”