A new report from the Institute of Fiscal Studies (IFS) has revealed that the NHS might need to prioritise the less sick to recover elective performance should they wish to achieve their 18-week target.

NHS England’s approach to make changes to the factors that improve performance include an expansion of Advice and Guidance services to refer the number of patients, as well as increased productivity measures to increase the rate at which patients can be treated.

The IFS recognise that while reducing demand and increasing treatment volumes will shrink the overall size of the list, there is no simple read-across to waiting times. Statistics show that 18-week performance was 59 per cent in September 2007, 71 per cent in April 2020 and 90 per cent in July 2017, but all had an identical waiting list of four million.

The IFS iterate the need to look at the shape, as well as size, of the waiting list, which will depend on who is treated and in what order.

The IFS reports that the first way to improve waiting times is to treat more patients, which comprises the majority of the NHS’s strategy, although this is alone is unlikely to be enough. The IFS calculates that relying on productivity alone would require a 4.9 per cent annual activity growth, and activity only grew by 3.8 per cent in 2024.

The IFS estimates that under a more realistic, but still ambitious, growth rate of 3.5 per cent, 74 per cent of patients will hit the 18-week target. Although an improvement from the current rate of 59 per cent, that is still far from the 92 per cent target.

Another way to reduce waiting times is to reduce the number of referrals, and the IFS estimate that a reasonable reduction in demand alongside a 3.5 growth rate could have 82 per cent of cases reaching the 18-week target by mid-2029.

Finally, the IFS emphasises the need to prioritise patients on a waitlist by changing which patients hospitals treat first from the waiting list. Treating patients who have been waiting longer than 18 weeks first would help to meet the target. Should all of these recommendations be used together, the IFS hypothesises that this could get 18-week performance to 86 per cent by mid-2029.

The IFS warns that none of these changes would come without costs, such as potentially sacrificing those who are genuinely in need of elective care for the sake of reaching a target, or by not tending to those who have just been added to the waitlist, who might be in need of urgent medical attention.

These are the trade-offs that NHS leaders might need to make should they wish to get to 92 per cent of patients receiving elective care within 18 weeks by mid-2029.