13 Feb 2025

Reforming Elective Care for Patients (England) – January 2025

The BOA has put together a paper highlighting some of the more pertinent initiatives announced by the Prime Minister to meet the 18-week standard in England by March 2029. The paper includes a mixture of extracts and commentary. You can read the full paper below.

SUMMARY

The Prime Minister made a commitment in December 2024, as one of the Government’s six milestones in the Plan for Change document, to meet the NHS Constitution access standard for elective care in England by March 2029. In January, the PM, DHSC and NHS England published details of how this commitment is to be achieved – although there are matters of implementation that have yet to be addressed.

At the time of writing, the 2025/26 priorities and operational planning guidance and supporting information has yet to be published, although NHS England has confirmed that the ringfenced elective care fund will be scrapped for 2025/26, although NHS trusts will be expected to carry out a similar level of elective activity next year as 2024/25 while each trust will be set an individual 18-week target.

This paper highlights (extracts and commentary) some of the more pertinent initiatives to meet the 18-week standard by March 2029. NHS England envisages performance to increase from the current 58% (in December 2024) to 65% by March 2026, with every trust expected to deliver a minimum 5 percentage point improvement by March 2026. Furthermore, the expectation is that there will be sufficient increases annually (exact figures to be confirmed in the planning guidance) to reach 92% in 2029.

It has been reported that NHS leaders have only committed to doing around the same level of elective activity in 2025/26 as they are doing now – around 18 per cent more than pre-Covid levels – and are sceptical whether the 2025/26 target can be met. The Royal College of Surgeons England has stated that the 2025/26 target could be met but has warned this would leave the system with too much to do in future years to achieve the 92 per cent by 2029.

In the short-term NHS England will continue to set expectations for further reductions in waits of a year or more, as well as expectations for reducing the time to first appointment for all patients.

The BOA’s initial response to the January announcement can be viewed here.

It is also worth noting that at a system-wide level the documents suggest Integrated Care Boards (ICBs) are to revert to being ‘hands-on’ commissioners with an increased focus on contracting, rather than the strategic role previously identified by the Secretary of State.

Whilst providers will ‘continue to be paid in line with the number of patients they treat’, the money they will receive will be based on a ‘planned level of activity with commissioners’. This will be problematic given the number of existing variables, let alone the new initiatives set out in the reform package, which require increased activity by providers and a set limited budget for ICBs.

Initiatives 2024/25 are largely concerned with requiring providers to improve the experience of waiting for care and to ensure that capacity upgrades – in particular, community diagnostic centres and surgical hubs – deliver ‘maximum possible benefit within the relevant system’s financial plans’. The main changes begin in 2025/26.

The Operational and Financial Priorities and Planning Guidance for 2025/26, as well as allocations and supporting information, at the time of writing yet have to be published – these will set out the funding allocations local health systems to achieve the interim waiting list targets by March 2026. Other initiatives include:

optimisation of Advice and Guidance (A&G), including by implementing changes to the payment scheme to support GP practices to manage in the community those who do not need secondary care.
continue to roll out patient-initiated follow-up (PIFU) and remote monitoring in appropriate pathways, to avoid unnecessary attendances.
extend adoption of the Federated Data Platform (FDP) to 85% of all secondary care trusts, to maximise the benefits seen in early adopters from waiting list validation, scheduling and theatre optimisation.
support more consistent use of the independent sector to increase capacity and choice for patients.
continue working towards greater connectivity between the e-Referral System, patient engagement portals and the NHS App, so patients have more control over their appointments and to improve the productivity of clinic booking.

NHS England will adjust the allocation of resources to support productivity and operational improvements by:

updating the finance and payment scheme to reflect elective priorities.
running a capital incentive scheme for providers who improve the most in meeting referral-to-treatment (RTT) standards.
strengthening elective performance oversight, including through a new NHS Oversight and Assessment Framework – the essence of the Framework is to ensure the alignment of priorities across the NHS and with wider system partners; identify where ICBs and/or NHS providers may benefit from, or require, support; and provide an objective basis for decisions about when and how NHSE will intervene developing clear standards and metrics for the administrative and operational delivery of elective care.
developing expectations for local clinic templates and job planning, to clearly set out the types and balance of activity clinicians should be undertaking, including sessions within the community.

The reforms address a number of specific topics which are set out below. Note: some of the initiatives are scheduled beyond 2025/26.

Empowering patients

NHS England will:

publish the minimum standards patients should expect to experience in elective care – September 2025
actively promote and monitor patients’ right to choose when and where they receive care
expand the NHS App and Manage Your Referral website to improve information and appointment management on elective care for patients, as well as parents and carers through proxy access – March 2027
work with providers to make the NHS App and Manage Your Referral website the default route so patients can choose their elective provider or decide not to make that choice themselves

Reforming delivery - diagnostics

There are 1.63 million waits for the 15 major diagnostic tests and demand is rising. With 170 community diagnostic centres (CDCs) due to be up and running by the end of March 2025, these centres can take on more of the growing diagnostic demand within elective care
During 2025/26 a number of existing CDCs will be expanded and up to 5 new ones built.
It is expected that waiting times for diagnostics will improve significantly by the end of March 2025 with all CDCs and hospital-based diagnostic services to:
- be open 12 hours a day, 7 days a week
- deliver the optimal standards of tests per hour – such as 4 CT scans per hour – to use diagnostic capacity productively
- remove low value test referrals to maximise capacity
- develop and deliver at least 10 straight-to-test pathways by March 2026, focusing on the diagnostic tests patients are waiting the longest for locally
Using funding identified in the Budget 2024/25 invest in up to 13 bone density scanning (DEXA) scanners to support improvements in early diagnosis and bone health, particularly in the highest priority locations, providing an estimated 29,000 extra scans.

Reforming delivery - surgical pathways and theatre productivity

There are more than 110 elective surgical hubs operational in England, and more are planned over the next 3 years. NHS England will further develop the GIRFT Elective Hub Accreditation programme throughout 2025/26.
NHS England will review relevant tariffs to support the Right Procedure Right Place programme to encourage a shift from admitted inpatient activity to outpatient procedures to reduce pressure on surgical facilities. Local providers should work with the Right Procedure Right Place programme to decide how to embed and maintain surgical hub approaches to reflect local requirements. Sufficient capacity should be explicitly included in plans for surgical hub rollout to meet demand and performance expectations.
Productivity and reform in surgical hubs will also be underpinned by investment in pathology and imaging with networks reaching maturity in 2025 and continuing to roll out the i-Refer clinical decision support tool. It will also include using the Federated Data Platform (FDP) inpatient solution and using commercial digital and AI solutions to support surgical productivity and reduce the administrative burden on surgical and administrative teams.

Reforming delivery – standards

Systems and providers will be expected to consistently focus on the smaller aspects of service delivery that can make a big difference, including:
- fully understanding and consistently applying the referral to treatment waiting times rules, with regular and good quality validation of waiting lists
- effective patient tracking list meetings to provide operational grip, including understanding the percentage of patients on the waiting list who have a booked appointment
- more productive use of outpatient clinic capacity including through overbooking approaches, reducing missed appointments, and running short notice cancellation lists
- clinic templates and job planning, which clearly set out the types and balance of activity clinicians should be undertaking, including sessions within the community
- embedding theatre scheduling, look back and list allocation within planning and scheduling for elective surgery
Beginning in January 2025, NHS England will establish a Task and Finish Group to work in partnership with clinical and operational staff, to set out by September 2025 clear expectations for administrative practice and operational management in the delivery of elective care. Providers will be expected to consistently meet these delivery standards. NHS England will also provide a suite of metrics that will demonstrate ‘operational grip’ and monitor these on a regular basis ‘to provide confidence in how elective care is being delivered’.
Under ‘Delivery Standards’ NHS England articulates the need to ensure that supervision (including of resident doctors) as well as time for clinical leadership is appropriately allocated in job planning and that independent sector providers enable appropriate access to training opportunities within their organisation.
In 2025/26 the NHS IMPACT Clinical and Operational Excellence Programme will provide:
- training for 8,000 clinical and operational leaders in how to manage elective pathways effectively
- publishing and promoting improvement guides for outpatients and theatres, which include best practice co-produced with clinicians and operations managers and creating 2 new compartments in the Model Health System reporting on a range of process, outcome and quality indicators that reflect the improvement guides
- establishing learning and improvement networks focused on improving performance on time to first outpatient appointment. Each network will be led by a local chief executive and operate on a regional footprint
- increasing improvement capacity by, for example, using GIRFT and the Elective Care Intensive Support Team, to support non-tiered elective improvement activity
- establishing a national Outpatient Improvement Collaborative that will use an improvement methodology to work with a small group of high performing providers and systems to co-design, test, evaluate and iterate the future model of outpatient pathways
The Further Faster 20 (FF20) programme is working with 20 trusts in areas of high economic inactivity to rapidly reduce waiting times and support people returning to the workforce. The programme delivers a series of FF20 masterclasses on subjects such as community musculoskeletal services, obesity services, etc.

Reforming delivery – perioperative care

NHS England will:
- extend the Digital Weight Management Programme to people waiting for knee and hip replacements in 2025/26
- ask providers to give patients a date for their routine (non-cancer) procedure only once they have been confirmed in their pre-assessment as fit to proceed
- from April 2025, establish an acceptable maximum number for each system of short notice cancellations due to clinical reasons. Providers are required to review their current level of cancellations and ensure these are reported to NHS England
- closely monitor productivity metrics, including length of stay and short notice cancellations, and raise with providers where these metrics are out of step with similar providers

Care in the right place

Initiatives seek to reduce the number of out-patient appointments with a specialist as a precursor to elective care deeming the process as resource-intensive and often unproductive model and inconvenient for patients. The proposals seek to achieve more integrated working between primary and secondary care, community, diagnostics, tertiary centres and the independent sector is essential.
Embedding referral optimisation in reformed elective care (non-cancer) pathways will include using Advice and Guidance and triage. NHS England will:
- ensure both primary care and secondary care are funded to deliver Advice and Guidance (A&G), by splitting the existing elective tariff to deliver better outcomes for patients. In an expansion of the current approach, GPs will receive £20 per A&G request, to recognise the importance of their role in ensuring patient care takes place in the most appropriate setting, so they receive the care they need in primary and community care settings, as opposed to being added to the elective waiting list. It is estimated that this expansion will deliver up to 4 million advice requests from GPs in 2025/26 (up from 2.4 million in 2023/24) and see an increase in diversions from elective care from 1.2 million in 2023/24 to 2 million in 2025/26.
To support systems to optimise the use of specialist advice, NHS England will provide access to:
- new Model Health System metrics and dashboards
- regularly updated resources including on referral optimisation and GIRFT’s Advice and Guidance toolkits and templates
NHS England will develop supporting resources by March 2026, including an implementation toolkit for triage services and standard operating procedures for routine pre-investigations and sub-specialty booking criteria, where they do not already exist.
NHS England will require systems to work with their providers to develop clear and accessible:
- pathway referral criteria, including for pre-referral investigations carried out in diagnostic settings and which are visible to referrers, by July 2025
- commissioning arrangements for A&G services, including resource allocation through job planning, by September 2025
- triage standard operating procedures for high-volume specialties, outlining referral criteria, investigation requirements and sub-specialty booking criteria, by December 2026.

Optimised pathways

Patient-initiated follow-up (PIFU) reduces the number of outpatient follow-up appointments, as patients are not booked for a follow-up by default. Systems will offer PIFU to patients with long-term conditions as standard in all appropriate pathways by March 2026. To support the expansion of PIFU to at least 5% of all outpatient appointments by March 2029, NHS England will:
- pilot digital options for signing-up patients for PIFU via the NHS App
- enhance how patients suitable for PIFU are identified using artificial intelligence and automation

Using data analysis and informed by Royal College resources and recommendations, NHS England will take a phased approach to optimising clinically led pathways. Reflecting the required shift of care from hospital to community with significant elective reform to be delivered, initially in 5 large volume specialties with a high proportion of non-surgical care: ENT, gastroenterology, respiratory, urology and cardiology.

Outpatient transformation

NHS England will set out a consistent clinical model of ‘collective care’ approaches by September 2025. These are not currently commonplace across the NHS (although physiotherapy-run group appointments are increasingly common for MSK patients). Examples include:
- group appointments, where patients with long-term conditions are supported together, either in-person or remotely
- clinics where patients can be assessed and diagnosed or reviewed on the same day
- ‘super clinics’, where a wider range of clinicians working at the top of their licence are responsible for seeing patients while being overseen by an accountable consultant
NHS England will work with Royal Colleges, specialty associations and NICE to understand what is driving clinical activity that may not be needed and what can enable more consistent practice.
NHS England will ensure validation of patient waiting lists is, for the first time, formally reflected as a form of activity within the 2025/26 NHS Payment Scheme.
AI will be increasingly used to predict which patients are likely to miss appointments.

Digital technologies and data

National development and support for elective care reform will be focused on 3 digital initiatives: the NHS App, the Federated Data Platform and the electronic referral service (e-RS).
By March 2025 it is expected that there will be 36 million registered users and 85% of acute hospitals will be connected to the NHS App.
By March 2026, NHS England will require all acute and specialist acute trusts make at least 70% of all elective care appointments available for people to view and manage through the NHS App. More types of content about patients’ treatment available on the NHS App – such as discharge letters – must be available by December 2025.
NHS England is keen that NHS trusts adopt digital patient engagement portals (PEPs). These enable patients and their healthcare team to send messages and share documents, and for the NHS App to host patient questionnaires to help validate waiting lists, monitor patients remotely and gather information before an appointment. Providers need to make these digital tools available to all clinical teams within their organisations, along with the appropriate support to adopt and embed them in clinical and administrative workflows. NHS England will continue to provide support to all acute trusts adopting these technologies, and through the GIRFT programme will provide targeted on-the-ground improvement resources and tailored support packages to trusts.
Expanding the use of the Federated Data Platform (FDP) provides an opportunity to consolidate multiple frontline operational systems into a single view, aiming for 85% coverage of acute trusts by the end of March 2026.
NHS e-RS is a national digital platform for referring patients from primary care into elective care services and is a significant enabler of patient choice. Ongoing development throughout 2025/26 will support effective joint clinical decision making, improving the quality of information shared between primary and secondary care through standardised referral guidelines. Work with primary and secondary care clinicians to improve e-RS functionality will focus on:
- accepting and rejecting referrals
- standardising referral information, including data to enable better prioritisation of children and young people and service naming conventions
- developing the ability to only categorise services as triage where appropriate
- increasing digital integration of e-RS with hospital systems by adopting e-RS application programming interfaces (APIs)
Using digital questionnaires through PEPs and the NHS App, NHS England will:
- expand remote monitoring so it is a standard offer across all long-term conditions where clinically appropriate (removing up to 500,000 lower value follow-up appointments per year) from 2026/27 onwards
- integrate and automate remote monitoring tools with clinical and administrative systems to reduce the manual burden on local services
- produce remote monitoring technical blueprints to support the sharing of best practice across providers.
Current uses of AI to be rolled out in 2025/26 include:
- AI prediction that helps prevent missed appointments and maximise clinic utilisation by supporting teams to fill appointments that patients can no longer use. Specific areas of opportunity include using AI to identify patients at highest risk of non-attendance, raising awareness of vulnerable patient groups who can then receive targeted support
- using AI to reduce workforce pressures by streamlining administrative tasks and enabling dynamic appointment scheduling to better facilitate consultant job planning

Financial reforms

NHS and independent sector providers must have funding certainty so they will continue to be paid in line with the number of patients they treat, based on a planned level of activity agreed with commissioners. ICBs will be set individual activity targets and allocated funding needed to deliver the 18-week standard. Increasingly, money will follow the patient and those organisations that perform the best will receive the most reward, so that incentives drive improvement.
There will be changes in 2025/26 (subject to consultation on the NHS Payment Scheme) to the way some elective care is paid for, including:
- introducing best practice tariffs to encourage a shift of activity from day case to outpatient settings for 6 procedures
- identifying, throughout 2025/26, up to 30 further areas of clinical activity, and work with clinicians and finance colleagues to develop and test best practice tariffs, with the expectation they will be introduced system-wide in 2026/27
- identifying how to better link payment more closely to activity that directly ends a patient’s wait for their care.
NHS England operate a capital incentive scheme for providers who perform well or improve the most in meeting RTT standards.

Transparency

NHS England will:
- will publish a suite of adult and children’s elective performance metrics (including 18-week performance, long waits and waiting times) ‘in an accessible format that can be ranked and used by both NHS staff and the public’
- also publish data that can be ranked on all aspects of choice. This will sit alongside, and make use of, published information on NHS England’s website and will be available on the NHS App.
- improve understanding of clinical conditions by expanding diagnostic coding in elective care, with expectations that this will be standard practice in acute providers by March 2027.

Relationship with the Independent Sector (IS)

NHS England has published an agreement between the NHS and IS Partnership Agreement – the first of its kind for 25 years. This sets out the expectations for reducing the elective care waiting list, maintaining quality and patient safety, and how both parties will support the most challenged specialties. The agreement also ensures patients in deprived areas are offered choice of providers as a priority.
NHS England will:
- review NHS prices, particularly for activity where the IS can significantly help to reduce NHS waiting times
- work with the IS to review clinical exclusion criteria, with the expectation that a broader range of patients will be safely treated by the IS as a result
- work with the IS to enable its systems to be more closely aligned with those in the NHS around a national set of standards, so patients can more easily see appointments and results on the NHS App.
- ‘encourage’ ICBs to put in place longer-term contracting arrangements to ensure greater choice for patients. One of the barriers to effective patient choice is the conflict of interest that arises when referrers deliver part of the patient pathway (including follow up care). All providers commit to ensure that they do not provide incentives that distort patient choice.
The agreement also provides for the IS and NHS to work together closely to enable further independent sector capital investment to support future growth in NHS diagnostic and elective capacity, building on the successful collaboration on community diagnostic centres.
The agreement recognises that there are a finite number of suitably qualified professionals regardless of where they work, therefore, to ensure local health services are sustainable and productive:
- NHS and independent healthcare employers should work together to identify existing and future local staffing requirements to support workforce planning and professional training
- Independent providers should ensure that capacity offered to the NHS provides additionality to system capacity and is capable of being staffed without having a material impact on the existing local NHS workforce. This includes supporting joint training locally with NHS partners
- NHS England will establish plans with national and local professional NHS trainee programmes to provide them with access to training within the independent sector. Independent providers will provide access for training opportunities where appropriate and required in line with the NHS Standard Contract.

Source documents:

Additional material:

HSJ (various)
Hansard (various)
Health Foundation - Government’s plan for 18-week NHS waiting times: is it realistic? (17th January 2025)

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