Recovering services from the COVID-19 crisis is the big task for NHS leaders for the foreseeable future. 

A projection today that the NHS waiting list could hit 10 million by April appears an unlikely scenario. But concerns about the huge and growing reservoir of unmet need remain just as valid regardless of how accurate this projection turns out to be..

The NHS waiting list could hit 10 million people by April — more than double the 4.5 million patients who were on the list as of the last official figures in December — a report by think tank Reform and Edge Health, published today, says.

Closer scrutiny reveals this figure, though it may succeed in hitting headlines, is in fact very unlikely to be reached. What is arguably more illuminating, however, is thinking about how the number has been calculated.

The figure is based on “cohorts of untreated patients” — those who have missed out on treatment over the past 12 months, compared to what would have happened without COVID-19. The analysis assumes many of them will, in the next few months and as COVID-19 fears ease, start coming forward to seek the care they ‘should’ have already received.

Edge Health director George Batchelor acknowledged the 10 million was an unlikely upper end of the forecast, telling me: “We modelled four scenarios based on different assumptions about how many [patients] will return for treatment, of which the 10 million projection was the largest.

” Progressively it seems unlikely that the full cohort of untreated patients will return in total, but it will also not disappear completely. Precisely this prospect is now concerning some hospital managers and clinicians as they look ahead. Coping with already built-up lists of waiters, including enormous numbers of very-long-waiters, is one thing. But can the health system and its staff cope with a pent-up influx, both in urgent and planned care, or those who have stored up problems?

“We would expect something between 25 and 50 per cent of patients to come back at some point over the next few months — possibly after being vaccinated. If these people come back, then the waiting list would grow to between 6 and 7.5 million.”

Leading waiting list expert Rob Findlay went a step further. He told me: “I’ll go so far as to repeat Alastair Campbell’s famous bet: if there are 10 million on the [referral to treatment] waiting list by April 2021, then I’ll eat my kilt.”

Mr Findlay pointed out that getting to the 10 million, under the Reform/Edge Health analysis, assumed three things, all of which he thinks are unlikely to happen in full:

(a) The ‘missing referral’ patients, who have carefully avoided the NHS throughout 2020, choose this winter to come back (a maximum impact of six million);

(b) Referrals in January to March return to pre-COVID-19 levels, and the NHS ceases treating and discharging elective patients (maximum impact of five million); and

(c) Hospitals who had not previously conformed to the rule — that delayed follow-ups should be added to the RTT waiting list — abruptly decide this winter to start conforming to it (the maximum impact of which is unknown as there are no published figures on overdue follow-ups).

Mr Findlay explained: “Given the well-known and extraordinary pressures on the NHS this winter, I think the above possibilities are all very unlikely… By April 2022 though? Now that is plausible.”

If the prediction of 10 million patients on the waiting list sounds familiar, it is because it is. The NHS Confederation had a go at modelling the pandemic’s impact on electives back in June, warning the list could hit 10 million by December.

That also proved way off the mark, in that case because it assumed new referrals were pouring in at a similar rate to before COVID-19. The latest official data puts the list at 4.52 million, up 60,621 from November to December.

But the underlying reality of pent-up health need is no less concerning if it has not yet turned up on published RTT lists — quite the opposite. Mr Batchelor argued, regardless of the numbers by April, “the vast and growing reservoir of unmet need will still be there —- it just might not show up yet on the reported list, which is very concerning”.

The Royal College of Surgeons said a “new deal” was required “for surgery with investment in NHS capacity, to get back to meeting legal waiting times standards”.

The college said it agreed with “the spirit” of Reform’s recommendation in its report, which said: “NHS England and Improvement should mandate the publication of waitlist recovery plans by integrated care systems and trusts”.

RCS president Neil Mortensen added in a statement: “A huge waiting list has built up over the last year, and it is important for patients and the public to understand how we are working to restore timely access to surgery.”