Evidence Paper


Impact of the waiting times backlog on people in Wales who are waiting for diagnosis or treatment




1.    The Welsh Government welcomes the Committee’s inquiry into the impact of waiting times backlog on people in Wales. Waiting times for planned care have lengthened considerably over the last two years and there are now many people waiting longer than we would like for their health care. This is not unique to Wales and can be seen across the four nations of the UK.


2.    A clear priority for the NHS as we start to recover is to focus upon reducing waiting times across all specialities.  Given the scale of the challenge, it will not be enough to get back to the pre covid-19 activity levels, with some models of care antiquated and unsustainable before the pandemic. NHS Wales has transformed many of its pathways during covid-19 and clinicians have aspirations for further developments and new ways of working. We will seek to embed this in our planning and delivery framework.


3.    In the meantime the health service is working in a number of ways, to ensure that there is effective support for patients who are experiencing delays in accessing planned care. 




4.    In March 2020, in order to support the NHS to prepare for the expected increase in covid-19 cases, a directive was issued to suspend all outpatient and routine planned care activity. Essential services and cancer care continued to be delivered where it was safe and in the best interest of the patient.  This was a necessary approach to protect the NHS and meet urgent and emergency covid-19 capacity requirements.


5.    During summer 2020, outpatient activity and routine planned care restarted. The infection control requirements to deliver safe services during covid-19 however greatly reduced the productivity of core service activity, resulting in waiting lists and lengths of waits continuing to grow.


6.    In 2021, an investment of £248m to increase capacity was provided, and we started to see activity levels rise and mitigate the capacity / demand gap. However, the infrastructure and staffing constraints, together with the continued implications of covid-19 and new variants, have meant that pre covid-19 activity levels could not be achieved.


7.    In order to help health boards manage local COVID-19 surges, Welsh Government introduced the Local Choices Framework in December 2020.  This framework supports health boards to take immediate decisions about the suspension of local services in response to immediate covid-19 demand. All health boards have utilised this framework as necessary from December 2020 to January 2022.


8.    The volume of patients waiting in excess of 36 weeks had reduced to a six year low in March 2019 and the NHS was on track to improve on the position during 2019/20 – however, the start of the covid-19 pandemic significantly impacted on capacity and associated activity levels.


9.    Since March 2020 the total waiting list and those waiting over 36 weeks has grown markedly.  At the end of November 2021 the total waiting list was just over 682,000 (an increase of 225,500 on March 2020) and the number waiting 36 weeks was 241,700 (an increase of 213,000 on March 2020). The size of the waiting list fell very slightly in November, however it is expected to grow during December and January following decisions to suspend some routine activity in response to covid-19 pressures.


10. Health boards are now working to ensure that their waiting lists are accurate. It is likely that over the last 18 months that some people’s conditions and circumstances may have changed. This will not be an exercise of removing genuine patient pathways, but will ensure the waiting lists are correct, enabling health boards to plan effectively.


11. Difficulties with recruitment and retention for many specialities, and particularly rural areas, continues to be a restraint. Whilst increased recruitment and training plans are in place, the impact will not be seen for a number of years. Winter pressures, coupled with the pandemic and the need to support the vaccine programme continues to place further strain on services and staff.  Staff have been very hard-pressed coping with the pandemic and need a period of recovery. 


12. The focus in Wales is not only to increase capacity, but also to grow our own workforce, making posts retainable and appealable. An example of this working well can be seen through the introduction of new clinical fellow posts within dermatology.


13. To support workforce challenges, an investment of £262m is being made available next year to support education and training programmes for healthcare professionals in Wales. This represents an increase of 15% compared with 2021-22 and will deliver the highest number of healthcare training opportunities in Wales. 


14. We will maintain and strengthen investment in education and training of healthcare workers, delivering 12,000 more clinical staff by 2024-25.


15. Significant pressures on the social care system are impacting on timely discharges from hospital and the availability of care at home. We are working closely with health boards and local authorities to monitor impact and promote joined up approaches. Working with health boards, local authorities are increasing investment in social care and we have introduced step down facilities as can be seen in the new developments at Llandudno Hospital. This has been supported by an additional £48m for social care recovery and £42m for winter care pressures to support social care. £10m has also been announced to enable local authorities to make equipment available that supports the independence of people with care and support needs or in an early intervention and prevention context to maintain people in their own homes.


16. Health board’s infrastructure is also a key factor impacting upon planned care delivery. National guidance provided during the pandemic clearly indicated the importance of protecting patients from the risk of covid-19 transmission and dividing the estate based on risk of transmission. Some health boards, such as Cardiff and Vale, were able to respond to this. Others struggled as unscheduled care, urgent and planned care are all delivered on one site. This is particularly relevant with the constraints caused by delayed transfers of care where reduced flow of patients out of hospital, particularly into nursing or residential homes because of restrictions in place due to the pandemic, reduces the flexible use of beds and adds pressure on the estate.


17. Health board estates will need to be used differently in order to respond to the waiting list challenges. More one-stop clinics where patients are seen and treated in a single appointment are required. The introduction of Rapid Diagnosis Clinics are an excellent example of how this can be delivered.


18. The new £50m capital fund for social care includes the development of 50 local community hubs and the strengthening of arrangements to support the integration of health and social care and support the residential care estate.

Plans for addressing the backlog of patients waiting for treatment, including prioritisation of patients/services.


19. The whole solution will need to be a combination of:

·                Additional sessional work

·                Using the independent sector to deliver activity for NHS patients

·                Regional options which will allow protected planned care capacity at a higher volume than traditional hospital based theatres

·                Transformation and introduction of new models of care


20. The immediate focus has to be recovery of the waiting list so that we minimise the impact of the pandemic on outcomes and provide timely access of care to those that need it most. This has been set as a priority for the system and will be reflected in health board integrated medium term plans.


21. Over the past year, the national planned care programme has developed a new approach to planned care. The ‘Five Goals for Planned Care’ have been developed alongside clinical and operational leads.  The five goals are effective referral, advice and guidance, treat accordingly, follow up prudently and measure what is important – modernising the clinical model of care.


22. The Clinical Programme for Planned Care covers seven clinical specialities, which are orthopaedics, urology, dermatology, ENT, ophthalmology, general surgery and gynaecology.  In November 2022, they account for 65% of the total number of pathways waiting, and 82% of the pathways waiting over 36 weeks. An Outpatient Transformation Programme leading on national work supports the programme.


23. For each of these areas, actions are already in place.  For example in orthopaedics, the board is developing a national clinical strategy, there are plans to extend virtual joint clinics and improve MSK management.  For urology, the development of a PSA self-management programme alongside improved referral guidance for primary care.  A tele-dermoscopy pathway is being developed for dermatology alongside the See-on-Symptom (SOS) and Patient Initiated Follow-Up (PIFU) pathways.



24. This year health boards have been allocated an additional non-recurrent £248m to increase the number of clinical sessions available, increasing activity and mitigating the capacity and demand gap caused by the productivity reduction that covid-19 has brought. There are a number of actions underway ranging from, new modular theatres and additional diagnostic capacity to moves to extend the working day such as a six-day working week for radiotherapy. Health boards have been working to reduce the backlog by using alternative providers, they have used their own staff in local independent facilities, as these are safe green pathways for services and hired mobile units that have been used to carry out a number of day case procedures.  The ability to source additional activity has been problematic as organisations from across the United Kingdom are all looking to purchase activity from a small pool of suppliers – hospital estate and workforce availability are key constraints.


25. Health board plans have also included collaborative action between GP practices and community health and care teams to undertake regular reviews and checks for people living with long-term health conditions, such as asthma and diabetes, to help them stay well.


26. From 2022-23 onwards, £170m has been allocated on a recurrent basis specifically for planned care.  When combined with the allocations in 2021-22, this will mean a total of £818m will have been allocated towards NHS recovery over 4 of the 5 years of the current Senedd term. This will enable health boards to put some of those staffing plans into place and to develop more sustainable and transformational solutions.


27. We are clear that we will need to deliver services in a different way and are working with the clinical boards to develop sustainable approaches. The national Orthopaedic Clinical Board is currently developing a long-term orthopaedic clinical strategy. In the short term, health boards are looking at regional solutions, and the Welsh Government has invested in two new theatres at Prince Philip hospital in Llanelli.  These will deliver up to 4,600 additional day case procedures a year as a dedicated ‘green’ pathway.


28. Health boards are developing regional approaches for cataracts, with plans to increase capacity in South East across the three health boards. For South West, the plan is to increase capacity at two sites and to share the workforce across the two sites. In the next few months, significant additional capacity for cataracts will be in place in Swansea, Hywel Dda and Cardiff.


29. Betsi Cadwaladr University Health Board is looking at developing regional diagnostic and treatment centres to provide outpatient, cataract services, diagnostics, including endoscopy and inpatient orthopaedics.


The services in place for people who are waiting for diagnostics and treatment, particularly pain management support.


30. Patients are waiting longer across all stages of the pathway, from outpatients, diagnostics, therapy services, mental health support, pain relief and treatment.


31.  The number of patients waiting for a diagnostic test in November 2021 is 106,559, this an increase of 53% since March 2019. Just over 45,500 (43%) patients have been waiting longer than 8 weeks for their diagnostic procedure. This is however a reduction of 15,500 patients from November 2020, highlighting that diagnostic services have been able to start recovery at a faster rate than that of both outpatient and inpatient procedures.  

32. The National Imaging Programme Board and National Endoscopy Programme Board have both evidenced that core demand and capacity has been significantly out of balance even pre COVID-19 given the ever increasing demands for diagnostic testing. This has previously resulted in high levels of outsourced activity, waiting list initiatives and the need for additional or temporary modular facilities. Each Board is supporting local recovery efforts and finalising plans for additional capacity as part of their IMTP submission for 2022/23.



33. During the pandemic Allied Health Professions[1] (AHPs) have played a critical role in setting up new and specialist services to contribute to reducing waiting times for patients. These are for patients with persistent pain, vascular presentations, musculoskeletal, orthopaedic and urogynaecological problems as well as signposting to self-management resources.


34. Enabling people to access AHPs directly and earlier in the care pathway can affect demand and reduce disability. ‘Prehabilitation’ programmes prepare people for surgery and help people remain well while they wait, thus ensuring people are ready for treatment and recover more quickly from that surgery. Prehabilitation and access to rehabilitation and reablement can also enable some people to recover to the point where their need for surgery is less or removed.


35. Services by podiatrists for people with diabetes are helping reduce and avoid amputations. Physiotherapy in orthopaedics and rheumatology can influence the need for more invasive treatment, including surgery.


36. AHPs have been very effective in adopting new ways of working, and they deliver a large proportion of their work virtually. However the combined effect of the additional workload, workforce challenges and patients who are potentially presenting at later stages of their illness, are affecting upon the total numbers and length of waits. In November 2021 there were 56,592 people on the therapy waiting list. Just over 8,350 (15%) patients have been waiting longer than 14 weeks in November 2021 for their therapy intervention. We published our AHP Framework in 2019, supported by £289,681 in 2021-22 and £292,577 in 2022-23 to HEIW to deliver a 2 year National Programme with national clinical leads and models of good practice.  


Pain Services

37. In April 2019, Welsh Government published “Living with Persistent Pain in Wales” guidance against which health boards could quality assure the services they were providing. 


38. Pain management services have moved virtually where possible and there are a number of services developed on offer throughout Wales to support those living with persistent pain. These include Escape Pain, a group rehabilitation programme with a focus on self-management and coping mechanisms, and Education Programmes for Patients (EPP Cymru), who provide a range of self-management health and wellbeing courses and workshops for people living with a health conditions or for those who care for someone with a health condition.


39. To support a national consistent approach to pain services, we are in the process of appointing two national clinical leads to determine areas of improvement and to help develop future services to meet the growing demand. 



40. The number of patients waiting for treatment has also grown over the past 21 months. In March 2020, 95,056 patients were waiting at treatment stage (inpatient / daycase), compared to 121,996 in November 2021, a 28% increase.


41. Clinical need, in particular cancer care, has always taken priority on the use of planned care resources. This approach has been the main guiding principle during the pandemic and this has had a significant impact on waiting lists. At present, there is limited capacity available for routine patients for review and/or treatment. Planned care resources are pooled, and available theatre slots are allocated based on clinical risk, with emergency and urgent care taking priority. The Welsh Government role has been to provide national guidance and policy support to ensure safe and effective delivery of NHS and social care during the pandemic. Where appropriate, health boards have been able to adapt and revise guidance based on local risk assessment and resources available.


42. NHS Wales has utilised a risk-based approach to prioritisation for surgical interventions. At the start of the pandemic, the Royal College of Surgeons developed a set of clinical guidelines to aid decision making in terms of surgery with procedures categorised as priority 1 (emergency surgery), priority 2 (operate within a month), priority 3 (operate within 3 months) and priority 4 (operate after 3 months). All health boards took action to maintain elective surgery for the highest risk patients, including cancer (priority 2). Patients assessed, as priority 3 and 4, were determined as clinically less urgent patients waiting for treatment.  Cancer services were designated as essential right at the start of the pandemic. We have done all that we can to sustain them throughout the pandemic, but there has inevitably been disruption due to the nature of the waves of new COVID-19 strains.


43. Clinicians have been constantly reviewing their patients on the waiting lists and have reviewed the patient priority at each review ensuring that their priority has been adequately recorded and patients who experience a worsening condition can be treated.


44. In April 2021, NHS Wales agreed on a consistent, national approach to review outpatient waiting lists. The process was developed in collaboration with NHS planned care leads and consultation with the Wales Council for the Blind and Community Health Councils to ensure the accessibility of public-facing resources. The initial purpose of this was to make contact with patients and to reassure them that they were not been forgotten. Secondly, it was to understand the health status of the patient and to determine whether their symptoms have deteriorated which may indicate the need for an earlier appointment. Finally, it was important to determine whether the patient still needed an appointment as they may have had further treatment from primary care, pharmacy or their condition had improved. The first stage of this communication campaign, which started last June, was to write to all patients who have been waiting over 52 weeks for a new outpatient appointment, then those who are waiting for a follow up appointment. Health boards will use the responses from this communication to prioritise patients through a clinical review.


Access to psychological therapies and emotional support for those who may be experiencing anxiety or distress as a result of long waiting times.


45. Before the pandemic, around one in four people in Wales was experiencing mental health issues.  Latest data from Public Health Wales and other surveys show that overall; levels of anxiety within the population remain higher than pre-pandemic. Aspects of personal health and wellbeing, concern about health and wellbeing of others and personal finances have all caused worry for individuals to differing extents over the course of lockdown. A self- management online tool called SilverCloud is available by both self-referral and clinician referral if required. The uptake of this mode of support continues to increase, and is well evaluated.


46. At the onset of the pandemic, additional resources were released to health boards to support the maintenance of essential mental health services while responding to the immediate pandemic pressures. Additional funding for inpatient surge capacity in adult and Children’s provision was provided. We have also strengthened the CALL mental health helpline to meet the increased demand and we continue to promote it as one of our key offers. We have also provided funding for a range of regional approaches to reduce suicide and self-harm including bereavement support, training and awareness raising.


47. There are pressures within memory assessment services. To support this a £3m allocated to Regional Partnership Boards (RPBs) was provided, in addition to the £9m allocated at the time of the publication of the Dementia Action Plan, representing a significant increase in funding.


48. We are prioritising mental health across government and investing over £100m of additional funding across the next three years. £90m of that is in the HSS portfolio. (£50m in 22-23 rising to £90m by 24-25).

The contribution the third sector can make in providing peer support and information to patients waiting on an NHS waiting list.


49. Both NHS Wales and the Welsh Government work closely with a range of related third sector partners to support patients and policy development. Third sector organisations such as Cymru Versus Arthritis have created online communities to provide support and offer a wealth of information available on their websites. This includes specific information and advice for those waiting on waiting lists. RNIB Cymru work closely with Welsh Government, they helped to develop a new measure for eye-care, and continue to be pivotal in supporting the health service with clear information to patients. The Cancer Alliance were pivotal in the development of the Suspected Cancer Pathway and constantly hold us to account on cancer performance. There are many examples of the third sector effectively supporting patients alongside health boards.


50.Health board services and websites signpost patients waiting for appropriate support from the third sector. This is an important aspect of the mental health services’ approach to supporting patients on waiting lists.  Letters sent to patients waiting for treatment include a section on signposting patients to suitable charities and third party bodies.

51. Welsh Government has worked with the British Red Cross on the establishment of a “Waiting Well Support Service”.  This service will support patients on waiting lists for elective treatment through the provision of practical and emotional support, signposting and supported referral in order to help people maintain their independence and improve their ability to better self-manage.   Four health boards will start to pilot this model for a 12- month period from March 2022.



The effectiveness of messaging and engagement with the public about the demands on the service and the importance of seeking care promptly.


52. In the early part of the pandemic, Welsh Government communications focused upon public health information around the covid-19 risk. This message was provided through national daily briefings, national documents (electronic and paper) and was reinforced by local NHS communication teams. High-level messages around planned care and the impact of covid-19 on waiting lists formed part of these national and local messages.


53. In 2020, Welsh Government procured external communication resources to support the continuing national campaign, “Help us to Help you”. This provided resources to local NHS communication teams to reinforce and adapt national messages to local needs.


54. A list of “staying healthy/keeping well” information links have been developed for health boards to use to signpost patients. The planned care programme in collaboration with the Help Us Help You campaign has developed a series of patient facing videos. These have been used on websites and social media.


55. Health boards have also developed a number of local strategies to support and improve patient communication. Hywel Dda University Health Board, for example has  developed a one-point contact for all patient waiting enquiries initially piloted for orthopaedics.


The extent to which inequalities exist in the elective backlog, with deprived areas facing disproportionately large waiting lists per head of population compared to least deprived areas.


56. There is an absolute focus upon health inequalities across Welsh Government. Specific funding is targeted to ensure that this principle is embedded across delivery. We know that the pandemic has affected the inequalities gap, and we are prioritising how we will enable and help to support positive change.


57. Analysis using the Welsh Index of Multiple Deprivation (WIMD) on activity data does not show any significant change in patterns of treatment across the different deprivation groups during COVID-19. It does, as expected, show the general increase in length of waits across each of these groups. Evidence shows that the effect of long waits for people in lower deprivation groups may have proportionally more health consequences due to their existing health issues.


58. More targeted support and signposting to people from deprived areas is required across the whole system to reduce harm while waiting.


59. From a population health perspective, we know that two of the biggest causes of avoidable ill health and death, and drivers of health inequality, are smoking and obesity. Working with health boards, we ensure resources are directed to evidence based interventions. There is additional targeting of these interventions towards groups and communities where tobacco use and obesity prevalence rates are higher, such as more deprived communities.


60. The draft Welsh Government Race Equality Action Plan recognised the unequal impact of the COVID-19 pandemic across certain groups of the population and proposed a specific goal and actions to tackle the health inequalities experienced by Black, Asian and Minority Ethnic people.


61. The consultation on the draft LGBTQ+ Action Plan concluded on 22 October. The draft plan acknowledged the health inequalities experienced by LGBTQ+ people and proposed a range of actions targeted at improving health outcomes of LGBTQ+ people. Work is currently underway to refine the Action Plan in light of consultation responses.

Plans to fully restore planned NHS care in Wales.


62. In March 2020, Health and Social Care in Wales COVID-19: Looking Forward was developed that that sets out Welsh Government’s ambitions and approach to building back our health and care system in Wales, in a way that places fairness and equity at its heart. It builds on key lessons learnt, and describes the opportunities and priorities as we recover from the devastating impacts of the pandemic. It demonstrates our commitment to social partnership, values and expects integration and integrated approaches, and sets out our expectations of delivery.


63. Our intention is to develop a plan to address the waiting times for those patients whose treatment has been delayed by the pandemic. This will be published in April of this year. This will set out our ambitions and priorities for planned care giving a clear steer and direction to the NHS and our partners about our aspirations and expectations for planned care recovery.


Innovations developed to support patients


64.  Health and social care services in Wales have been at the forefront of responding to the pandemic.  Covid-19 has accelerated change in how health and social care services are delivered.


Supporting Patients

·         All health boards have patient support lines in place, and local GPs are aware of their existence.  The lines themselves do not all offer direct patient support but they direct patients appropriately depending on the nature of the call. Additionally, the call handlers are able to review current waiting times.  

·         From January 2022, Cwm Taf Morgannwg University Health Board has an operational Wellness Hub; two of the key programmes on offer are mental health and pain management.

·         Cardiff and Vale University Health Board has a number of services and approaches in place to support patients who are waiting to access planned care. Their Prehab2Rehab project promotes an innovative behavioural change approach to health messaging and ‘prehabilitation’ style advice for patients on the inpatient waiting list.  An important aspect of the Prehab2Rehab project is the https://keepingmewell.com website, services signpost patients on waiting lists to resources on this website. 

·         Orthopaedic patients at the early stages of waiting are contacted to join the 'Living Well' programme which, advises them on pain management through medication and health and wellbeing advice including smoking cessation and dietetics.  


·         A modelling tool to assist in predicting the demand for rehabilitation services supports the Rehabilitation Framework published in May 2020. The Adferiad (Recovery) Programme launched in June 2021 is supported with £5m of additional funding. This programme supports patients experiencing the symptoms associated with long covid. It is supported by a package of comprehensive education and resources. It means that across Wales health professionals have access to the same information and treatment advice on this condition and they have a clear guide on when and how to refer onwards for treatment and support.



·         Significant and accelerated investment in digital technology has enabled rapid service transformation and the continuation of essential services in a safe environment. Attend Anywhere was rolled out at pace to offer virtual appointments across primary, community and secondary care.

·         Video group clinics (VGCs) have been introduced, an effective model that allows the clinical team to assess multiple patients together. VGCs are being used in cancer services, mental health, and for life-long conditions such as rheumatology and diabetes and dermatology. Physiotherapist led VGCs are working well in pain management and in cancer services.


Community Provision

·         Optometrists are being upskilled to deliver new patient care pathways. The targeted investment for IT, data and digital improvements enables shared care, and enables optometrists to manage and treat more patients in primary care.

·         An example of a delivery model ensuring a multi-disciplinary approach is the South West Cardiff Cluster’s integrated child health clinic, where outpatient clinics held in GP practices led jointly by a consultant paediatrician and GPs. This model has produced outcomes in terms of reduced waiting times, reduced 'Did Not Attend' rates and reduced need for follow up appointments.

·         17 pharmacies within the Llanelli cluster of Hywel Dda University Health Board will be participating in a 12- month pilot of a Community Pharmacy Mental Health and Wellbeing Service. The service will allow trained pharmacists and pharmacy staff to offer low level Mental Health and Wellbeing signposting support to a targeted group of patients recently prescribed medication for a low-level mental health condition.

·         There is a pilot ongoing in Hywel Dda University Health Board, which utilises pharmacy delivery drivers to complete a basic well-being assessment of isolated and potentially vulnerable patients. This pilot currently flags well-being issues with Pembrokeshire Association of Voluntary Services who then raise the need for a review by the GP.

·         The reform of the Community Pharmacy Contract Framework means that all community pharmacies in Wales will be able to offer an extended range of services via a national clinical community pharmacy service. From April 2022, the contract will enable all pharmacies to provide treatment for common minor ailments, access to repeat medicines in an emergency, annual flu vaccination, and some forms of emergency and regular contraception.


New Models of Care

·         See on symptoms and patient initiated follow up appointments are being implemented across NHS Wales, where safe and appropriate to do so as an alternative to a follow up appointment.

·         With support from the Transformation Fund and Integrated Care Fund, Regional Partnership Boards have developed new models of care that have proved invaluable during the COVID-19 response including rapid discharge from hospital to home and admission avoidance models. A new five year ‘Health and Social Care Regional Integration Fund’ will be launched on the 1st April 2022.


65. NHS Wales has worked extremely hard over the last 20 months to respond to the covid-19 challenge, keeping patients safe and responding effectively to those requiring cancer, urgent and essential care.


66. This response has resulted in waiting times for planned care lengthening considerably over the last two years. Many people are unfortunately waiting longer than we would like for their health care. 


67. Our challenge as we move forward is to reduce the size of the overall waiting list and the length of time people are having to wait. This will take time, but there are some excellent examples of clinicians doing this. At the same time we need to ensure that there is effective communication and support for patients whilst they wait.

[1] 13 individual professions including physiotherapists, occupational therapists, dietitians, podiatrists, psychologists, speech and language therapists.