The NHS had failed to stay up-to-date with changing and evolving needs. It faced funding pressures, staff and resource shortages, a lack of national standards, and outdated systems of practice, and needed a more patient-focused model of care with reduced waiting times.
The NHS is immensely important to Britain, not only for the healthcare services that it provides but also for the place it occupies in British society. For the public, the NHS represents values of fairness and inclusion which are not based on a person’s income. In 2013, Britons across a range of social backgrounds ranked the NHS first in a survey that asked which British social institutions made participants most proud to be British. Despite its centrality to the everyday lives of the public, the NHS failed to stay up-to-date with changing and evolving needs. It faced problems of funding pressures, staff and resource shortages, a lack of national standards, and outdated systems of practice.
One of the biggest obstacles to NHS success was its underfunding. From 1960 to 2000, increases in healthcare spending in real terms per capita were lower in the UK than other OECD countries: the UK increased its healthcare spending by 3.6 percent, while the OECD average was 5.5 percent. From 1979 to 1997, the increase in healthcare spending averaged 2.9 percent, which varied between less than 0 percent to more than 6 percent in real terms. The result of this underfunding was too few resources and staff to meet the demands of the public.
Without sufficient staff and resources’ there were often long waiting times for treatment, which were a cause for concern among patients. In 1998, over 380,000 patients waited longer than 6 months to access hospital care, and there were 68,000 who waited more than a year. The average waiting time for half of inpatients was 15.2 weeks.
Additionally, a lack of national standards meant that there were great differences in healthcare standards delivered across the country. Delivering levels of treatment and care came under the purview of the local health authorities, which resulted in a “postcode lottery” in terms of treatment and care. It was observed that the poorest areas often had the worst services and outcomes within the healthcare system.
The NHS was designed to meet the needs of a society with different societal norms and a different burden of diseases. Significant social changes between the 1940s and the early 2000s, such as the emergence and predominance of consumer culture, meant that patients wanted to have more say in their treatment. Modern Britain had outgrown its hierarchical, paternalistic healthcare delivery model. Not only did patients have different expectations but the old system was inefficient. “Old-fashioned demarcations” between the roles and duties of different healthcare professions were considered to be a source of delay. Patient information was not shared between different healthcare staff within the system; for instance, a patient might have to repeat the same information to a GP, nurse, junior doctor, and consultant, as well as to administrative staff. What was needed to serve the best interests of the public was a more patient-focused model of care with reduced waiting times.
The NHS Plan was launched in July 2000 to reform the NHS’s operations. The plan was based on a set of ten core principles, which included access to healthcare based on need rather than on the ability to pay, the provision of a comprehensive range of services, and patient-focused care and services. The main objectives of the NHS Plan were to reduce waiting times to new targets, modernise NHS facilities and healthcare equipment, and recruit thousands of healthcare professionals to meet increasing demand on the service. The plan stated that “successful services thrive on their ability to respond to the individual needs of their customers... Services have to be tailor-made not mass-produced, geared to the needs of users not the convenience of producers.”
Public consultation on the NHS Plan found that the top concern among the general public regarding the health service was waiting times, although this was not the main concern of NHS staff (see Alignment below). As a result, reducing waiting times became a central objective for the government. Targets were set to reduce waiting times for both primary and hospital care for outpatients and inpatients. By 2004, the aim was that patients would see a primary care professional within 24 hours and a GP within 48 hours. Maximum waiting times for Accident and Emergency (A&E) were set at 4 hours, with an average waiting time of 75 minutes expected. By 2005, outpatient waiting times were to be reduced from 6 months to 3; maximum waiting times for inpatients were to be reduced from 18 months to 6. By 2008, the target was for all treatments to take place within a maximum waiting time of 3 months, and this period was called the referral-to-treatment (RTT).
In order to reduce waiting times, there were organisational changes and investments in facilities and staff recruitment. NHS Direct was set up as a 24-hour helpline which provides basic advice to callers and helps direct them to the appropriate care providers. A new system for booking hospital appointments was also introduced to allow patients to make appointments in the consultation room for outpatient treatment and operations. These measures were designed to be more efficient, thereby relieving pressure on hospitals and enabling them to provide better quality of care.
As well as the new operating systems, the NHS Plan pledged to provide more resources and recruit more staff to enable the NHS to meet new waiting time targets. The plan committed to investing in 7,000 extra beds, over 100 new hospitals, 500 new primary care centres, the modernisation of over 3,000 GP premises, 250 new scanners, and modern IT systems. Additionally, there would be an additional 7,500 consultants, 2,000 GPs, 20,000 nurses, 6,500 therapists, and 1,000 more medical school places. This investment in facilities and staff was to provide sufficient resources to reduce waiting times..
The public impact
The NHS Plan was wide in its scope, and had many targets and objectives to achieve. Between 2000 and 2010, the NHS successfully met its waiting time targets, reducing waiting times across the health service. However, the then-secretary of state for health, Andy Burnham, said in 2009 that “a decade of investment has given the country a capable, resilient and self-confident health service ready for the challenges of a new era. Yet, while we celebrate its progress, it would be wrong to over-claim for the NHS. It has gone from struggling to generally good.” 
Waiting times for patients were substantially reduced across the NHS, reaching their lowest level in its history.  Data for 2007/8 showed that 87 percent of patients saw their GPs within 48 hours. By 2005, 97 percent of patients were seen in A&E within the desired target of four hours. The figure rose slightly to 97.8 percent by the end of 2009. By the end of 2009, the average waiting time for inpatients had been reduced from over 13 weeks in 1997 to four and a half weeks. Moreover, the 18-week RTT target was met nationally. In 2009, 93 percent of inpatients and 98 percent of outpatients started treatment within 18 weeks. The median wait for inpatients was 8 weeks for inpatients and 5 weeks for outpatients. There were 45,000 patients who waited more than 18 weeks for inpatient admission, a small proportion of the overall numbers.
By December 2009, healthcare spending in the UK had increased and was closer to the EU average. Before the plan was implemented, the UK spent significantly less on healthcare than other OECD countries. For instance in 2000, healthcare spending in the UK was almost 6 percent of GDP while in France and Germany it was almost 10 percent. By 2010, healthcare spending as a percentage of GDP increased to 8.5 percent in the UK, which still lagged behind France and Germany where the figure had risen, albeit less sharply, to 11 percent.
The positive impact of reduced waiting times was discernible through patient responses. In its NHS Plan for 2010-2015, the Department of Health reported that, as of 2009, 91 percent of patients rated their treatment as being “good,'' “very good” or “excellent” while 91 percent were “satisfied” or “very satisfied” with their GP surgeries or health centres.
Despite success in reducing waiting times and increasing positive patient experiences, there were concerns about the consequences of waiting time targets, and there is even evidence to suggest that primary care units and hospitals were consciously “gaming” the system in order to meet targets. For instance, there were reports of patients being kept waiting in ambulances outside A&E until a 4-hour treatment time was assured. Another concern with targets was highlighted in a British Medical Association (BMA) survey in 2005. It found that “82 percent of A&E staff thought there were possible threats to the safety of patients due to the adverse effects of the 4-hour target, such as being discharged from A&E prematurely or pressures to treat patients waiting the longest rather than those with the greatest clinical need”. Moreover, trying to meet these targets often put NHS staff under immense pressure, with some healthcare professionals referring to them as “targets and terror”.
In recent years, a combination of issues has seen an increase in waiting times. The NHS is under pressure, with demand for its services rising: admissions to A&E have increased while the number of hospital beds has fallen. The A&E target of a 4-hour treatment for 95 percent of patients has not been met since 2013; between July and September 2017, only 90.1 percent of patients were seen within 4 hours, while in the busiest A&E departments the figure was 85.2 percent. As of late 2018, almost one-fifth of NHS hospital services failed to meet any waiting time targets.
Written by Ella Jordan
Public Confidence Good
The NHS is a widely supported and admired institution in the eyes of the British public. The plan stated in 2000 that “four-fifths of people today say the NHS is critical to British society and the country must do everything it can to maintain it”. At the same time, the public had become generally dissatisfied with standards in the NHS and many believed the government was responsible.
In 2000, a poll conducted on behalf of the BMA found that: the number of people satisfied with the NHS had dropped from 72 percent in 1998 to 58 percent in 2000; the percentage of people who were dissatisfied rose from 17 percent to 28 percent; and 94 percent of respondents said that the NHS needed to improve. When asked to choose who was responsible for conditions in the NHS, 51 percent said the previous Conservative government, while 48 percent said the Labour government. NHS managers were also blamed (by 46 percent), as were doctors (although by only 9 percent). It was evident that the public had become increasingly unhappy with the NHS’s performance, and hence supported the policy to decrease waiting times because that was their number one concern with the NHS. Alan Milburn noted that “What really struck me is that, for the public, waiting was the thing. They were suffering it and wanted it changed.”
Stakeholder Engagement Strong
As part of the drafting of the NHS Plan, there were extensive consultations with the public, patients, and healthcare professionals to listen to their input and gain an insight into the needs of the NHS. Those consulted in the preparations for the plan were “frontline staff, professional groups, and patient representatives – alongside senior doctors, nurses and managers”. Detailed analysis was carried out by Modernisation Action Teams, which included leading representatives from organisations including the Royal College of Physicians, the BMA, and The King’s Fund. There was a large response to the preparation of the plan with 152,000 members of the public and 58,000 NHS staff submitting their opinions and suggestions on necessary changes to the service. The Office for Public Management also consulted with people who had recently received treatment within the NHS to hear about their experiences and “hopes for its future”.
Political Commitment Good
There was clear political commitment to improving and reforming the NHS through the policy measures in the NHS Plan. However, the opposition parties had some reservations about the nature and content of the plan.
The prime minister, Tony Blair, was determined to implement successful reforms, acknowledging that “For all of us it is a challenge. But it is one we intend to meet.” Commitment to making the plan a success was also demonstrated by the then-secretary of state for health, Alan Milburn, who said that: “Like key stakeholders, the government is committed to the NHS core principles... Together with all those who share our vision, we will work day in and day out to make it happen.”
However, the leader of the Conservative Party, William Hague, criticised the plan, stating that Labour’s pledges were set “so far into the future that [Tony Blair] cannot possibly be held to account on whether they are met or not". The leader of the Liberal Democrats, Charles Kennedy, supported the plan but had reservations about its failure to provide free personal care and basic nursing-home care for long-term patients.
Clear Objectives Strong
Amongst other targets such as modernising NHS facilities and recruiting more healthcare professionals to meet the increasing demand, the NHS Plan outlined clear, measurable targets for the reduction of waiting times. Targets were set for 2004, 2005 and 2010, and they included:
- By 2004, maximum waiting times in A&E should not exceed 4 hours;
- By 2004, access to primary care professionals, such as pharmacists, will be available within 24 hours, except for GPs with whom an appointment will be available within 48 hours;
- By the end of 2005, maximum waiting times for outpatients should decrease from 6 months to 3 months, with average times of 5 weeks; and
- By the end of 2005, maximum waiting times for inpatients should decrease from 18 months to 6 months, with the average decreasing from 3 months to 7 weeks.
A follow-up plan in 2002 reaffirmed that the maximum waiting time for a hospital operation would drop to 3 months by 2008.
There is a lack of clear, demonstrable evidence to support how the Department of Health set targets for waiting times. Although the Plan outlined specific targets to reduce waiting times, it did not detail the basis for those targets. For instance, the 18-week RTT target had no data to support whether it was achievable when it was set in 2004. The Department of Health made a draft policy which included a maximum waiting time of 12 months for treatment. However, this was unacceptable to Alan Milburn in light of maximum waiting times of 3 months in some European countries.
To reduce waiting times, there were several important measures to ensure that achieving objectives was feasible. An increased budget for the NHS was made available, as were additional places in educational courses to meet the increasing demand for healthcare staff.
In 2000, the Labour government dedicated more money towards funding the NHS budget. The government spent GBP54.2 million on the NHS in 2000, but by 2005 the amount was GBP89.6 million and by 2010 it was GBP122 million. This represents an increase of 9.3 percent in 2000 and 5.9 percent in 2005 on previous annual expenditure, while there was a 0.1 percent fall year-on-year in 2010. Healthcare spending as a percentage of GDP rose steadily during the period from 5.5 percent in 2000 to 7 percent in 2005 and 8.2 percent by 2010. In addition to increases in funding, the plan recognised that recruiting more staff was essential for targets to be met. The plan pledged to recruit and train more nurses and medical professionals, and between 1999 and 2004 there was a 21 percent increase in staff.
However, there were also some likely challenges to the implementation of the plan’s objectives. Although it was important to recruit more staff, certain members of the BMA felt that even more would be needed than was stated in the plan. Similarly, the perspective of the Royal College of Nursing was that it was important not only to recruit more nurses but also to keep them working in the NHS.
To ensure that hospitals were working hard to meet waiting time targets, a “delivery unit” within the Prime Minister’s Office monitored actual waiting times. Alan Milburn commented that the Department of Health put pressure on departmental civil servants, who in turn pressured hospital trust CEOs to perform and meet targets. Responsibility for meeting targets lay with the local hospital; however, there was pressure from above to make sure they were being met.
Devolution was a key element of the management structure of the NHS Plan, which proposed a system of “earned autonomy”. The central government’s role was to “set standards, monitor performance, put in place a proper system of inspection, provide backup to assist modernisation of the service and, where necessary, correct failure”. However, the focus was on providing greater autonomy for doctors and healthcare professionals, giving them more control over decision-making – with the best interests of the patient in mind.
The day-to-day management of the NHS was devolved to 28 new Strategic Health Authorities, whose role was “to hold to account the local health service, build capacity and support performance improvement”. Local Primary Care Trusts (PCTs) were given more autonomy, and by 2004 they controlled 75 percent of the NHS budget. This allowed PCTs to commission healthcare services from healthcare providers either within the NHS or privately.
To assist with this work and improve patient services, several new organisations were established. The Modernisation Agency’s objective was to spread best practice and “help local clinicians and managers redesign local services around the needs and convenience of patients”.  The Commission for Health Improvement was an independent body that inspected and assessed how NHS organisations were performing. The National Institute for Clinical Excellence was established “to ensure growing NHS spending is targeted on the most cost-effective treatments” and that access to medicine and treatment is not based on where a patient lives.
In order to assess whether sufficient progress was being made on reducing waiting times, the Department of Health collected data from “NHS-funded, consultant-led services”. In 2005, the Chief Executive’s Report to the NHS published data on waiting times from before the NHS Plan until the present.
Additionally, the Department of Health published annual reports on waiting times. Data was submitted to the Department, which then analysed it before publishing its report. It established a traffic-light measurement system, whose criteria were based on “how well [hospitals] work in partnership with others, and how well the local ‘health economy’ as a whole is performing on key shared objectives”. Standards were set nationally, but assessment was done locally and verified by the CHI. “Green” organisations were those that met all national targets and were in the top 25 percent of organisations; “yellow” organisations met most or all targets but were outside the top 25 percent; and “red” organisations were ones that had “poor absolute standards of performance”. The CHI inspected green-rated NHS organisations every four years and red-rated organisations every two years.
Additionally, different frameworks were introduced to provide a reference for national standards. For instance, the Performance Assessment Framework monitored six areas of NHS performance: “health improvement; fair access to services; effective and appropriate delivery of health care; outcomes from healthcare; efficient use of resources; and high quality experience for patients and carers”.
There was a general alignment of interest between many of the relevant parties involved in the NHS Plan. However, patients – and subsequently policymakers – were more concerned with waiting times than were healthcare professionals. Patients ranked waiting times as their top concern for the NHS, while NHS staff rated it only 7th – their top concerns were staff and training.
The government was actively involved in ensuring that the plan was implemented successfully, and they put pressure on civil servants to make sure that hospital CEOs were working to achieve the plan’s objectives. Alan Milburn said that “it was [a] relentless focus. The prime minister holding me to account, the delivery unit holding the department to account, me holding the department to account and the department holding chief executives to account – with the NHS knowing that this was the absolute top priority, because people were suffering and dying.”
Despite their shared interest in improving patient care and outcomes, many clinicians were not fully supportive of targets, as they felt that these imposed restrictions on their professional judgment. Rather than using their clinical expertise to assess which patients should be treated next, waiting times forced clinicians to treat patients in a specific order. Performance management was used to achieve meeting targets, and it involved “establishing a formal, regular and rigorous system of data collection and usage to indicate trends and measure the performance of services”.
Under this system, the pressure to meet waiting time targets was high and it became informally known as “targets and terror” (see also Public Impact above). In order to meet these targets, “gaming” tactics were often employed to misrepresent data and make it appear as though targets were being met. In some instances, the focus became meeting targets rather than the quality of care and treatment. For example, targets put an emphasis on treatment times, outpatient appointments and surgical waiting lists, overlooking diagnostics procedures such as MRI scans.
Similarly, there were many who felt that the NHS Plan was opening the door to the commercialisation and eventual privatisation of the NHS, which was a cause for concern. The distinction made between health providers, such as hospitals, and health purchasers, such as GPs, allowed competition to enter the health service in England, despite the Plan’s criticism of internal markets.