As of July 2025, the NHS waiting list stood at 7.4 million incomplete pathways, representing 6.2 million patients, with 191,648 waiting over 52 weeks. These are not abstract figures, they represent patients living in pain and uncertainty, healthcare workers forced into impossible choices, and a workforce stretched beyond safe limits.

Government claims there are “more doctors and nurses than ever before” are technically true, but deeply misleading. Once population growth of over 6 million people since 2010 and rising care complexity are factored in, the NHS has fewer clinicians per head of population than it did a decade ago. On a per-capita basis, the UK has only 3 doctors per 1,000 people, well below the OECD average of 3.7, and fewer nurses per capita than countries like Germany or France. Far from progress, the reality is a shrinking workforce relative to demand.

With winter approaching, urgent care surges looming, and the private sector also struggling for capacity, the narrative of “elective recovery” looks increasingly fragile. This blog takes a deeper look at the backlog, the state of the workforce, the limits of private sector reliance, and the politics shaping healthcare as winter 2025 closes in.

The Elective Backlog by Numbers

The July 2025 Referral to Treatment (RTT) data confirms a worsening trend:

• 7.4m incomplete pathways, up from 7.2m in June.
• 191,648 patients waiting more than 52 weeks, showing that long waits remain stubbornly high.
• Top 10 specialties driving the backlog:
  • Orthopaedics (hips, knees, spinal surgery)
  • Ophthalmology (cataracts, retinal surgery)
  • ENT
  • General Surgery
  • Urology
  • Gynaecology
  • Dermatology
  • Cardiology
  • Gastroenterology
  • Neurology

These are not just numbers. They represent older people unable to walk, patients losing independence as sight fades, and lives put on hold.

Winter Overlay: A Perfect Pressure Multiplier

Winter demand threatens to overwhelm an NHS already operating beyond safe limits.

• Emergency admissions will surge with RSV, flu, COVID variants, and frailty-related conditions.
• Makeshift wards are becoming the norm, with a Hospital in Kent forced to convert a café into an A&E ward, a striking example of the system straining at its seams.
• Diagnostics bottlenecks (imaging, endoscopy) already visible in July’s DM01 figures will ripple through surgical lists.
• Staffing shortages and high sickness absence will further cut capacity.

Elective activity is consistently the first casualty when urgent care surges, and this winter will be no different unless systems find new ways to protect it.

Workforce at Breaking Point

Elective recovery is impossible without staff, yet the workforce enters winter already depleted:

• The NHS Staff Survey 2024 recorded record burnout, with many staff saying they cannot deliver safe care within current conditions.
• GP workforce attrition continues, 1 in 3 GPs no longer work in the NHS, compounding urgent and elective demand.
• Agency restrictions have stripped out flexibility. By forcing systems to cut agency use to hit spending targets, without building sustainable alternatives, the government has weakened resilience internally and externally just as demand peaks.

Behind every RTT statistic is the stark truth: without workforce, there is no healthcare.

Financial Illusion: Deficits and Cuts

NHS England faces a £6.6bn deficit in 2025/26. Trusts are told to:

• Reduce agency and bank spend
• Deliver more elective activity
• Balance books despite inflation and wage pressures

This is a broken equation. You cannot cut the very workforce needed to deliver elective recovery while claiming to be tackling waiting lists. The result is demoralisation on the ground and a widening gap between political promises and system reality.

The Private Sector Myth

Government often points to private sector referrals as proof of progress, but this narrative is deeply flawed:

• Private hospitals are also at capacity. Clinics cannot endlessly absorb NHS referrals.
• Big players such as Spire Healthcare are under investor pressure to sell assets, reflecting fragility in the sector.
• The same workforce underpins both NHS and private providers. With staffing supply cut, both systems strain simultaneously.

There is no silver bullet in outsourcing. The government cannot endlessly export the backlog to the private sector and claim success. While attacking agency costs, it is simultaneously paying more for outsourced referrals than it would to have consultant surgeons operating within their own hospitals.

Political Responsibility: Hollowing Out the System

For two years, Wes Streeting has pursued a strategy of cuts and caps, dressed up as reform. Promises of transformation under the Labour Government’s 10-Year Plan sit in sharp contradiction to the daily reality:

• Funding has been throttled.
• Workforce pipelines have been cut off.
• Agency restrictions have artificially reduced demand and removed essential flexibility which millions of vulnerable patients benefit from each year.

The result: an NHS workforce demoralised, patients left waiting, private providers squeezed, and leaders tasked with delivering the impossible. The system has been hollowed out, and winter 2025 will expose this more starkly than ever.

Where Leaders Stand

System leaders face unenviable decisions. There is no single lever that will clear waiting lists, protect urgent care, and sustain the workforce. But there are steps that can mitigate harm:

• Protecting elective activity even during escalation.
• Deploying insourcing and targeted capacity increases where safe.
• Supporting staff through rest, wellbeing, and fair rostering.
• Being honest about what is and is not possible under current constraints.

Final Word – Altin Biba, MBA, AMBA

The elective backlog is not just an NHS performance metric; it is a reflection of national choices. By starving the service of funding, restricting the workforce, and pretending private providers could fill the gap alone, government has created a perfect storm. As leaders, we cannot look away. We must protect patients and support our healthcare workforce, there is no healthcare without healthcare workers. The only way forward is to rebuild trust and invest in people.

References

• NHS England. Referral to Treatment (RTT) Waiting Times Data, July 2025.
• NHS England. Monthly Diagnostics (DM01) Statistics, July 2025.
• The Telegraph. William Harvey Hospital Uses Café as Makeshift A&E Ward. September 2025.
• NHS Staff Survey 2024. Workforce Engagement and Burnout Findings.
• King’s Fund. NHS Performance Tracker: Elective Care.
• Health Foundation. Elective Recovery and System Pressures, 2025.
• BMJ. GP Workforce Analysis, 2025.
• Financial Times. Spire Healthcare Investor Pressure Report, 2025.