Labour’s NHS Waiting List ‘Success’ Exposed as a Statistical Illusion
This morning’s Times reports that Labour’s widely praised reduction in NHS waiting times may not be as impressive as it first appeared.
“An analysis of official NHS statistics by The Times reveals that this drop was achieved only by removing thousands of patients from the waiting list through a process known as ‘validation’.”
The report continues with sobering figures regarding the reality of patient care during this period:
“In November, the month that Starmer was referring to, 346,300 were removed from NHS waiting lists, 82,000 more than the month before, which accounted for almost the entire claimed drop in the waiting list. At the same time, NHS data shows that in November hospitals actually carried out about 10 per cent fewer operations and appointments than they did in October, suggesting that fewer people were being treated.”
The illusion of success
With hindsight, this outcome appears unsurprising. When public discussion focuses on the number of people waiting for treatment rather than the amount of treatment actually delivered, any institution seeking a quick and visible success may be tempted to reduce waiting lists by administrative means rather than by treating more patients. In recent years, the British Government has often found itself in this position.
This approach is not always inappropriate, as its value depends on how patients leave the waiting list. One example given of patients removed through the NHS “validation” process includes those for whom “other options such as physiotherapy might be more beneficial”. If this assessment is accurate, then identifying such patients is sensible and beneficial.
However, another group removed from waiting lists consists of patients who have died. Counting such cases as progress in reducing waiting lists appears deeply misguided, particularly if this is presented as an achievement.
A paid incentive?
It must also be noted that central government has been paying NHS trusts to carry out these validation exercises:
“Between April and September last year NHS England paid hospital trusts a total of £18,818,566 for validation exercises, with the organisation saying that trusts were paid about £33 for each patient removed from the list. This would mean that over the six-month period more than half a million patients were removed through the ‘validation’ process.”
It is unlikely that this system was designed to directly reward removals, as such an incentive would be too obvious. Nevertheless, the structure and expectations surrounding these exercises would have been clear to those involved.
It is also worth noting that Rishi Sunak reportedly refused to fund validation schemes, arguing that NHS trusts should have been carrying them out regardless. This argument appears strong, not only on moral grounds but also practical ones. If paying consultants to review patient lists genuinely produced large savings, which seems likely given that most patients require far more than £33 worth of care, then NHS trusts already had a strong incentive to carry out these reviews independently. The question is why they did not do so.
The Soviet parallel
Overall, this situation resembles a mild version of the examples described in Red Plenty, a book that offers a fictionalised account of the Soviet economy. In these stories, organisations manipulated targets in absurd ways, such as deliberately breaking machines to meet production goals, only to be sent heavier but less useful replacements because factories were judged by weight rather than usefulness.
Designing an effective incentive system for an organisation like the NHS is extremely difficult. Without a profit motive, there is limited pressure to pursue efficiency. At the same time, the NHS’s near monopoly as a healthcare provider reduces the incentive to prioritise customer service. As a result, governments attempt to impose incentives from the outside, a task that is complex and risky.
The danger of wrong metrics
If waiting lists are not measured, what should replace them? One obvious alternative is measuring the amount of work done, such as the number of operations and appointments. However, this would create a different set of perverse incentives. Hospitals might prioritise unnecessary or trivial treatments simply to improve statistics.
This has occurred before in education under New Labour. Schools were judged by exam results, which initially seemed reasonable. However, policymakers failed to properly weight GCSEs and A Levels against short vocational qualifications. Some schools responded by steering pupils towards qualifications that were easy to obtain but of little long-term value.
While such systems could be better designed, over time bureaucracies tend to become more skilled at exploiting performance measures than politicians are at designing and enforcing them. Ministers change frequently, while institutions remain constant.
Political consequences
Ultimately, politicians bear the cost of these failures. As the Starmer Government may discover, public dissatisfaction with the NHS is shaped primarily by personal experience. Announcements about falling waiting times may attract attention, but they will only provide lasting political benefit if patients genuinely experience better care.
If claims of reduced waiting lists are accompanied by reduced levels of treatment, those claims will come to be treated with the same scepticism as Soviet production statistics. Even the Communist Party of the Soviet Union did not attempt such tactics in a system where voters had the power to remove them from office.