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There was a time when Chancellors went into pre-budget purdah…
… for a couple of months they’d be invisible.
If there was a budget-leak, there’d be hell to pay.
In 2013, the leak of George Osborne’s budget ran him into deep trouble and in 1947 when the then, Labour chancellor, Hugh Dalton, revealed key budget details to a newspaper… ouch…
… a day later he quit.
These days, Chancellor Reeves seems to be doing leaking as part of the job.
As a result, we can confidently predict, there’s more money coming the way of the NHS… my guess it’ll be focussed on getting waiting lists down.
Good, but…
… there’s an uncomfortable truth… it’s too late.
Despite Labour’s promises, the 18-week target will not return in this parliament.
That’s my prediction and to be honest, it's not only me!
It’s mathematically impossible, politically very inconvenient and operationally unachievable.
Why? It’s all about…
… Little’s Law…
… a fundamental principle from queueing theory, first formulated by John D.C. Little in 1954.
It applies to any stable system where ‘items’ flow through a process… customers through a supermarket, or patients through a hospital.
Bobble-hats excuse an oversimplification… here’s how it works.
John Little links capacity, flow and waiting times in a simple formula;
- The average number of items in the system (patients on a waiting list) is equal to…
- The average arrival rate or throughput (patients treated per unit of time),
- Multiplied by the average time an item spends in the system (how long a patient waits for treatment).
This means… if you know how many patients you can treat per year (throughput) and how long patients wait, you can estimate the ‘natural’ size of the waiting list.
The NHS treats 18-20m per year (pre-pandemic number)… first visits, follow-ups, scans, injections.
Actual elective procedures, or interventions are usually 4-5m per year in England (pre-pandemic baseline).
Diagnostics are part of throughput calculations, but since they are easier to expand quickly (with scanners, evening sessions and AI support), they don’t dominate the sustainable-waiting-list estimate.
It's the elective bottleneck that drives real waiting.
This is where mathematical magic turns into misery.
The elective waiting list sits at around 7.5 million. To hit 18 weeks, Little's formula tells us, the system allowing for cancellations, seasonal spikes, winter pressures, specialties with longer waits, operational variation…
...needs it to be nearer 3.5 million.
We are at more than double the sustainable, waiting capacity, capable of being treated in 18 weeks. Without a huge capacity increase, the NHS cannot process enough patients to halve the list in the years to the next election.
Small productivity gains (2–3% per year) barely dent the number because the gap is measured in millions, not thousands.
We’d need a productivity gain of maybe 60%, sustained for years.
Instead, ministers have bet the farm on a 2% productivity target…
… nowhere near enough and anyway the NHS is already at full stretch, being told not to overspend its budgets…
… which means more waiting.
There’s no hidden capacity waiting to be ‘unlocked by innovation’, which may make work easier or more accurate, otherwise it’s just a meaningless political slogan.
You can buy scanners and if you've got somewhere to put them, with a fair wind, have them installed in six months. However, it takes three years to conjure a radiographer.
Build surgical hubs; you still need anaesthetists, there a shortage.
Capital without workforce is just expensive furniture.
You can see the real culprit isn’t money or machinery. It’s something you can't make, or buy... it's time.
Streeting wasted too much time. Left it too late to grip the waiting list while it was still manageable. He makes a song and dance over reductions of 250k, but it’s nowhere near enough. Tiny shifts won’t do it.
There are just too many people joining the queue.
If ministers were serious, they’d stop everything that isn’t about reducing waits but even then, the change of gear is probably too late.
A moratorium on everything except capacity, diagnostics, flow, discharge and staff. One job. One focus. No noise. Maybe but I doubt it. Streeting’s wasted the best part of two years.
Chancellor Reeves may write a cheque but the risk is the cash will be spaffed in overtime, buildings with no people and reorganisation.
For all Streeting’s boasting and braggadocio about the NHS being broken…
... the only thing that is really broken is his waiting-list promise.
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