30 April 2025

The NHS will be paid to cut waiting lists – at great cost to patient safety

Are some people destined to become collateral damage so that lists “fall” faster?

Imagine the furore if a Conservative government announced a scheme to shrink hospital waiting lists using financial incentives. First, they’d pay cash-strapped hospitals unlimited bonuses to kick patients off the lists. Then, they’d offer GPs cash to stop referring patients to hospital. I’m not sure anyone would hold back from calling it what it was: an overt attempt at using the profit motive to distort safe decision-making.

There is no need to imagine this scenario. A Labour health secretary has decided to go where not even Andrew Lansley, Jeremy Hunt and Sajid Javid dared tread. Earlier this month, the Guardian revealed hospitals in England are being offered unlimited bonus payments to remove people they have decided do not need treatment from their waiting lists. Something like this was in place before, but with a payment cap of 5 per cent of the trust’s total waiting list. Now the cap has been lifted. Trusts have been instructed to “validate” their entire list. They will receive an “incentive payment” for every patient they remove, with no limit to the amount awarded. Deficits at NHS trusts in England have more than doubled over the past year. Do we really expect hospital bosses not to be tempted to game their figures by taking a scythe to those waiting?

Then, the BBC ran a story headlined: “Plan for GPs to keep millions out of hospital.” The health minister Karin Smyth said the scheme would “save time and stop masses of people having to head to hospital for unnecessary appointments”. This would be achieved, apparently, by linking “GPs and hospital specialists before patients are referred on to waiting lists, so that tests and treatments can be offered in the most convenient place”. The piece cited the examples of earwax, IBS and menopause symptoms – as though hapless GPs routinely refer patients with earwax to specialists (they do not). Only mentioned at the end of the piece was that every time a GP decides not to refer a patient to hospital, they will be paid £20 for doing so.

Is this a patient-safety scandal or simply common sense? Are waiting lists really clogged up with thousands of patients who don’t need to be there? In theory, some patients – those whose symptoms have eased, or who have already resorted to paying for private care – could perhaps be taken off lists safely. But experienced GPs do not make referrals lightly. Indeed, part of the art of general practice lies in using one’s judgement to decide who really needs to be referred and who can be safely managed in a community setting.

More so, the danger of incentivising a particular behaviour is that providers become so fixated on the goal that they cease to notice, or choose to ignore, harm to patients. The NHS has a long and egregious record of doing precisely this. The Mid Staffordshire scandal, for example, was caused by the trust cutting staff to unsustainable levels to try to meet financial targets. Immeasurable harm to patients followed.

No one can doubt Wes Streeting’s zeal to tackle NHS waiting lists, or how vital doing so is after a succession of Conservative governments permitted them to double, from 2.3 million to 4.6 million cases from 2010 to 2019. Are some patients destined to become collateral damage, denied treatment to make the lists “fall” faster?

The words of Streeting’s predecessor on this issue are worth quoting in full. When, in 2018, it was revealed some clinical commissioning groups had started trying to balance their books by offering GPs cash not to refer patients to hospital, Jonathan Ashworth, the then shadow health secretary, was unequivocal: “The minister should step in and ban this practice immediately. Patients should be referred for treatment on the basis of their medical needs. These cash handouts – which some might even describe as ‘bribes’ – to block referrals are totally unacceptable and the latest pernicious effect of Tory underfunding of our NHS.”