£4.3 Million Review Finds NHS Waiting Lists Caused Primarily by Patients Being Ill

The following is based on a leaked copy of the Interim Summary Report of the Independent Commission on NHS Demand, Capacity, and Systemic Pressures (Phase One), dated March 2025, obtained by The Daily Despatch. The Department of Health and Social Care has confirmed the document is genuine but described our characterisation of its findings as 'reductive'. We have read the document twice. We do not believe our characterisation is reductive.

Executive Summary

The Independent Commission on NHS Demand, Capacity, and Systemic Pressures was established in February 2023 to conduct a comprehensive, evidence-based assessment of the root causes of extended patient waiting times across NHS England. The Commission was chaired by Professor Alan Whitmore, formerly of the King's Fund, and included representatives from seventeen stakeholder groups, four royal colleges, two patient advocacy organisations, and a management consultancy whose name appears in the acknowledgements but not the methodology section.

Over twenty-six months, the Commission reviewed 4,200 documents, conducted 340 stakeholder interviews, held twelve regional engagement events, and commissioned three sub-reports from external research partners. Total expenditure came to £4.3 million, of which £1.1 million was spent on the engagement process, £900,000 on the sub-reports, and the remainder on what the accounts describe as 'operational and administrative functions', including, according to a line item on page 218, £34,000 on 'catering and venue hire for deliberative forums'.

The Commission's central finding, set out on page 4 and restated, with minor variation, on pages 47, 89, 134, 201, and 267, is as follows:

'Demand for NHS services is driven, in the first instance, by the prevalence of illness, injury, and health-related need within the population. Where such need is high, demand is correspondingly elevated. This relationship is broadly consistent across demographic groups, geographic regions, and clinical specialities, with some variation attributable to access, awareness, and referral pathway factors as outlined in Chapter 7.'

Or, as one civil servant who read an early draft reportedly put it in an internal email that has since been circulated widely: 'They've spent two years finding out that sick people go to hospital.'

Ministerial Response

The Health Secretary welcomed the report at a press conference on Monday, describing it as 'a significant first step in building the evidence base we need to tackle one of the most complex challenges facing our health system'.

Asked whether the finding that illness causes healthcare demand was something the government had not previously been aware of, the Health Secretary said the report 'goes much further than that headline would suggest', and directed journalists to Chapter 7, which deals with referral pathway variation.

Chapter 7 concludes that referral pathway variation 'may account for a proportion of demand-side pressures in some areas', and recommends 'further analysis to quantify the extent of this effect across different system contexts'. It does not quantify the effect. It recommends quantifying it.

The Health Secretary said she was 'committed to taking forward the Commission's recommendations in full'.

The recommendations are: a pilot scheme, a stakeholder engagement forum, and a further review.

The Recommendations in Detail

Recommendation 1: A Pilot Scheme

The Commission recommends the establishment of a pilot scheme in three to five NHS trusts to test 'demand-responsive capacity management approaches'. The scheme should run for between eighteen months and three years, after which point its outcomes should be evaluated. The evaluation should inform subsequent policy decisions. The Commission notes that the design of the pilot scheme should itself be subject to a 'co-production process' involving relevant stakeholders, and recommends that this process begin 'at the earliest practicable opportunity'.

The report does not specify what the pilot scheme will actually do. This, it explains, 'is appropriately a matter for the co-production process'.

Recommendation 2: A Stakeholder Engagement Forum

The Commission recommends the creation of a standing NHS Demand and Capacity Stakeholder Engagement Forum, to meet quarterly, bringing together 'representatives of patients, clinicians, commissioners, providers, and relevant third-sector organisations' to 'maintain ongoing dialogue around the evolving demand landscape'.

The Forum's terms of reference, membership criteria, and governance arrangements should be developed by the Department of Health and Social Care 'in consultation with key stakeholders'. It should produce an annual report. The annual report should be 'made publicly available'.

The Commission acknowledges that a broadly similar forum — the NHS Capacity and Demand Advisory Group — existed between 2018 and 2022, was wound down following a 'machinery of government change', and produced three reports, none of which appear in the Commission's bibliography.

Recommendation 3: A Further Review

The Commission recommends a further review. Specifically, a 'Phase Two analysis' examining the supply-side factors affecting NHS capacity, including workforce, infrastructure, and funding. The Commission notes that this review 'falls outside the scope of the present Commission's mandate' but 'represents a natural and necessary complement to the findings of Phase One'.

Phase Two, the report suggests, should be completed within two to three years. It should be independently chaired. It should involve stakeholder engagement. It should cost, the Commission estimates, 'in the region of £3–5 million, subject to scoping'.

Expert Panel Reactions

Professor Whitmore, speaking at the launch event, described the report as 'the most thorough examination of NHS demand pressures ever undertaken in this country'. He said the findings were 'both confirmatory and generative' — confirmatory in that they validated existing assumptions, generative in that they 'open up new lines of inquiry for Phase Two'.

Dr Sarah Okafor, a health policy analyst at the think tank Reform Health (not to be confused with Reform, the other think tank, or Reform UK, the political party), said the report was 'a solid foundation' but expressed concern that the recommendations were 'somewhat process-heavy'. She said she would 'like to have seen more concrete intervention proposals', before adding that she understood 'the evidence base isn't quite there yet', and that the pilot scheme and further review were 'probably the right call'.

Dr James Lyle of the Nuffield Trust said the report 'tells us what we broadly knew but in considerably more detail', which he described as 'not without value'. He noted that the finding on referral pathway variation in Chapter 7 was 'genuinely interesting' and warranted further investigation. He recommended a further review.

A spokesperson for NHS England said the organisation 'welcomed the Commission's work' and looked forward to 'engaging with the recommendations through the appropriate channels'.

What Happens Next

The Department of Health and Social Care has committed to responding formally to the report within six months. The response will 'set out the government's position on each recommendation and outline next steps for implementation'.

The pilot scheme is expected to begin recruitment in late 2026, subject to the completion of the co-production process. The Stakeholder Engagement Forum will hold its inaugural meeting 'before the end of the financial year', which the Department subsequently clarified means the financial year after next. Phase Two of the review will be scoped 'once Phase One recommendations are sufficiently embedded'.

Asked when patients currently on waiting lists might expect to see a tangible improvement as a result of the Commission's work, a Department spokesperson said the report 'is not intended to be an immediate operational intervention' but rather 'a strategic contribution to the longer-term evidence architecture underpinning system reform'.

They were asked to say that in plain English.

They said they would follow up.

They have not followed up.

The waiting list currently stands at 7.5 million people. It is expected to feature prominently in Phase Two.