Summarising the impacts of the crises hospitals have experienced in recent years: COVID-19, inflation, one of the worst flu seasons on record and ongoing industrial action.

Key figures

  • 7.8 million – the size of the elective backlog in August 2023, 0.5 million higher than when Rishi Sunak promised to cut waiting lists in January 2023 and 3.2 million more than before the pandemic.
  • 1.1 million – hospital appointments rescheduled due to industrial action since December 2022.
  • 2 – the number of years between 1970 and 2020 that the UK invested more than the OECD average in health capital.
  • 10% – of people attending A&E in the year to September 2023 waited more than 12 hours, compared to 3.1% in 2019/20.
  • 1 in 7 – hospital beds were occupied by someone who was eligible for discharge during the winter of 2022/23.

The return to pre-pandemic activity

These crises have compounded existing performance problems caused by underinvestment in capital and cuts to management capacity. These have made it impossible for the hospital service to operate normally, which is evident in the difficulties that the service is having in returning to pre-pandemic activity levels in some areas – a standard of performance that was already well below that of 2010. For instance, hospitals completed fewer elective cases and conducted fewer outpatient appointments in 2022/23 than in 2019/20. In addition, the slower flow of patients through hospitals continues to contribute to poor performance in urgent and emergency care.

Increased spending

The government is spending considerably more on hospitals than before the pandemic. Spending on NHS providers rose substantially during the first year of the pandemic by 9.8% in real terms between 2019/20 and 2020/21. The real-terms increase of 3.3% between 2020/21 and 2021/22 was smaller than the previous year but still well above the annual average increase of 2.3% between 2009/10 and 2019/20. Much of this increase is COVID-related, as the government increased spending to help the service deal with the additional pressures; however, it is impossible to quantify how much the NHS spent on responding to COVID in hospitals, as estimates such as the National Audit Office’s COVID tracker are aggregated across the entire NHS.

Following the launch of the NHS Long Term Plan in 2019, it’s likely that spending would have increased regardless of the pandemic. The plan aimed to increase spending by 3.3% per year between 2018/19 and 2023/24; what we’ve actually seen so far is 6.3% a year on average between 2018/19 and 2022/23. A substantial portion of this extra spending has been on staff costs, with the NHS employing more staff as opposed to raising salaries.

A bigger workforce

In March, there were 18.8% more nurses and 19.7% more doctors working in hospitals and community settings than in March 2019 (in FTE terms). During the pandemic, the source of new nurses and doctors in hospitals changed. More British staff started to leave the service from June 2021 onwards, with their roles then filled by staff from outside the UK and EEA. This is a legitimate route to filling workforce vacancies and is preferable to not being able to staff wards. However, it comes with risks, including a higher risk of doctors abandoning their licence to practice after qualifying sooner than their British counterparts might.

When we were around a year into the pandemic, staff retention rates fell, but this trend is now in reverse. The percentage of workforce voluntarily resigning reached a peak of 10.8% in the year to September 2022, and this has since fallen to 9.7% to June 2023, though this remains the joint highest level of any 12-month pre-pandemic period.


Vacancy rates, which fell in hospitals during the early stages of the pandemic, have largely returned to pre-COVID levels. The total number of vacancies across the NHS rose to a high of 9.6% as at the end of June and September 2022 – the highest level since the NHS started publishing this data in 2017.

Protracted industrial action

Dissatisfaction with pay and working conditions are the two primary contributing factors to the ongoing industrial action that started in summer 2022, and common belief is that the government’s strikes strategy has likely extended the action, which has been hugely detrimental to hospital activity. Since December 2022, the NHS has rescheduled over one million appointments due to strike action, but the picture is bigger than that – there will have been many appointments that should have been made that it was simply not possible to as a direct consequence of industrial action.

Winter 2022/23

The NHS experienced the worst winter in its history during 2022/23. December 2022 saw historic lows in ambulance response times, long A&E waiting times and ambulance handover delays. In major A&E departments, only 65% of patients were seen within the targeted four hours. The government responded to this crisis by providing £750m to both the NHS and local authorities to increase capacity in social care, the number of ambulances, and the number of beds in hospitals. The overall aim of this was to improve flow through hospitals and speed up treatment times.