Indirect health impacts of COVID-19 – NHS performance and waiting times

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The COVID-19 pandemic and associated restrictions have had a significant impact on the NHS in Scotland. Not only as a direct consequence of treating people with COVID-19 but also because of the measures put in place to prevent the spread of the disease.

This blog will look at some of the impacts of COVID-19 on the performance of the NHS in Scotland and in particular at waiting times. It uses data from Public Health Scotland.

In March 2020, the NHS in Scotland was put on an “emergency footing” with non-urgent planned care being postponed. In its report NHS in Scotland 2020, Audit Scotland, said:

“The pandemic led to a substantial backlog of patients waiting to be seen, with NHS boards prioritising those in most urgent need. As highlighted in our previous NHS in Scotland reports, NHS boards have found meeting national waiting times targets very challenging”.

In May 2020, the Scottish Government published Re-mobilise, Recover, Re-design: the framework for NHS Scotland and each NHS Board published its own remobilisation plan. These outlined how Boards intended to deal with growing demand, urgent referrals and routine services. These plans have been updated to cover April 2021 to March 2022 and replace the Board’s usual Annual Operating Plans.

In November 2020, the Scottish Government published a clinical prioritisation framework for supporting elective care. This is a new way of prioritising people in relation to the urgency of their need:

  • Priority level 1a Emergency – operation needed within 24 hours
  • Priority level 1b Urgent – operation needed with 72 hours
  • Priority level 2 Surgery – scheduled within 4 weeks
  • Priority level 3 Surgery – scheduled within 12 weeks
  • Priority level 4 Surgery – may be safely scheduled after 12 weeks.

Audit Scotland noted that “these timescales are ambitious, considering that NHS boards already found it challenging to meet waiting times targets”.

The Scottish Government’s supporting elective care – clinical prioritisation framework outlined that NHS Boards are required to maintain essential and urgent services including critical care capacity, maternity, emergency services, mental health provision and critical cancer services.

What is the scale of the issue?

Waiting lists across a wide range of specialities have increased since the start of the pandemic. Demand has continued, and in some cases increased, alongside a significant drop in activity.

Diagnostic waiting times

Diagnostic tests are a test or procedure that is used to identify a patient’s disease, condition or injury to enable a diagnosis to be made. The Scottish Government’s waiting time standard is that people waiting for one of eight key diagnostic tests and investigations should wait no longer than six weeks.

The eight key diagnostic tests are:


  1. Upper Endoscopy
  2. Lower Endoscopy (excluding Colonoscopy)
  3. Colonoscopy
  4. Cystoscopy


  • CT Scan
  • MRI Scan
  • Barium Studies
  • Non-obstetric ultrasound

The most recent figures show that at 31 March 2020 there were 105,630 people waiting for one of the eight key diagnostic tests. This 24.9% higher than the same time in 2020.

Of those people waiting, 38.6% had been waiting more than six weeks compared to 24.9% at 31 March 2020.

The percentage of people waiting less than 6 weeks was lower at the end of March 2021 than at the end of March 2019 for all radiology tests, all endoscopy tests and the eight key diagnostic tests combined.

At the end of March 2021 there were 33,444 patients waiting for an endoscopy test. This is 43.4% higher than at the end of March 2020.

Of those waiting, 65.4% had been waiting more than six weeks compared to 40.0% at the end of March 2020.

It is also important to consider that COVID-19 has resulted in a reluctance of some people to see their GP for non-COVID-19 related healthcare. This may have had a knock-on effect on the number of people being referred for diagnostic tests.

Waiting times for outpatient appointments

At the end of March 2021 there were 354,782 new outpatients waiting for an appointment. This is 37.1% higher than at 31 March 2020.

Of those waiting 51.9% had been more than 12 weeks or more compared to 25.6% at the same time in 2020.

Public Health Scotland also notes that as the waiting list size continues to increase, the percentage of people experiencing longer waits has also increased. At 31 March 2021, 13.5% (47,884) of people had been waiting 52 weeks or more, up 7% (23,928) from 31 December 2020. The chart below shows the distribution of waits for new outpatient appointments at 31 December 2020 and 31 March 2021.

Waiting times for treatment

Under the Treatment Time Guarantee people should wait no longer than 12 weeks for inpatient or day case treatment after the decision to treat is made.

During the quarter ending 31 March 2021, 36,582 patients were admitted for  inpatient or day case treatment. This is 43.4% lower than the same period in 2020.

Of those people admitted, 28.5% had waited more than 12 weeks compared to 31.7% for quarter ending 31 March 2020. This shows that more people are waiting for treatment and in many cases the waits are longer – at the end of March 2021 over 28,203 people had been waiting 52 weeks+ for treatment, up from 15,128 at December 2020.

More information on the trends in demand and activity for acute services can be found in Public Health Scotland publications and in the Audit Scotland Report NHS in Scotland 2020. We have also written a blog on Cancer and COVID-19.

Health inequalities

What is not reported is how different groups are impacted by the longer waiting lists and delays in treatment. We know that the pandemic has not impacted on all groups of people equally. For example, people living in the most deprived areas of Scotland were twice as likely to die from Covid-19 than those living in the least deprived areas. What is also important is how these existing inequalities have also manifested in indirect health harms, which includes access to services, and delays in diagnosis and treatment.

How these inequalities are addressed will be key in the recovery from COVID-19. The Scottish Government, in its remobilisation framework, comments that:

“This pandemic has exposed and exacerbated deep-rooted health and social inequalities. We will act to mitigate these and ensure that services are provided in a way that is proportionate to need. The framework that we take forward will focus on how to best support those that are most vulnerable (socially and clinically) in our society.”

You can read more in our briefing Health inequality and COVID-19 in Scotland.

How will the NHS respond?

In its report Audit Scotland commented that the Scottish Government’s Waiting Times Improvement Plan was paused at the start of the pandemic and. Although, the Scottish Government has indicated to NHS Boards that it will financially support initiatives that help to enhance the delivery of services and that the release of funding will be contingent on demonstrating sufficient planned progress towards key performance targets.

As mentioned earlier the Scottish Government now has a clinical prioritisation framework for supporting elective care. Audit Scotland commented that these timescales are ‘ambitious’. It made a number of recommendations, including the need to:

  • take action to meet the needs of those whose access to healthcare has been reduced as a result of the pandemic and monitor the long-term impact of this on health outcomes
  • publish data on performance against the clinical prioritisation categories to enable transparency about how NHS boards are managing their waiting lists.

It also referred to the Scottish Government’s Re-mobilise, Recover, Re-design programme of work. Recommending that:

  • The work should have clear priorities including achievable and realistic objectives and timescales for completion. Progress should be monitored and reported.
  • All NHS leaders should have the support they need to balance the ongoing challenges presented by Covid-19 with the need to remobilise services.

The Priorities for Government statement notes “In our first hundred days, we will publish an NHS recovery plan”. The aim of the plan will be to increase inpatient, day case and outpatient activity by 10%. A debate on health recovery was held on the 01 June 2021.

The Scottish Government has also commissioned the establishment of the Centre for Sustainable Delivery. This national unit aims to support the Remobilise, Recover and Redesign Framework and the Redesign for Recovery agenda. 

How the Scottish Government and the NHS responds to the challenge of meeting pent-up demand and how it redesigns services will be key to ensuring the success and sustainability of the NHS in years to come.

Lizzy Burgess, Senior Researcher, Health and Social Care and the Data Visualisation Team