New research from NIHR ARC West Midlands reveals how a 2002 NHS policy, the 2008 recession, and the COVID-19 pandemic have influenced cancelled elective operations and breaches of the 28-day re-admission standard in England (Quinn, et al. 2025). This comprehensive study, spanning three decades that saw elective admissions almost double to 2 million per quarter, offers valuable insights into the resilience of the UK health service.
The study shows that a policy introducing financial penalties for hospitals that failed to operate on a patient within 28 days of a last-minute cancellation was initially highly effective – breaches of this standard dropped rapidly after the policy’s implementation and remained at a low level for many years. However, the findings show that this success could not be sustained in the face of significant external pressures. While the 2008 recession did not affect cancellation rates, it did cause an increase in breaches of the 28-day standard. The most dramatic impact was seen during and after the COVID-19 pandemic, when breach rates surged to their highest levels, effectively cancelling out the gains made by the 2002 policy.
Interestingly, there was a profound difference between hospitals with and without accident and emergency (A&E) departments. Hospitals with A&E departments experienced a significantly higher increase in breach rates following the COVID-19 pandemic compared to those without, suggesting that the added pressure of emergency admissions meant that hospitals were less able to protect beds for elective procedures.
These findings highlight a crucial point, that while policies and targets can be well-intentioned, they are most effective when a health system has sufficient resources and the capacity to manage demand. Without this fundamental resilience, even the best policies can become ineffective, especially in the face of unforeseen crises. This study provides a critical reminder that while targets are important, they must be set within a realistic understanding of the system’s capacity.
Publication:
Quinn L, Bird P, Hofer TP, Lilford R. Cancelled elective operations and 28-day breaches in the NHS in England: an interrupted time series analysis of the 2002 penalty policy, 2008 recession, and COVID-19 pandemic (1994-2023). Lancet Reg Health Eur. 2025; 56: 101368