The NAO report found the NHSE diagnostic transformation programme met its objectives to increase diagnostic tests but its surgical and outpatients' transformation programmes had not achieved their targets.
Gareth Davies, head of the NAO, said: ‘To achieve its aims on elective reform NHSE will need to make sure all its transformation programmes are delivering quicker access to treatment for patients as planned. This has not consistently been the case so far.
‘With its reset of how it manages its programmes NHSE has an opportunity to ensure that it learns from its experience in the first phase of the programmes – particularly where it has failed to meet its targets – and there is some evidence that it has started to apply these lessons.'
The NAO said NHSE had made slower progress than planned on reducing waiting times, with around 6.3m people (as of Jan 2025) waiting for elective care across 7.4m pathways. The NHS last met its 18-week elective care waiting standard target in 2015.
In 2024-25, the NHS has so far delivered a 116% increase in activity, compared to 19/20 baseline levels, but fell short of its 129% target. NHSE has broadly achieved its aim of eliminating waits of more than 2 years and more than 18 months but it will not achieve its target to eliminate waits of more than a year by March 2025, the NAO said.
As of the end of January 2025, 22% of patients waiting for a diagnostic test waited more than six weeks, against a recovery target of 5% by March 2025.
In addition, NHS trusts with surgical hubs are delivering 48% less additional elective activity than they planned to.
Thirdly, NHSE set a target to reduce outpatient follow-up appointments by 25% compared with 2019-20 levels, but NHSE's reporting showed that appointments reduced by 0.1% between June 2022 and July 2023.
NAO said there were signs NHS England has learned lessons from the programmes, adding there was scope for stronger governance arrangements, performance tracking and clinical leadership to improve the management of the programmes.
Reaction
An NHS spokesperson said: ‘In an extremely challenging period when months of industrial action caused nearly 1.5m appointments to be rescheduled amid rising demand, NHS staff made a range of vital progress for patients – with the longest waits being almost eliminated, a record 28.3m tests and checks delivered in 2024 and significant strides made in cancer referrals and diagnosis.
‘Latest figures show NHS staff have more than halved the average wait for tests and checks since the height of the pandemic – and we are committed to getting people the right help, quicker, as outlined in our new elective reform plan - this includes patients being able to get directly referred and booked in for tests, checks and scans by their GP, a same day service for diagnostic tests, and speeding up diagnosis times.'
Assistant director of policy at The Health Foundation, Tim Gardner, said: ‘A relentless focus will be needed to ensure the service changes in the new elective care reform plan can unlock vital productivity improvements. The recent decision to scrap NHS England and expected cuts to local NHS management budgets are unlikely to help; disrupting an already overstretched health service risks undermining its ability to deliver on the government's plans.
‘What the NHS needs now is a systematic approach to improving performance and capacity to reform how care is delivered.'
Rory Deighton, acute director at the NHS Confederation, said the report also ‘rightly emphasises the importance of continued long-term capital investment into the health service, something which the NHS Confederation has long been calling for and which can be transformational in improving care and increasing productivity'.
Deighton added: ‘However, continued recovery will take time and is set against one of the toughest financial settlements we have ever seen, and with significant cuts to both NHS trust and ICB funding, this may take longer than hoped for.'
