Customer story | Addressing waiting list health inequalities

The NHS continues to face significant pressure from the elective care backlog, with millions of patients waiting for treatment. Extended waits can lead to deteriorating health and greater demand on urgent and emergency services. In line with the NHS 10-year plan’s ambition to move from treating illness to preventing it, integrated care systems (ICSs) are seeking innovative, data-driven approaches to manage this challenge, while ensuring patient safety and equity.

University Hospitals Plymouth NHS Trust (UHP) identified a critical issue: patients on elective waiting lists were not only at risk of deterioration but also faced unequal access and outcomes, particularly those with a learning disability. These patients were four times more likely to require emergency care than those without a learning disability, highlighting a stark health inequality.

Proactively supporting at-risk patients

To address this, UHP partnered with Optum to implement a ‘waiting well’ programme using PHM Pathfinder Analytics to analyse population data. The goal was to proactively support at risk patients awaiting treatment, with a focus on reducing inequalities.

Key steps included:

Segmentation of over 40,000 patients on the waiting list by clinical risk, social vulnerability and likelihood of deterioration
Identification of priority groups, including patients with a learning disability
Coordination of targeted interventions across primary, secondary and community care settings

Data analysis revealed:

434 patients with a learning disability had an emergency admission in the previous 12 months
65 of these were also on the elective waiting list
Emergency care costs for patients with a learning disability on the waiting list were £1.4 million higher than for those without

Results that matter

The programme delivered measurable improvements:

Reduced waiting times for patients with a learning disability

Improved patient experience and wellbeing during waiting periods

Lower risk of deterioration, reducing emergency admissions

Enhanced visibility of waiting list pressures across the system

Strengthened collaboration, enabling more joined-up care

The UHP waiting well initiative demonstrates how population health management can be used to turn reactive care into proactive support. By identifying and addressing health inequalities within the elective backlog, ICSs can improve outcomes, reduce avoidable demand and make waiting safer and more equitable for all patients.