Great British PAC: NHS Cannot Lose Track of Patients and Ministers Cannot Refuse to Answer

NHS patient referrals have been vanishing from the digital worklists that hospitals rely on to manage care, and nobody at either end of the referral was told. An investigation by the Health Services Safety Investigations Body (HSSIB), the health service’s independent safety watchdog, has documented cases dating back to 2018 of referrals dropping off the NHS e-Referral Service, the platform GPs use to send patients to hospital, including referrals removed automatically after 180 days of inaction before a patient had been booked in.

The watchdog concluded that the technology behind those worklists “was not designed to manage the current volume of referrals” in the health service, particularly since the pandemic, and that a built-in removal function “creates a hazard to patients”. Nick Woodier, a senior safety investigator at HSSIB, went further, saying the system “has created an immediate patient safety risk”.

The findings land at the worst possible moment for ministers. The waiting list for routine hospital treatment in England has risen for two consecutive months to 7.37 million, its highest level since October 2025, and 113,339 people have now been waiting more than a year for the treatment they were referred for.

Great British PAC is demanding answers from ministers and NHS England about how the failures were allowed to persist, and about what safeguards will now be put in place. The distinction matters: a referral disappearing from an e-Referral Service worklist is not the same event as a patient being struck from the official national waiting list, and NHS England said every patient in the report had been offered an appointment. What the watchdog’s findings describe is a system in which people waiting for care can be quietly lost from the administrative pipeline, with the risk of delayed or missed treatment, while the official statistics show nothing amiss.

Great British PAC’s position

Great British PAC argues that no patient should become invisible because of a failure in NHS administration. A referral is not merely an entry in a digital system. It represents a person waiting for medical care, often while living with pain, uncertainty or worsening symptoms. The organisation believes the NHS must be able to account for every referral, identify patients who have been overlooked and ensure that administrative safeguards never take precedence over patient safety. A country that prides itself on a health service free at the point of use owes those patients more than a silent deletion in a database.

A deletion no one notices

The NHS e-Referral Service (e-RS) builds digital worklists that hospitals use to manage the patients GPs have sent them. Referrals are removed automatically when a member of staff accepts one or books an appointment. They are also removed when 180 days pass with no action at all.

That six-month removal function was designed into e-RS by officials to protect the performance of the system, preventing large worklists from slowing it down. HSSIB’s investigation found the effect is that patients can fall out of the queue entirely. A family doctor believes the referral is live and the hospital believes the list it can see is complete. In some cases the loss was only discovered when a GP chased the hospital to ask why a patient had heard nothing.

The watchdog’s report documents how long this has been happening. In 2018, 72 referrals disappeared from an appointment slot issue list, where referrals sit while no appointments are available. In 2019, more than 1,000 patients potentially dropped off the waiting list. In 2023-24, about 1,000 patients had to be added back after their referrals were removed at the six-month mark, because clinic capacity constraints meant nobody had booked them in. HSSIB did not establish a definitive cumulative total of unique patients affected, and the figures come from separate reporting periods that do not necessarily add together, but the pattern they show is consistent: referrals can vanish from worklists, and when they do, the system rarely notices on its own.

“Patients waiting for a hospital appointment are often living with symptoms and the worry of not knowing when they will be seen,” said Mr Woodier. “If a patient’s referral is removed from a list without warning, they may wait far longer than they should. This is a risk created by the system itself, but it has created an immediate patient safety risk, which is why we have published an interim report.”

A risk nobody wrote down

The removal function is not new. What is new is that anyone has formally acknowledged it is dangerous. HSSIB found the hazard had never been documented as a patient safety risk, and that at the time of the investigation the national digital clinical risk documentation for e-RS, maintained under the DCB0129 clinical safety standard, made no reference to the function at all.

Managing that risk was left to individual trusts, and in practice the delegation failed. HSSIB found gaps in organisational knowledge about the function, hospitals unable to provide evidence that they had complied with the DCB0160 digital clinical safety standard for deploying e-RS, and local safety processes varying widely in formality and effectiveness. Where administrative capacity had been cut or roles left unclear, the same incidents happened repeatedly.

NHS England insists its guidance is clear that e-RS “should not be used to manage waiting lists”. HSSIB’s findings show that this is precisely how the system is being used, by hospitals relying on its worklists to track the very patients it can remove.

A spokesman for NHS England said: “As the Health Safety Investigation Body acknowledged all patients in this report were offered appointments, but no one should ever wait 180 days for their referral to be processed in any circumstance. NHS guidance is clear that e-Referral services should not be used to manage waiting lists and we are working with NHS trusts to ensure they identify patients who are waiting the longest and take appropriate action to get them the care they need.”

HSSIB said NHS England is now updating its national clinical risk documentation to recognise the problem and will share it with trusts.

Where the responsibility lies

The automatic removal was not a maintenance error but a design choice. The e-Referral Service was launched in June 2015 under the Conservative government of the day, replacing the old Choose and Book system, and the 180-day function has been part of it for years. The constitutional standard of treating 92 per cent of patients within 18 weeks has not been met for a decade, much of that on the Conservatives’ watch. Credit where it is due, however: HSSIB itself exists because of the Conservative government’s Health and Care Act 2022, which put the safety investigator on a statutory footing in October 2023 and gave it the legal powers behind this investigation.

Inherited systems do not exempt the current government from accountability. Labour’s 2024 manifesto pledged that 92 per cent of patients in England would wait no longer than 18 weeks by the end of this parliament. Two years on, the Labour government remains responsible for delivering that commitment, yet the latest evidence suggests the target is becoming increasingly difficult to achieve. Analysis published by the Health Foundation this month found that, on current trends, the NHS would treat 92 per cent of patients within 35 weeks by 2029, nearly double the promised time, and warned that the prospects of meeting the pledge are receding. That is a projection, not a settled outcome, but the direction of travel is the government’s to change. The NHS Alliance, which represents trusts, says the government is not going to achieve its manifesto promise. Great British PAC has already reported on that analysis, which shows waiting times could remain almost twice as long as Labour promised.

A pattern, not a one-off

The report is the second set of interim findings from HSSIB’s investigation into electronic patient record systems. Its first interim report, published in January 2026, found that advice and guidance services had contributed to near misses and patient harm, including delayed and missed diagnoses, where they were poorly implemented or monitored. It found local pathways requiring GPs to seek specialist advice rather than refer directly, and referrals for specialist assessment declined despite persistent clinical concern, while interoperability problems and delayed upgrades to e-RS made it harder to track patients through their pathways. In August, The Telegraph reported that one in four patient referrals to NHS hospitals are being rejected.

HSSIB has called on hospitals and other providers to check they have reliable processes in place and to ensure referrals are not removed from their lists. Its final report on electronic referral systems is due in early 2027.

Rachel Power, chief executive of the Patients Association, said: “HSSIB’s finding that referrals can disappear from NHS worklists without healthcare providers realising shows how easily this can happen and raises serious questions about how the system is failing patients.

“Patients should be able to trust that when they are referred for care, their referral will be followed up. They should not have to worry that they have been lost in the system, or carry the responsibility for making sure the NHS does not lose track of them.

“Managing referrals is too often treated as an admin task, but it is part of patients’ clinical care and when it fails, people can come to real harm.”

Great British PAC reaction

Claire Bullivant, Chief Executive Officer of Great British PAC, said:

“This is an absolute disgrace. We have reached the extraordinary point where the NHS can lose track of the very people it exists to care for, and the system doesn’t even raise the alarm. These are not inconvenient numbers on a spreadsheet. They are someone’s mother, father, husband, wife or child, waiting in pain, frightened about their health and trusting that the NHS hasn’t forgotten them.

“Imagine being told by your GP that you need hospital treatment, waiting month after month for an appointment, only to discover that your referral has quietly vanished from an administrative worklist. What sort of health service allows that to happen?

“This is a failure of government and Labour ministers must put it right. They cannot hide behind NHS bureaucracy or another glossy announcement promising to fix waiting lists.

“Labour promised the British people they would get waiting times under control. Instead, we have 7.37 million on the waiting list, more than 113,000 waiting over a year, and now a safety investigation exposing a system that can silently remove referrals before patients have even been booked in. How can ministers credibly promise to cut waiting times when the NHS cannot reliably keep track of everyone waiting?

“Britain is one of the most heavily taxed countries in its history. The public are entitled to expect the basics in return. A health service that knows who its patients are, where they are in the system and who is responsible for their care is surely the absolute minimum.

“We need an urgent nationwide audit, proper safeguards, full transparency about how many patients have been affected and clear answers from ministers. If patients have suffered harm because their referrals were lost, that must be investigated.

“The NHS was created to look after the British people, not to lose them in a computer system. Patients should never have to chase the NHS to prove they still exist. And ministers should never be allowed to hide behind a system that has forgotten them.”

Great British PAC is calling on NHS England, NHS trusts and the government to act on the watchdog’s findings, and the organisation’s demands are specific.

First, an immediate patient safety audit: NHS England and every trust using e-RS should identify referrals removed from worklists before appropriate clinical follow-up took place, and establish whether the patients behind them experienced delays or harm.

Second, safeguards against silent removal: no referral should be allowed to disappear from an active administrative workflow without an effective alternative tracking mechanism, documented responsibility for the patient’s ongoing care and appropriate escalation when a referral is at risk of being lost.

Third, notification and accountability: patients, referring clinicians and receiving services should all have reliable mechanisms to identify unresolved referrals and respond before avoidable delays occur, rather than relying on a GP’s persistence to discover a loss the system itself failed to flag.

Fourth, transparent reporting: NHS England and the Department of Health and Social Care should publish clear information about the scale of the problem, the corrective measures now being introduced and how their effectiveness will be assessed, so that parliament and the public can judge whether the fix is real.

Fifth, government responsibility: ministers must explain how patient safety risks of this kind will be addressed while the government pursues its waiting-time commitments, including the resources and oversight required to prevent recurrence. A pledge to cut waiting times means little if the NHS cannot reliably track every patient referral and ensure that nobody is overlooked because of failures in its administrative systems.

Patients are not entries to be erased

Waiting-time targets matter. The 18-week constitutional standard exists because months of delay carry consequences for the people enduring them, and the government’s pledge to restore it is a measure against which its record will be judged. But a target is only as honest as the list beneath it, and the fundamental responsibility of the health service is simpler and older than any target: no patient who has been referred for care should be overlooked because of an administrative failure. Behind every referral lost from a digital worklist is a patient whose care may be delayed, whose condition may worsen and whose trust in the NHS deserves to be protected. The NHS exists to serve those people. Great British PAC’s demands are aimed at nothing more than that: a health service that can account for every person it promises to see, and a government prepared to answer for the ones it has lost.