With demand for hospital treatment outstripping capacity even before COVID-19, it is no surprise that the demands of delivering care during a pandemic have led to significant backlogs and longer waits for patients.
This page provides analysis on capacity in secondary care services and is updated monthly with new data.
Last updated: 20 April 2022
A growing backlog of care in England
What is the backlog?
The backlog in secondary care consists of the care that the NHS would normally have delivered but which was disrupted as COVID-19 impacted service delivery. This includes:
- patients on a waiting list for treatment who would ordinarily have been seen by now
- patients who have not yet presented to their GP to seek a referral for symptoms due to concerns of burdening the health service or fears around COVID-19 infection
- patients who have had procedures cancelled
- patients who have had referrals delayed or cancelled
- patients who have had referrals refused due to a lack of capacity.
It will take years to clear the backlog. The ongoing need for stringent infection prevention control measures and workforce shortages mean it will take even longer to work through as demand continues to rise.
More patients than ever are waiting for treatment
Prior to the pandemic in February 2020 there were already 4.43 million people on a waiting list for care.
At the beginning of the pandemic, the number of people joining the waiting list initially dropped, but this has since been rising. The latest figures for February 2022 show a record of over 6.1 million people waiting for treatment.
Despite some improvements earlier in the year, waiting times remain far higher than pre-COVID. The total number of patients waiting over 18 weeks for treatment now exceeds 2 million, while the number of patients waiting over one year for treatment stands at almost 300,000.
This is 186 times the number waiting over a year pre-pandemic in February 2020.
In February 2022 the average patient spent 13.1 weeks waiting for treatment.
The hidden backlog is growing
The waiting list is a visible backlog, but the shutdown of most non-COVID-19 services in the first wave, combined with changes in patient behaviour, has created a growing 'hidden backlog'. These are patients that require care but have either not yet presented, or who have had referrals cancelled.
Procedures now vs pre-COVID
Between April 2020 and February 2022, compared to pre-COVID averages there were:
- 4.51 million fewer elective procedures
- 31.39 million fewer outpatient attendances.
Despite improvements in 2021 compared to the first year of the pandemic, the amount of electives and outpatient attendances currently being carried out is still well below pre-pandemic levels.
This is storing up greater problems for the future. These backlogs are likely to result in worsened conditions down the line, leading to greater demand on health services.
Some parts of the backlog are visible, such as the number of people on waiting lists. Other parts are harder to calculate as they are in effect the absence of patients. Patients who, in normal times, would have been referred for treatment, received elective care and attended outpatient appointments, but who for a number of reasons relating to the pandemic have not yet found their way into the health system. We refer to this as the 'hidden backlog' of care.
Different organisations calculate this differently. We use NHS Digital’s monthly hospital episodes statistics to compare activity in electives and outpatient care during the pandemic, specifically from April 2020 onwards, with activity in previous, pre-pandemic years.
For the hidden backlog in electives, we calculate the month-by-month difference between day-case and ordinary elective performance data from April 2020 onwards with that of the previous year (2019/20). The cumulative total of these monthly differences is our estimated total elective backlog.
For the hidden backlog in outpatient attendances, we compare monthly performance from April 2020 onwards with data from 2018/19 and 2019/20 to calculate a cumulative total of the pandemic difference for each month, in order to generate a total estimated backlog.
To ensure comparability with previous years, our calculation does not include statistics for treatments added to the data collection since April 2020.
Cancer targets continue to be missed
The proportion of patients seen by a specialist consultant within two weeks of an urgent GP referral for suspected cancer remains worryingly low. The 93% target for patients to be seen within that time frame has not been met since May 2020.
The percentage of patients receiving their first treatment within two months of attending a screening service dropped dramatically during the initial few months of the pandemic. It has since picked up, but remains below the operational standard.
Activity is low compared to pre-pandemic levels. The decline in these key indicators shows the level of pressure the system is under and is a clear sign that more capacity is needed.
Patients are waiting longer for emergency care
Prior to the pandemic, the situation in A&E was increasingly difficult with demand soaring and the percentage of people being seen within the four-hour target reaching an all-time low over the 2019/20 winter.
Since the start of the pandemic, A&E attendance decreased significantly which led to performance improvements. Since lockdown eased demand has steadily risen, reducing performance against targets.
Demand in A&E departments has significantly worsened in March 2022, with the highest levels of total A&E attendances (2.17 million) seen since December 2019 (2.18 million).
Waiting times have rocketed
The combination of ongoing pressure on services, the backlog of care and chronic workforce shortages means waiting times have increased to record highs.
The number of patients waiting over 12 hours in for admission has remained high with over 22,506 in March 2022. This is almost twenty times the amount waiting this long pre-pandemic in March 2020.
GPs are finding it harder to make referrals
GP referrals into consultant-led outpatient services have fallen in line with the waves of COVID-19. These drops are likely due to changes to patient behaviour combined with capacity issues in secondary care effectively forcing GPs to take a more cautious approach with timings of referrals.
GPs can still refer patients, but the pressures in hospitals means there is no capacity in secondary care, and those referrals are rejected.
The number of GP referrals to consultant-led outpatient services that have been unsuccessful because there are no slots available has jumped from 238,859 in February 2020 to a staggering 401,115 in November 2021 (an 87% increase).
When GPs are unable to refer into hospital services, the care for these patients does not disappear. Instead, these patients need to be cared for by GPs while they wait for hospital treatment to go ahead, adding to the backlog in primary care.
The role of the private sector
Enlisting the help of the private sector is one of the measures the Government has taken to reduce pressures on hospitals and help cut waiting lists.
Purchasing private capacity is not new, but the pandemic has demanded unprecedented block-booking arrangements.
A recent BMA survey found that under these arrangements, 60% of private practice doctors who responded were unable to provide care to their patients at the time.
The extent to which private hospitals will be able to take on NHS waiting list initiatives going forward is unclear given the increased demand in the self-pay market and the backlog of private sector patients.
Given that the NHS and the private sector largely draw on the same pool of doctors, additional capacity may be less than it initially appears. This was made clear in the 2020 block-booking arrangements, which saw the NHS gain facilities rather than the workforce to run them.
What the BMA is calling for
Given the immense strain on secondary care, the BMA is calling for immediate actions to be taken to prevent waiting lists from growing faster than they already are and to prevent increased pressure on hospitals. Actions can be found in our weathering the storm report.
The extent to which the NHS can address these capacity challenges is in large part determined by the resources available to it. That is why the BMA has called for an additional £7 billion on top of the £10 billion previously announced. Existing resources and funds must also be directed to where they are needed the most.
The BMA is advocating for measures to prevent attrition of doctors, including:
The Government must develop a credible plan to meaningfully increase NHS hospital capacity and ensure that the NHS is not reliant on private sector capacity in the long-term.
Over the longer term, the BMA has called for increased measures to support effective collaboration between primary and secondary care.
This will help tackle:
- waiting lists
- high workload
- the need to adapt physical spaces to prevent the spread of infection
- lack of joined up IT and data sharing
- lack of consistent communication and trust between different parts of the health system.