Pressure points in the NHS

Analysis of monthly data releases by NHS England to highlight the huge pressures being placed on an over-burdened healthcare system.
Location: England
Audience: All doctors
Updated: Friday 3 April 2020
NHS Structure Article Illustration

With annual increases in demand for care, the NHS in England is under a growing amount of pressure and has begun to noticeably struggle to meet targets.

As this pressure grows, so too does the importance of highlighting it and lobbying for the government to address this issue.

The BMA will be analysing monthly data published by NHS England to shed some light on the massive pressures being placed on an already over-burdened healthcare system.

 

Monthly data on A&E, waiting list and delayed transfers of care

Key indicators for January/February 2020

Emergency departments
  • Demand for care decreased relative to January, however it continues to increase annually overall.
  • There were over 1.9 million attendances at emergency departments and 510,811 emergency admissions in February. This is approximately 14,700 more attendances and 5,000 more admissions than February 2019.
  • The monthly number of trolley waits decreased for the first time since August 2019 from 100,578 to 78,646 4-hour waits and from 2,846 to 1,621 12-hour waits. However, these still represent the highest numbers of trolley waits for any February on record.
  • The proportion of people being admitted, transferred, or discharged from all emergency departments within four hours hit a record low for any February since records began at 82.8%. There was a slight improvement from the previous month, however.
  • This compares to 73% of patients leaving major (type 1) emergency departments within four hours (up from 71.2% in January), also a record low.
Delayed transfers of care

There were over 160,000 delayed days as a result of delayed transfers of care, a month-on-month increase compared to the 148,101 delayed days in December 2019.

This is also an 18.6% increase compared to the 135,428 delayed days that occurred in January 2019.

Cancer
  • There was a general deterioration in progress towards meeting cancer treatment targets in January.
  • 90.1% of cancer patients were seen by a specialist consultant within two weeks of urgent GP referral, a 1.7% point decrease from December. The 93% target has been missed in 18 of the last 22 months, and performance is below what it was this time last year (91.7% in January 2019).
  • 73.6% of cancer patients were treated within two months of an urgent GP referral (4.4% point increase from December), making December the 50th consecutive month that the Government target (treatment of 85% of patients within two months) has been missed.
RTT waiting list
  • Including estimates for missing data, the elective treatment waiting list was stable at 4.42 million people. Although the list is no longer increasing, the monthly waiting list sizes for March 2019 to January 2020 were all larger than any month since August 2007.
  • The median wait for treatment increased from 8.3 weeks in December to 8.4 weeks in January - this is larger than January 2019, which saw a 7.8-week median wait.
  • Only 83.5% of patients were treated within 18 weeks (a decrease from 83.7% in December 2019 and 86.7% in January 2019). This is the worst performance against this target since September 2008.

Key indicators for December/January 2020

Emergency departments
  • Demand for care decreased relative to December, however it continues to increase overall.

  • There were over 2.11 million attendances at emergency departments and 559,058 emergency admissions in January. This is approximately the same amount of attendances as January 2018 and approximately 5,000 fewer admissions. 

  • There was a record high number of 4-hour (100,578) and 12-hour (2,846) trolley waits. This represents a 68% increase in 4-hour waits and over a 900% increase in 12-hour waits from December 2018.

  • The proportion of people being admitted, transferred, or discharged from emergency departments within four hours hit a record low for any January since records began at 81.7%. There was a slight improvement from the previous month, however.

  • Performance within major emergency departments (type 1 admissions) was also a record low for the month of January. Again, there was an improvement from the previous month. 71.2% of patients leaving major A&E within four hours in type 1 emergency departments compared to the previous month. 
Delayed transfers of care

There were over 148,000 delayed days as a result of delayed transfers of care, a month-on-month increase compared to the 145,876 delayed days in November 2019. This is also a 15% increase compared to the 129,000 delayed days that occurred in December 2018.

Cancer
  • 91.8% of cancer patients were seen by a specialist consultant within two weeks of urgent GP referral, a 0.5% point increase from November. The 93% target has been missed in 17 of the last 21 months, and performance is below what it was this time last year (93.7% in December 2018). 

  • 78% of cancer patients were treated within two months of an urgent GP referral (0.6% point increase from November), making December the 49th consecutive month that the Government target (treatment of 85% of patients within two months) has been missed.
RTT waiting list
  • Including estimates for missing data, the elective treatment waiting list was stable at 4.42 million people (0.03 million decrease from October 2019). Although the list is no longer increasing, the monthly waiting list sizes for March-December 2019 were all larger than any month since August 2007.

  • The median wait for treatment increased from 7.7 weeks in November to 8.3 weeks in December - this is larger than last December's 7.6-week median wait.

  • Only 83.7% of patients were treated within 18 weeks (a decrease from 84.4% in November 2019 and 86.6% in December 2018). This is the worst performance against this target since September 2008.

Key indicators for November/December 2019

Emergency departments
  • Demand for care continues to rise: there were over 2.18 million attendances at A&E and 560,801 emergency admissions, increases of 6.5% and 2.9% from this time last year (all trusts).
  • There was a 15-year record low proportion of people being admitted, transferred, or discharged from A&E within four hours (79.8%), a 1.6 percentage point decrease from November 2019 and a 6.7 percentage point decrease from December 2018.
  • Performance within major emergency departments (type 1 admissions) also dropped, with only 68.6% of patients leaving major emergency departments within four hours in type 1 emergency departments, compared to 71.3% in November 2019 and 79.1% in December 2018.
  • There was a record number (98,452) of 4-hour trolley waits. This represents a 11% increase in 4-hour waits from November 2019 and a 65% increase on December 2018.
  • The number of 12-hour trolley waits was also a monthly record: 2,347 people waited over 12 hours on a trolley bed in December 2019. This is over double the number from last month (1,112 waits in November 2019) and over eight times the number of waits last December (284).
Delayed transfers of care

There were over 145,800 delayed days as a result of delayed transfers of care, a month-on improvement (4.4% decrease) compared to the 152,522 delayed days in October 2019. However, this is 7.1% more delayed days than the 136,183 that occurred in November 2018.

Cancer

91.3% of cancer patients were seen by a specialist consultant within two weeks of urgent GP referral, a 0.01% decrease from October.

The 93% target has been missed in 16 of the last 20 months, and performance is below what it was this time last year (92.5% in November 2018).

77.4% of cancer patients were treated within two months of an urgent GP referral (0.3% increase from October). November was the 48th consecutive month that the Government target (treatment of 85% of patients within two months) has been missed.

RTT waiting list

Including estimates for missing data, the elective treatment waiting list decreased to 4.42 million people (0.03 million decrease from October 2019).

This is the first time in the past ten months in which the waiting list has decreased in size.

However, the monthly waiting list sizes for March-November 2019 were all larger than any month since August 2007.

The median wait for treatment increased from 7.6 weeks in October to 7.7 weeks this month - this is larger than last November's 6.9-week median wait.

Only 84.4% of patients were treated within 18 weeks (a decrease from 84.7% in October 2019 and 87.3% in November 2018), falling well below the 92% target, which has been consecutively missed monthly since March 2016.

This is the worst performance against this target since September 2008.

BMA analysis

These latest data have been released amidst the the rapid proliferation of Covid-19. This set of indicators are all from January and February 2020, when Covid-19 slowly developed a presence in England, but cases had not yet started to climb as dramatically as they did in March.

These data may therefore be capturing some of the 'coronavirus effect' on the health service, however most of this effect will be far more apparent in the March data.

Drop in A&E attendances and trolley waits

The decline in demand shown in the drop in A&E attendances in February is a common seasonal pattern seen every February for the past several years.

However, the December-February percentage decrease in attendances was larger this year (10.7%) than 2019 (4.7%) or 2018 (10.1%). Demand easing up may have been a contributing factor to the coincident drop in monthly 4-hour and 8-hour trolley waits, both of which had been increasing rapidly since August 2019.

These trends suggest that public health messaging emphasising use of NHS 111 instead of A&E during the outbreak may be successfully causing people to avoid unnecessary visits to A&E. However, as the February decline in demand is a normal seasonal trend, it is too soon to tell whether these two events are directly linked.

Improvement against the four hour wait standard

Despite a month-on improvement in performance toward the four hour standard, the proportion of people being admitted, transferred, or discharged from A&E within four hours was still the lowest observed for any February on record.

So far this winter 233,000 more people have waited over four hours in A&E compared to the same point last winter. It is unclear how A&E departments already experiencing high levels of pressure will cope with a increase in pressures related to Covid-19 in the coming months.

Waits for elective treatment continue to rise

The already high elective waiting list and continually rising median treatment wait are likely to continue to go up over the next few months. The NHS will likely ramp up critical care capacity, especially if we see large scale postponement of non-emergency elective procedures.

Patients waiting longer for cancer treatment

A large increase in the proportion of patients waiting longer than two weeks to see a specialist or to receive treatment may be representative of the shift away from elective procedures as the NHS gears all resources towards Covid-19.

As the outbreak intensifies there is no doubt that there will be an overwhelming amount of pressure placed on an already strained NHS.

The most that can be done at this point to relieve pressure on the NHS is to follow advice regarding regular hand washing, symptoms, and social distancing.

 

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