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: Tuesday 17 November 2020
NHS Structure Article Illustration

September/October 2020 analysis

New data reveals the cumulative impact Covid-19 has had on NHS services in England

New activity data for September and October 2020 lay bare the continued disruptive impact of the Covid-19 pandemic on NHS care. With services already under severe strain the first three months of 2020, unprecedented steps were needed to ensure the NHS would be able to cope with a large influx of Covid-19 patients from late March onwards. Significant amounts of capacity had to be created by:

  • cancelling planned operations
  • large numbers of patients being discharged back into the community
  • non-Covid-19 patients and staff had to be protected by conducting GP consultations remotely.

Whilst these changes meant that intensive care did not have to be rationed to Covid-19 patients, the new data indicates that the shutdown of most non-Covid services, combined with drastic changes in patient behaviour, mean the NHS is now facing a large backlog of non-Covid-19 care, storing up greater problems for the future.

Infection control measures and the ongoing diversion of healthcare resources towards Covid-related services mean that this backlog of care will take even longer than usual to work through. 

Long waits for specialist treatment skyrocket

Whilst the overall median waiting time for treatment decreased in September, the number of patients waiting over one year for treatment has risen to 107-fold its 2019 value.

This 12-year high highlights the large proportion of unmet care in a significant portion of the waiting list, with an increasing fraction of patients being de-prioritised for care and therefore experiencing longer waits.

The unmet care is also hidden by the size of the waiting list. The overall size of the waiting list dropped during the first few months of the Covid-19 crisis due to less referrals.

In June, the waiting list started to increase - this represents the pent up backlog of referrals restarting whilst treatment rates remain low due to reduced capacity. The waiting list now stands at 4.35 million, however this is still lower than its 2019 value of 4.42 million. There is likely a number of patients still waiting to be referred onto the waiting list, and this total therefore is not representative of the backlog of care from the pandemic.

Source: NHS England - graph shows number of patients on waiting list Source: NHS England - graph shows number of patients on waiting list

Unrealistic activity targets not being met

The volume of patients experiencing such long delays for treatment at the end of September raises important questions about preparedness as we enter a tough winter supplemented by a rise in Covid-19 hospitalisations.

Doctors are also concerned that the NHS has been given unrealistic targets for returning to near-normal levels of elective and outpatient activity, with these latest figures showing most services are not hitting these.

For example, day case elective activity was supposed to be at 80% of last September’s activity, however it was only at 76% in September according to the latest figures.

The Government must guarantee that NHS trusts will not be financially penalised for not meeting these targets.

There is likely to be reduced outpatient activity over the coming weeks due to the impact of the second wave and winter pressures. Multiple cancellations have already been reported by trusts across England.

Cancer waiting time target performance drops

Despite some improvements towards cancer waiting time targets occurring in the later summer months, many targets' performance dropped in September.

The overall number of treatments has increased relative to earlier in the pandemic, however the proportion of patients being treated rapidly has decreased. Urgent action is needed to ensure that those most in need receive the treatment they require, especially for highly prevalent conditions such as cancer where outcomes are time-dependent on rapid diagnosis and treatment.

This decrease in cancer treatment and screening is particularly unacceptable considering the Government’s statements that cancer care would be unaffected during the pandemic. There is now irrefutable evidence that cancer treatment was severely affected during the first peak of Covid-19 hospitalisations – all measures need to be put in place to prevent this reoccurring over the winter months.

Source: NHS England - graph shows % of patients receiving first cancer treatment and seen after an urgent referral Source: NHS England - graph shows % of patients receiving first cancer treatment and seen after an urgent referral

Emergency department demand stabilises whilst waits rise

Away from planned and primary care, radical changes in activity have occurred in emergency departments.

Prior to the pandemic, the situation in A&E was increasingly catastrophic with demand soaring, the number of trolley waits being highest on record, and performance against the four-hour target reaching an all-time low over the past winter.

The most recent data show that in April and May, A&E demand decreased to significantly lower levels, leading to a large drop in the number of trolley waits and significant improvements to performance to the four-hour target.

Whilst demand is likely to have reduced partially due to less road- and alcohol-related accidents during lockdown, there is concern that some patients were avoiding seeking care from A&E even when suffering life-threatening symptoms.

As lockdown eased in June and July, demand started to rise towards pre-Covid levels. This trend continued in September for admissions and has been accompanied by an increase in trolley waits and deterioration in performance against waiting time targets (4-hour wait performance decreased).This raised worrying questions about about how A&E departments will cope with high demand whilst maintaining social distancing and infection control.

The October data show that despite admissions and attendances stabilising, long waits have continued to increase and are at similar levels to last year, despite lower demand. This is likely partially due to social distancing requirements causing slower flow of patients through A&E.

Altogether, these data reflect the reality that emergency departments can only provide the timely care that they want to give when demand is approximately half its usual levels. Improved performance towards targets is unlikely to occur whilst demand increases unless significant investments are made across the health and social care system.

A&E attendances

A&E attendances remained stable in October. This may be due to increased social distancing as restrictions tighten across the country.

It is important that patients are not deterred from seeking any emergency care even though Covid-19 cases are rising. During the first wave in March, many patients avoided A&E due to fear of the virus or of overwhelming the health service. Across the country, A&Es are open and ready to receive patients – this must be communicated effectively to the public to avoid conditions worsening.

Source: NHS England - total emergency admissions and number spending >12 hours from decision to admit to admission Source: NHS England - total emergency admissions and number spending >12 hours from decision to admit to admission

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

Key indicators for September/October 2020

Emergency departments
  • Demand for care remained stable in October despite having increased in previous months – it remains at lower levels than usually expected due to the pandemic.
  • There were 1.6 million attendances at emergency departments in October, a 2% increase from the 1.69 in September and a 26% decrease from the 2.2 million attendances that occurred last October.
  • The total number of emergency admissions (481,846) increased marginally relative to the 479,800 that occurred in September; however, this is still a dramatic 14% decrease from the number last October (563,100).
  • Despite little change in the number of attendances, the proportion of people being admitted, transferred, or discharged from all emergency departments decreased to 84.4% (down from 87.3% in September and up from 83.6% last October).
  • This compares to 77.6% of patients leaving major (type 1) emergency departments within four hours (down from 81.7% in September).
  • The monthly number of 4-hour trolley waits increased by 22,000 to 66,795 – this is still far lower (17% less) than last October’s count of 80,091. 12-hour trolley waits also increased to 1,267, 75% more than last October’s count of 725.
Referral to treatment waiting list
  • Including estimates for missing data, the elective treatment waiting list increased to 4.35 million in September. This is lower than the 4.42 million people that were waiting last year, and is likely due to the knock-on effect of the large drop in GP referrals during the Covid-19 pandemic.
  • The median wait for treatment decreased from 14.8 weeks in August to 12 weeks in September; whilst this decrease is good, this is still 4 weeks more than the median wait seen last September.
  • Only 60.6% of patients were treated within 18 weeks (an increase from 53.6% in August 2020 and 84.8% in September 2019). There has been consecutive improve to this target since July, which was the worst performance against this target since it started being recorded in 2008.
  • 139,545 patients were waiting over 52 weeks (1 year) to receive treatment at the end of September, a huge 107-fold increase from the count of 1,305 in September 2019. This is the highest monthly count of patients that have waited this long since August 2008.
  • Only 209,562 patients were admitted to a bed for consultant-led treatment in September 2020, 27% less than the 288,230 in September 2019.
Cancer
  • 86.2% of cancer patients were seen by a specialist consultant within two weeks of urgent GP referral, a 1.6% point decrease from August. The 93% target was met recently in May - this deterioration of performance is likely to now be due to the backlog of referrals feeding into the system and treatment not keeping up.
  • 74.7% of cancer patients were treated within two months of an urgent GP referral (3.2% decrease from August), making September the 59th consecutive month that the Government target (treatment of 85% of patients within two months) has been missed.
Delayed transfers of care

Due to COVID-19 and the need to release capacity across the NHS to support the response, the NHS have paused the collection and publication of this statistical bulletin.

Key indicators for August/September 2020

Emergency departments
  • Demand for care decreased slightly in September despite having increased in previous months – it remains at lower levels than usually expected due to the pandemic.
  • There were 1.69 million attendances at emergency departments in September, a 2% decrease from the 1.72 in August and a 20% decrease from the 2.1 million attendances that occurred last September.
  • The total number of emergency admissions (479,800) increased relative to the 473,903 that occurred in August; however, this is still a dramatic 9% decrease from the number last September (529,900).
  • Despite the slight decrease in attendances, the proportion of people being admitted, transferred, or discharged from all emergency departments decreased to 87.3% (down from 89.3% in August and up from 85.2% last August).
  • This compares to 81.6% of patients leaving major (type 1) emergency departments within four hours (down from 84.4% in August).
  • The monthly number of 4-hour trolley waits increased to 44,983 – this is still far lower (30 less) than last September’s count of 64,924. 12-hour trolley waits also increased to 333, 27% less than last September’s count of 458.
Referral to treatment waiting list
  • Including estimates for missing data, the elective treatment waiting list increased to 4.22 million in August. This is lower than the 4.41 million people that were waiting last year, and is likely due to the large drop in GP referrals during the Covid-19 pandemic.
  • The median wait for treatment decreased from 19.6 weeks in July to 14.8 weeks in August; whilst this decrease is good, this is still 6.7 weeks more than the median wait seen last August.
  • Only 53.6% of patients were treated within 18 weeks (an increase from 46.8% in July 2020 and 85% in August 2019). This is a slight improvement compared to July, which was the worst performance against this target since it started being recorded in 2008.
  • 111,026 patients were waiting over 1 year to receive treatment at the end of August, a huge 90-fold increase from the count of 1,236 in August 2019. This is the highest monthly count of patients that have waited this long since September 2008.
  • Only 155,789 patients were admitted to a bed for consultant-led treatment in August 2020, 43% less than the 275,267 in August 2019.
Cancer
  • Less cancer treatments and urgent GP referrals occurred in August due to the impact of the Covid-19 pandemic, however the number of both has started to increase relative to their levels since March - this has caused a drop in performance to cancer targets.
  • Only 55.9% of patients received a first cancer treatment less than two months after being screened in August – this is an improvement on the 25.4% performance in July, however is far below last August’s 87.9%.
  • In August, the number of urgent GP referrals decreased to 169,660 – this is a 15% drop from the 200,317 that occurred last August.
  • 87.8% of cancer patients were seen by a specialist consultant within two weeks of urgent GP referral, a 2.6% point decrease from July. The 93% target was met recently in May - this deterioration of performance is likely to now be due to the backlog of referrals feeding into the system and treatment not keeping up.
  • Only 20,177 patients received a first treatment for cancer following a decision to treat – this is 5,600 less than August last year.
  • 77.9% of cancer patients were treated within two months of an urgent GP referral (0.5% decrease from July), making August the 58th consecutive month that the Government target (treatment of 85% of patients within two months) has been missed.
Hospital activity
  • The number of GP referrals made for all specialties rose to 389,614 in May, however this is still a large proportionate decrease compared to the 1.18 million that occurred in May 2019. The monthly number of GP referrals was therefore approximately 33% of its normal value in May 2020.
  • Only 220,000 elective general and acute admissions occurred in May 2020, a huge decrease from the 732,000 that occurred last May. This reflects the large suspension in elective procedures that had to occur during the pandemic.
Delayed transfers of care

Due to COVID-19 and the need to release capacity across the NHS to support the response, the NHS have paused the collection and publication of this statistical bulletin.

Key indicators for July/August 2020

Emergency departments
  • Demand for care continued to increase in August relative to previous months. However, it was still at lower levels than usually expected, due to the Covid-19 pandemic.
  • There were 1.72 million attendances at emergency departments in August, a 8% increase from the 1.59 in July and a 8% decrease from the 2.1 million attendances that occurred last August.
  • The total number of emergency admissions (473,9903) also increased relative to the 472,646 that occurred in July; however, this is still a dramatic 10% decrease from the number last August (529,000).
  • Due to the relative increase in demand, the proportion of people being admitted, transferred, or discharged from all emergency departments decreased to 89.3% (down from 92.1% in July and up from 86.3% last August).
  • This compares to 84.4% of patients leaving major (type 1) emergency departments within four hours (down from 88.9% in July).
  • The monthly number of 4-hour trolley waits increased to 32,150 – this is still far lower (43%% less) than last August’s count of 56,498. 12-hour trolley waits also increased to 326, 12% less than last August’s count of 371.
Cancer
  • Less cancer treatments and urgent GP referrals occurred in July due to the impact of the Covid-19 pandemic, however the number of both has started to increase relative to their levels since March - this has caused a drop in performance to cancer targets.
  • Only 25.4% of patients received a first cancer treatment less than two months after being screened.
  • Although increasing, only 179,503 urgent GP referrals were made in July, a 19% drop from the 221,805 that occurred last July.
  • 90.4% of cancer patients were seen by a specialist consultant within two weeks of urgent GP referral, a 2.1% point decrease from June. The 93% target was met in May - this deterioration of performance is likely to now be due to the backlog of referrals feeding into the system and treatment not keeping up.
  • Only 21,599 patients received a first treatment for cancer following a decision to treat – this is 6,600 less than July last year.
  • 78.4% of cancer patients were treated within two months of an urgent GP referral (3.4% increase from June), making July the 57th consecutive month that the Government target (treatment of 85% of patients within two months) has been missed.
Referral to treatment waiting list
  • Including estimates for missing data, the elective treatment waiting list increased to 4.05 million in July. This is lower than the 4.37 million people that were waiting last July, and is likely due to the large drop in GP referrals during the Covid-19 pandemic.
  • The median wait for treatment increased sharply from 17.6 weeks in June to 19.6 weeks (over 4 months) in July; this is over double the 7.3-week median wait seen last July.
  • Only 46.8% of patients were treated within 18 weeks (a decrease from 52.0% in June 2020 and 85.8% in July 2019). This is the worst performance against this target since it started being recorded in 2008.
  • 83,206 patients were waiting over 52 weeks (1 year) to receive treatment at the end of July, a huge 80-fold increase from the count of 1,032 in July 2019. This is the highest monthly count of patients that have waited this long since November 2008.
  • Only 142,800 patients were admitted to a bed for consultant-led treatment in July 2020, 55% less than the 314,280 in July 2019.
Delayed transfers of care

Due to Covid-19 and the need to release capacity across the NHS to support the response, the NHS have paused the collection and publication of this statistical bulletin.

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