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 7 May 2021
NHS Structure Article Illustration

February and March 2021 analysis

New activity data for February and March 2021 keenly illustrates the continued disruptive impact of the COVID-19 pandemic on NHS care.

The new data indicates that the shutdown of most non-COVID-19 services in the first wave, 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.

The BMA estimates that, between April 2020 and February 2021, there were:

  • 3.24 million fewer elective procedures
  • 20.07 million fewer outpatient attendances.

A growing backlog of care

Infection control measures and the ongoing diversion of resources towards COVID services during the ongoing second peak of hospitalisations mean that this backlog of care will take even longer to work through as it continues to accumulate.

Many elective procedures have been cancelled as the second, worse wave of COVID-19 cases and hospitalisations sets in. This will cause strong further growth in the backlog.

Long waits for specialist treatment skyrocket

Both the overall median waiting time for treatment and the number of patients waiting over 18 weeks for treatment increased again in February. Moreover, the number of patients waiting over one year for treatment has risen 240-fold since last February. This figure has consistently risen since March 2020.

This 14-year high highlights the scale of unmet need occurring in a significant portion of the waiting list, with patients having been deprioritised for care and experiencing extremely long waits.

Emergency department waits rise despite demand stabilising

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 start of the pandemic

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.

Summer 2020

As lockdown eased in June and July, demand started to rise towards pre-COVID levels. This trend continued in September for admissions and was accompanied by an increase in trolley waits and deterioration in performance against waiting time targets.

This raised worrying questions about how A&E departments will cope with high demand whilst maintaining social distancing and infection control.

2021

The March data shows important, positive progress. Admissions and attendances both increased again relative to February, but remain lower than pre-pandemic levels.

Long waits have decreased again and are also at lower levels than last year.

Compared to March 2020, the number of patients waiting over 12 hours in corridor trolley beds for admission was 41% lower, while the number of patients waiting more than four hours before admission is now 1.5% lower.

Altogether, this shows a continued and fairly major reversal compared to previous months. Where, despite decreasing attendances, waiting times actually increased. However, it remains too early to determine whether this shows a new trend or not.

March saw an uptick in attendances and admissions, following many months of decline in both, potentially showing increasing patient willingness to visit emergency departments.

Across the country, A&Es are open and ready to receive patients – this must be communicated effectively to the public to avoid conditions worsening. It remains important that patients are not deterred from seeking any emergency care, but pressure on those services must be monitored closely.

Cancer waiting time performance drops

February saw important improvement against cancer waiting time targets, following a dip in performance in January.

However, the proportion of patients being seen rapidly remains lower than what would be expected, with the 93% target for patients to been seen by a specialist consultant within two weeks of an urgent GP referral last met in May 2020.

Unfortunately, the onset of both the second wave and winter pressures is likely to have disrupted cancer care further.

National screening services

The number of patients referred for treatment from a national screening service decreased again in February, representing a significant decline over recent months, but performance still remains significantly higher than in the summer of 2020.

Activity is still short of what would be expected at this time of the year, with 144 fewer patients referred from a screening service than in February 2020.

This decrease in cancer treatment and screening is unacceptable given the Government’s statements that cancer care would be unaffected during the pandemic.

There is 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 such large activity drops occurring as we grapple with the larger second peak.

 

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

Key indicators for February/March 2021

Emergency departments
  • Demand for care increased in March, following several months of successive drops in A&E attendances. It actually exceeded attendances for March 2020 – though was significantly lower than pre-pandemic levels and A&E attendances overall remain far lower than usually expected due to the COVID-19 pandemic.
  • There were 1.69 million attendances at emergency departments in March, a 35% increase from the 1.27 million in February and hitting 78% of March 2019 levels.
  • The total number of emergency admissions (503,913) increased by 19% compared to February (421,651); this represents 91% of March 2020 levels.
  • The proportion of people being admitted, transferred, or discharged within four hours from all emergency departments increased, to 86.1% (up from 83.9% in January and from 84.3% last March).
  • This compares to 80% of patients leaving major (type 1) emergency departments within four hours (up from 77.4% in January).
  • The monthly number of 4-hour trolley waits decreased again by 6,197 to 50,972 – compared to 51,790 last March.
  • 12-hour trolley waits also fell again, decreasing to 688 compared to 1,038 in February and 3,809 in January – this is more than double March 2019 levels, however.
Referral to treatment waiting list
  • Including estimates for missing data, the elective treatment waiting list increased to 4.7 million in February. This is higher than the 4.43 million people that were waiting last year and is likely an under-representation (due to a drop in referrals since March 2020).
  • The median wait for treatment increased from 12.1 weeks in January to 12.6 weeks in February; 5.1 weeks more than the median wait seen in February 2020.
  • 64.5% of patients were treated within 18 weeks (a small decrease from 66.2% in January, but a drastic one from 83.2% in February 2020). There has, however, been broad improvement to this target since July 2020, which was the worst performance against this target since it started being recorded in 2008.
  • 387,885 patients were waiting over 52 weeks to receive treatment at the end of February, a 240-fold increase from the count of 1,613 in February 2020. This is the highest monthly count of patients that have waited this long since September 2007.
  • 152,642 patients were admitted to a bed for consultant-led treatment in February 2021, an increase on the 139,378 admitted in January, but nearly 47% fewer than the 285,918 in February 2020.
Cancer
  • 90.3% of cancer patients were seen by a specialist consultant within two weeks of urgent GP referral in February, an important 6.9% increase from January. The 93% target was met last in May 2020 - this deterioration of performance is likely to be due to the backlog of referrals feeding into the system and treatment not keeping up.
  • 69.7% of cancer patients were treated within two months of an urgent GP referral (1.5% decrease from January), making February the 64th 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 January/February 2021

Emergency departments
  • Demand for care declined again in February and remains at far lower levels than usually expected due to the COVID-19 pandemic.
  • There were 1.28 million attendances at emergency departments in February, a 2.5% decrease from the 1.31 million in January and a 35% decrease from the 1.97 million attendances that occurred last February.
  • The total number of emergency admissions (421,651) decreased by 5% compared to January (445,600); this represents a 17.5% decrease from the number last February (510,811).
  • The proportion of people being admitted, transferred, or discharged within four hours from all emergency departments increased, to 83.9% (up from 78.5% in January and from 82.8% last February).
  • This compares to 77.4% of patients leaving major (type 1) emergency departments within four hours (up from 70.1% in January).
  • The monthly number of 4-hour trolley waits decreased by 37,820 to 57,169 – this is 73% of last February’s count.
  • 12-hour trolley waits also fell, decreasing to 1,038 compared to the to 3,809 in January – this is 64% of February 2020 levels.
Referral to treatment waiting list
  • Including estimates for missing data, the elective treatment waiting list increased to 4.59 million in January. This is higher than the 4.43 million people that were waiting last year and is likely an under-representation of the total volume of people waiting for treatment (due to a drop in referrals since March 2020).
  • The median wait for treatment increased from 11.2 weeks in December to 12.1 weeks in January; 3.7 weeks more than the median wait seen in January 2020 (8.4 weeks).
  • 66.2% of patients were treated within 18 weeks (a decrease from 67.8% in December 2020, but a drastic one from 83.5% in January 2020). There has, however, been broad improvement to this target since July 2020, which was the worst performance against this target since it started being recorded in 2008.
  • 304,044 patients were waiting over 52 weeks to receive treatment at the end of January, a nearly 185-fold increase from the count of 1,643 in January 2020. This is the highest monthly count of patients that have waited this long since February 2008.
  • Only 139,378 patients were admitted to a bed for consultant-led treatment in January 2021, 54% less than the 304,888 in January 2020.
Cancer
  • 83.4% of cancer patients were seen by a specialist consultant within two weeks of urgent GP referral in January, a 4.1% decrease from December. The 93% target was met last in May 2020 - this deterioration of performance is likely to now be due to the backlog of referrals feeding into the system and treatment not keeping up.
  • 71.2% of cancer patients were treated within two months of an urgent GP referral (4% decrease from December), making December the 62nd 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 December 2020/January 2021

Emergency departments
  • Demand for care declined again in December and remains at far lower levels than usually expected due to the COVID-19 pandemic.
  • There were 1.31 million attendances at emergency departments in January, an 11% decrease from the 1.48 million in December and a 47% decrease from the 2.11 million attendances that occurred last January.
  • The total number of emergency admissions (445,600) decreased slightly relative to the 460,260 that occurred in December. However, this represents a dramatic 20% decrease from the number last January (559,058).
  • Despite the drop in attendances and admissions, the proportion of people being admitted, transferred, or discharged within four hours from all emergency departments decreased again, to 78.5% (down from 80.3% in December and from 81.7% last January). This is the lowest performance against this target since records began.
  • This compares to 70.1% of patients leaving major (type 1) emergency departments within four hours (down from 72.1% in December).
  • The monthly number of 4-hour trolley waits increased by 5,182 to 94,989 – this is still lower (6% less) than last January’s count of 100,579. 12-hour trolley waits also increased slightly to 3,809, 34% more than last January’s count of 2,847.
Referral to treatment waiting list
  • Including estimates for missing data, the elective treatment waiting list increased to 4.52 million in December. This is higher than the 4.42 million people that were waiting last year and is likely an under-representation of the total volume of people waiting for treatment (due to a drop in referrals since March 2020).
  • The median wait for treatment increased from 10.4 weeks in November to 11.2 weeks in December; 3.9 weeks more than the median wait seen in December 2019 (8.3 weeks).
  • Only 67.8% of patients were treated within 18 weeks (a small decrease from 68.2% in November 2020, but a drastic one from 83.7% in December 2019). There has, however, been broad improvement to this target since July 2020, which was the worst performance against this target since it started being recorded in 2008.
  • 224,205 patients were waiting over 52 weeks (one year) to receive treatment at the end of December, a nearly 153-fold increase from the count of 1,467 in December 2019. This is the highest monthly count of patients that have waited this long since April 2008.
  • Only 190,604 patients were admitted to a bed for consultant-led treatment in December 2020, 28% less than the 253,318 in December 2019.
Cancer
  • 87.5% of cancer patients were seen by a specialist consultant within two weeks of urgent GP referral, a 0.5% increase from November. The 93% target was met last in May 2020 - this deterioration of performance is likely to now be due to the backlog of referrals feeding into the system and treatment not keeping up.
  • 75.2% of cancer patients were treated within two months of an urgent GP referral (0.3% decrease from November), making December the 62nd 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.

The Government must publish more comprehensive data

Doctors and healthcare staff will feel the effects of these changes in activity for weeks and months to come, as the NHS struggles to balance pent up demand for treatment with the reality of a virus that is here to stay (and is currently at an even worse second peak).

It is important to note that it is likely the most vulnerable in society who are affected by these changes, and the Government must do all it can to support doctors in providing treatment to prevent COVID-19 from exacerbating established health inequalities.

The Government must also commit to publishing more comprehensive and timely data to provide a more up-to-date picture of the challenges currently facing the NHS in England.

During the winter months data on NHS pressures is collected daily and published weekly – given the scale of the challenge now facing the NHS the government should now move to a similar regular publication cycle beyond winter.