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 15 October 2021
NHS Structure Article Illustration

August and September 2021 analysis

Activity data for August and September 2021 keenly illustrated the continued disruptive impact of the COVID-19 pandemic on NHS care.

The latest available 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 facing a large backlog of non-COVID-19 care, storing up greater problems for the future.

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

  • 3.90 million fewer elective procedures
  • 26.78 million fewer outpatient attendances.

A growing backlog of care

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

Many elective procedures were cancelled as the second, worse wave of COVID-19 cases and hospitalisations set in, causing further growth in the backlog.

Waiting lists remain high, despite progress

The latest figures show that important improvements across referral and waiting time targets. The overall median waiting time for treatment increased in August 2021, to 11.5 weeks, as did the total number of patients waiting over 18 weeks for treatment, more than 1.85 million.

Conversely, the number of patients waiting over one year for treatment has fallen slightly in August to 292,138, from 293,102 in July.

The number of patients waiting more than a year is still relatively enormous and is 236-fold the patients that were doing so in August 2019.

Despite the progress against these targets, the total waiting list currently sits at an alarming, record high 5.72 million and continues to grow.

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 latest data indicates that emergency admissions and A&E attendances have slightly increased when compared to August 2021, continuing to reach pre-pandemic levels.

Waits have increased again this month. The number of patients waiting over 12 hours in corridor trolley beds for admission increased to a record high of 5,025 compared to 2,794 in August and is 11-times higher than the 458 in August 2019.

The number of four hour waits also increased substantially, reaching 104,875 – a large increase compared to August (96,013) and performance in September 2019 (64,924).

Altogether, this shows continued improvement compared to previous months. However, if attendances and A&E pressures continue to grow, this trend may worsen.

Mixed cancer waiting time performance

August saw some decline in performance against a number of cancer waiting time targets after slight improvements in July.

The proportion of patients being seen rapidly still remains lower than what would be expected, though, with the 93% target for patients to be seen by a specialist consultant within two weeks of an urgent GP referral still unmet since May 2020.

National screening services

The number of patients referred for treatment from a national screening service decreased in July, following an improvement in performance in the previous month.

The percentage of patients receiving their first treatment within two months of attending a screening service decreased slightly to 74.8% from 75.9% in July - this remains significantly higher than in the summer of 2020.

Activity remains low compared pre-pandemic levels. This 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 peak.

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

Key indicators for August/September 2021

Emergency departments
  • Demand for care across all A&E departments increased in September, meeting pre-pandemic levels, and performance against the four and 12 hour waiting time targets has again suffered badly.
  • There were 2.13 million attendances at emergency departments in September, with an increase from the 2.04 million in August.
  • The total number of emergency admissions in September (506,916) increased slightly also, by 3,045 compared to August (503,871), but is still lower than 2019 levels.
  • The percentage of people being admitted, transferred, or discharged within four hours from all emergency departments has decreased to 75.2% - a record low (down from 77% in August).
  • The monthly number of 4-hour trolley waits increased for the fourth consecutive month, to 104,875 (compared to 96,013 in August and 64,924 in September 2019) – the highest levels seen on record.
  • 12-hour trolley waits also increased significantly, to 5,025 - an increase of 2,231 compared to the 2,794 waits in August. This is significantly higher than the 458 waits seen in September 2019.
Referral to treatment waiting list
  • Including estimates for missing data, the elective treatment waiting list increased to 5.72 million in August – a record high.
  • The median wait for treatment increased this month, to 11.5 weeks. This is still 3.5 weeks higher than August 2019.
  • 67.6% of patients were treated within 18 weeks (a small decrease from 68.3% in July, but far lower than the 85.0% in August 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.
  • 292,138 patients were waiting over 52 weeks to receive treatment at the end of August, a slight decrease of 964 compared to July – but still 236-fold higher than the number waiting in August 2019.
Cancer
  • Performance against the two week wait target from GP urgent referral to first consultant appointment slightly decreased from 85.6% to 84.7% (compared to 89.4% in July 2020).
  • The number of people receiving their first cancer treatment within two months of an urgent GP referral has decreased again slightly from 72.1% in July to 70.7% this month.
  • The percentage of patients receiving a first treatment for cancer after being seen by a national screening service has also decreased slightly to 74.8% compared to 75.9% in July.
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 2021

Emergency departments
  • Demand for care across all A&E departments remained high in July, meeting pre-pandemic levels, and performance against the 4 and 12 hour waiting time targets has again suffered badly.
  • There were 2.04 million attendances at emergency departments in August, with a marginal decrease from July.
  • The total number of emergency admissions in August (503,871) fell again, by 28,806 compared to July (532,677); and is now lower than August 2019 levels.
  • The percentage of people being admitted, transferred, or discharged within four hours from all emergency departments has decreased to 77.0% - a record low (down from 77.7% in July).
  • The monthly number of 4-hour trolley waits increased for the fourth consecutive month, to to 96,013 (compared to 89,798 in July and 58,532 in July 2019) – the highest levels seen since January 2020.
  • 12-hour trolley waits also increased significantly, to 2,794 - an increase of nearly 579 compared to the 2,215 waits in July. This is significantly higher than the 371 waits seen in July 2019.
Referral to treatment waiting list
  • Including estimates for missing data, the elective treatment waiting list increased to 5.61 million in July – a record high.
  • The median wait for treatment decreased again, to 10.9 weeks. Though this is still 3.6 weeks higher than July 2019.
  • 68.3% of patients were treated within 18 weeks (a small decrease from 68.8% in June, but far lower than the 85.8% in July 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.
  • 293,102 patients were waiting over 52 weeks to receive treatment at the end of July, an important decrease of nearly 11,701 compared to June – but still 284-fold higher than the number waiting in July 2019.
Cancer
  • Performance against the two week wait target from GP urgent referral to first consultant appointment slightly increased from 84.9% to 85.6% (compared to 92.5% in June 2020).
  • The number of people receiving their first cancer treatment within two months of an urgent GP referral has decreased slightly from 73.30% in June to 72.1% this month.
  • The percentage of patients receiving a first treatment for cancer after being seen by a national screening service has increased slightly to 75.9% compared to 73.2% in June.
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 June/July 2021

Emergency departments
  • Demand for care across all A&E departments remained high in July, meeting pre-pandemic levels, but performance against the 4 and 12 hour waiting time targets suffered badly.
  • There were 2.16 million attendances at emergency departments in July, with a marginal increase from July – this is the highest level seen since December 2019 (2.18 million).
  • The total number of emergency admissions in July (532,677) fell again, by 2,498 compared to June (535,175); but is considerably higher than July 2019 levels.
  • The percentage of people being admitted, transferred, or discharged within four hours from all emergency departments has decreased to 77.7% - a record low (down from 81.3% in June and 92% in July 2020).
  • The monthly number of four-hour trolley waits increased for the fourth consecutive month, to 89,768 (compared to 66,619 in June and 58,532 in July 2019).
  • 12-hour trolley waits also increased significantly, to 2,215 - an increase of nearly 1000 compared to the 1,289 waits in June. This is significantly higher than the 452 waits seen in July 2019.

 

Referral to treatment waiting list
  • Including estimates for missing data, the elective treatment waiting list increased to 5.45 million in June – a record high.
  • The median wait for treatment decreased again, to 10.4 weeks. Though this is still 2.9 weeks higher than June 2019.
  • 68.8% of patients were treated within 18 weeks (a small increase from 67.4% in May, but far lower than the 86.3% in June 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.
  • 304,803 patients were waiting over 52 weeks to receive treatment at the end of June, an important decrease of nearly 32,000 compared to May – but still 280-fold higher than the number waiting in June 2019.
  • 275,271 patients were admitted to a bed for consultant-led treatment in June, an increase on the 242,064 admitted in May, but significantly fewer than the 289,203 in June 2019.
Cancer
  • Performance against the two week wait target from GP urgent referral to first consultant appointment decreased from 87.5% to 84.9% (compared to 92.5% in June 2020).
  • The number of people receiving their first cancer treatment within two months of an urgent GP referral has increased slightly to 73.3%, following a slight decline in May.
  • The percentage of patients receiving a first treatment for cancer after being seen by a national screening service also declined slightly, to 73.2% compared to 74.5% in May.
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.