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: Thursday 17 September 2020
NHS Structure Article Illustration

July/August 2020 analysis

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

New activity data for July and August 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. 

Rising waiting times for specialist treatment

People on the waiting list for specialist treatment following a referral waited an average of 19.6 weeks (over four months) in July, as patients suffered the effects of cancellations and reduced capacity in general and acute specialties. This is over double the median amount of time patients waited last year.

Median waiting times graph Source: NHS England - graph shows median wait time for patients

Unlike the consecutive monthly increase in waiting times, the overall size of the waiting list dropped during the first few months of the Covid-19 crisis due to less referrals happening. In June and July, 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 large proportion of unmet care is highlighted in the rising number of people waiting over one year for treatment – this count rose to 80-fold its normal value in July. Less than half of people on the waiting list were treated within 18 weeks of referral in July – this means that the majority of patients are waiting over four months for treatment now.

NHS waiting list times Source: NHS England - graph shows number of patients on the waiting list for over one year at the end of the month

First cancer treatment after screening at an all-time low

The number of people receiving first cancer treatment following detection in a national screening service has reached an all-time low of only 319 people in July. Only a quarter of these patients received the treatment within two months.

Urgent action is needed to ensure that those most in need receive the treatment they require, especially for highly prevalent conditions such as cancer whose 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.

Number of patients on the waiting list for over one year at the end of the month graph Source: NHS England - graphs show patients receiving first treatment for cancer within two months of a national screening service

Emergency department usage continues to rise, but still not to ‘normal’ levels

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 has continued in August and has been accompanied by an increase in trolley waits and deterioration towards in performance against waiting time targets (4-hour wait performance decreased) – this begs theraises worrying questions about of how A&E departments will cope with high demand whilst maintaining social distancing and infection control.

A and E attendances graph Source: NHS England - graph shows A and E attendances

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.

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 may peak once more).

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.

 

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

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.

Key indicators for June/July 2020

Emergency departments
  • Demand for care continued to increase in July. However, it was still at much lower levels than usually expected, due to the pandemic.
  • There were 1.59 million attendances at emergency departments in July, a 13% increase from the 1.41 in June and a 30% decrease from the 2.3 million attendances that occurred last July.
  • The total number of emergency admissions (472,646) also increased relative to the 437,535 that occurred in June; however, this is still a dramatic 15% decrease from the number last July (554,069).
  • Due to the relative increase in demand, the proportion of people being admitted, transferred, or discharged from all emergency departments decreased to 92.1% (down from 92.8% in June and up from 86.5% last July).
  • This compares to 88.9% of patients leaving major (type 1) emergency departments within four hours (down from 90% in June).
  • The monthly number of 4-hour trolley waits increased to 20,928 – this is still far lower (64% less) than last July’s count of 58,532. 12-hour trolley waits also increased to 271, 40% less than last July’s count of 452.
Cancer
  • Far less cancer treatments and urgent GP referrals occurred in June due to the impact of the COVID-19 pandemic, however the number of both has started to increase and has caused a drop in performance to cancer targets.
  • Only 12.9% of patients received a first cancer treatment less than two months after being screened. This is the lowest performance to this target on record.
  • Although increasing, only 153,134 urgent GP referrals were made in June, a 21% drop from the 194,047 that occurred last June.
  • 92.5% of cancer patients were seen by a specialist consultant within two weeks of urgent GP referral, a 1.7% point decrease from May. Although the 93% target was met last month, this deterioration of performance is likely now be due to the backlog of referrals feeding into the system and treatment not keeping up.
  • Only 18,870 patients received a first treatment for cancer following a decision to treat – this is 6,200 less than June last year.
  • 75.2% of cancer patients were treated within two months of an urgent GP referral (5.3% decrease from May), making June the 56th consecutive month that the Government target (treatment of 85% of patients within two months) has been missed.
GP referrals

The number of GP referrals made for all specialties rose to 586,024 in June, however this is still a large proportionate decrease compared to the 1.10 million that occurred in June 2019. The monthly number of GP referrals was therefore approximately 53% of its normal value in June 2020.

Referral to treatment waiting list
  • Including estimates for missing data, the elective treatment waiting list increased to 3.86 million in June. This is lower than the 4.40 million people that were waiting last June, and is likely due to the large drop in GP referrals during the pandemic.
  • The median wait for treatment increased sharply from 15.3 weeks in May to 17.6 weeks (over four months) in June; this is almost double the 7.5-week median wait seen last June.
  • Only 52% of patients were treated within 18 weeks (a decrease from 62.2% in May 2020 and 86.3% in June 2019). This is the worst performance against this target since April 2008.
  • 50,536 patients were waiting over 52 weeks (one year) to receive treatment at the end of June, a huge 46-fold increase from the count of 1,089 in June 2019. This is the highest monthly count of patients that have waited this long since February 2009.
  • Only 94,354 patients were admitted to a bed for consultant-led treatment in June 2020, 67% less than the 289,200 in June 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.

Key indicators for May/June 2020

Emergency departments
  • Demand for care increased in June relative to May. However, it was still at much lower levels than usually expected, due to the pandemic.
  • There were 1.41 million attendances at emergency departments in June, a 12% increase from the 1.26 in May and a 33% decrease from the 2.11 million attendances that occurred last June.
  • The total number of emergency admissions (437,535) also increased relative to the 398,407 that occurred in April. However, this is still a dramatic 17% decrease from the number last June (528,801).
  • Due to the overall decreased demand, the proportion of people being admitted, transferred, or discharged from all emergency departments remained high at 92.8% (down from 93.5% in May and up from 86.4% last June).
  • This compares to 90% of patients leaving major (type 1) emergency departments within four hours (down from 91.2% in May).
  • The monthly number of four hour trolley waits increased to 17,886 – this is still far lower (69% less) than last June’s count of 57,760. 12-hour trolley waits also increased to 161, 65% less than last June’s count of 461.
Cancer
  • Far less cancer treatments and urgent GP referrals occurred in May due to the pandemic.
  • Only 106,535 urgent GP referrals were made in May, a 47% drop from the 200,600 that occurred last May.
  • 94.2% of cancer patients were seen by a specialist consultant within two weeks of urgent GP referral, a 6.2% point decrease from April. Although this means that the 93% target has been met, this performance is unlikely to be sustainable once the backlog of referrals that are not occurring restarts.
  • Only 16,678 patients received a first treatment for cancer following a decision to treat – this is 9,000 less than May last year.
  • 69.9% of cancer patients were treated within two months of an urgent GP referral (4.4% decrease from April), making April the 55th consecutive month that the Government target (treatment of 85% of patients within two months) has been missed. This is the lowest performance to this target on record.
  • Only 47.9% (less than half) of patients received a first cancer treatment less than two months after being screened. This is the lowest performance to this target to on record.
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.
Referral to treatment waiting list
  • Including estimates for missing data, the elective treatment waiting list decreased to 3.83 million in May. This is lower than the 4.39 million people that were waiting last May, and is likely due to the large drop in GP referrals during the pandemic. This is the lowest that the waiting list has been since March 2018.
  • The median wait for treatment increased sharply from 12.2 weeks in April to 15.3 weeks (over three months) in May. This is far higher than the 7.7-week median week seen last April.
  • Only 62.2% of patients were treated within 18 weeks (a decrease from 71.3% in April 2020 and 86.9% in May 2019). This is the worst performance against this target since April 2008.
  • 26,029 patients were waiting over 52 weeks (one year) to receive treatment at the end of May, a huge 25-fold increase from the count of 1,032 in May 2019. This is the highest monthly count of patients that have waited this long since September 2009.
  • Only 54,550 patients were admitted to a bed for consultant-referred treatment in May 2020, 82% less than the 296,000 in May 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.

Key indicators for April/May 2020

Emergency departments
  • Demand for care increased in May relative to the previous month. However, it was still at much lower levels than usually expected, due to COVID-19.
  • There were 1.26 million attendances at emergency departments in May, a 37% increase from the 916,581 in April and a 42% decrease from the 2.17 million attendances that occurred last May.
  • The total number of emergency admissions (398,407) also increased relative to the 326,581 that occurred in April; however, this is still a dramatic 27% decrease from the number last May (547,382).
  • Due to this decreased demand, the proportion of people being admitted, transferred, or discharged from all emergency departments rose to 93.5% (up from 90.4% in April and 86.6% last May); this is a monthly record high since September 2015.
  • This compares to 91.2% of patients leaving major (type 1) emergency departments within four hours (up from 87.2% in April), also a record high since September 2015.
  • The monthly number of 4-hour trolley waits decreased to 13,457, their lowest level since September 2013. 12-hour trolley waits also decreased to 93, their lowest level since October 2017.
Cancer
  • There was a small deterioration in progress towards meeting cancer treatment targets and making urgent GP referrals in April due to COVID-19.
  • Only 79,573 urgent GP referrals were made in April, a 60% drop from the 199,217 that occurred last April.
  • 88% of cancer patients were seen by a specialist consultant within two weeks of urgent GP referral, a 4% point decrease from March. The 93% target has been missed in 22 of the last 26 months, and performance is below what it was this time last year (89.8% in April 2019).
  • 74.3% of cancer patients were treated within two months of an urgent GP referral (4.6% decrease from March), making April the 54th 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 fell to 280,876 in April; this is a sharp decrease from the 802,435 that occurred in March and the 1.1 million that occurred in April 2019. The monthly number of GP referrals was therefore approximately 25% of its normal value in April 2020.
  • Only 22,594 elective general and acute ordinary admissions occurred in April 2020, a huge decrease from the 102,274 that occurred last April; this reflects the large suspension in elective procedures that had to occur during the pandemic.
Referral to treatment waiting list
  • Including estimates for missing data, the elective treatment waiting list decreased to 3.94 million in April. This is lower than the 4.30 million people that were waiting last April, and is likely due to the large drop in GP referrals during the pandemic. This is the lowest that the waiting list has been since March 2018.
  • The median wait for treatment increased sharply from 8.9 weeks in March to 12.2 weeks (almost 3 months) in April; this is far higher than the 7.2-week median week seen last April.
  • Only 71.2% of patients were treated within 18 weeks (a decrease from 79.7% in March 2020 and 86.5% in April 2019). This is the worst performance against this target since April 2008.
  • 11,042 patients were waiting over 52 weeks (one year) to receive treatment at the end of April, a huge increase from the 3,097 in March and the 1,047 in April 2019. This is the highest monthly count of patients that have waited this long since October 2011.
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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