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 19 February 2021
NHS Structure Article Illustration

December 2020 and January 2021 analysis

New activity data for December 2020 and January 2021 lay bare 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 and December 2020 there were:

  • 2.7 million fewer elective procedures
  • 18.66 million fewer outpatient attendances.

A growing backlog of care

Infection control measures and the ongoing diversion of resources towards COVID services in many parts of the country 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 once more as the second, worse wave of COVID-19 cases and hospitalisations sets in. This will cause strong further growth in the backlog, particularly in December, January, and February 2021.

Combined with seasonal winter pressures, the new data paint a worrying picture of what is shaping up to be the hardest winter yet for the NHS.

Long waits for specialist treatment skyrocket

The overall median waiting time for treatment and the number of patients waiting over 18 weeks for treatment continued increased slightly in November. However, the number of patients waiting over one year for treatment has risen to 153-fold its 2019 value. This figure has consistently risen since March 2020.

This 12-year high highlights the large proportion of unmet care occurring in a significant portion of the waiting list, with patients increasingly being de-prioritised for care and experiencing extremely long waits. This count may have risen further since December as NHS care has continued to be disrupted by COVID-19 hospitalisations.

The trend in year-long waits contrasts the number of over 18-week waits, which has declined steadily since July. This activity may be target-driven and shows why such targets can sometimes be unhelpful in guiding activity, as certain patients get left behind.

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 January data show that despite admissions and attendances decreasing relative to December and lower than their 2019 levels, long waits have continued to increase and are at higher levels than last year.

Despite lower demand for A&E, the number of patients waiting over 12 hours in corridor trolley beds for admission was 34% higher than last January. This is partially due to infection prevention control and COVID-19 testing requirements at admissions reducing the rate of patient flow through A&E.

This data reflects the reality that emergency departments can only provide the care that they want to give when demand is half its usual levels and COVID-19 isn't spreading rapidly in the community.

Improved performance towards targets is unlikely to occur if demand increases over winter unless significant investments are made across the health and social care system.

A&Es are open and ready to receive patients – this must be communicated effectively to the public to avoid conditions worsening.

Cancer waiting time performance drops

Despite large improvements towards cancer waiting time targets over the summer, progress has slowed over winter and performance against those targets is mixed.

The overall number of treatments and appointments is lower than pre-pandemic. However, the proportion of patients being seen rapidly is lower than what would be expected. Unfortunately, the onset of both the second wave and winter pressures is likely to have disrupted cancer care further (there were reports of this in January in London).

National screening services

The number of patients referred for treatment from a national screening service has continued to increase following drops to approximately 15% of 2019 levels over the summer.

However, activity is still short of what would be expected at this time of the year, but did increase slightly in December.

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 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 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.

Key indicators for November/December 2020

Emergency departments
  • Demand for care remained stable in December – it remains at lower levels than usually expected due to the COVID-19 pandemic.
  • There were 1.48 million attendances at emergency departments in December, a 1% increase from the 1.49 million in November and a 32% decrease from the 2.18 million attendances that occurred last December.
  • The total number of emergency admissions (460,260) increased slightly relative to the 451,800 that occurred in November - this represents a dramatic 18% decrease from the number last December (560,800).
  • Despite the stabilisation in attendances and admissions, the proportion of people being admitted, transferred, or discharged within four hours from all emergency departments decreased to 80.3% (down from 83.8% in November and up from 79.8% last December).
  • This compares to 72.1% of patients leaving major (type 1) emergency departments within four hours (down from 76.8% in November).
  • The monthly number of 4-hour trolley waits increased by 18,800 to 89,800 – this is still lower (9% less) than last December’s count of 560,795. 12-hour trolley waits also increased to 3,745, 59% more than last December’s count of 2,356.
Referral to treatment waiting list
  • Including estimates for missing data, the elective treatment waiting list increased to 4.46 million in November. 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 decreased from 11.1 weeks in October to 10.4 weeks in October; whilst this decrease is good, this is still 2.7 weeks more than the median wait seen last November.
  • Only 68.2% of patients were treated within 18 weeks (an increase from 65.5% in October 2020, but a decrease from 84.4% in November 2019). There has been consecutive improvement to this target since July, which was the worst performance against this target since it started being recorded in 2008.
  • 192,169 patients were waiting over one year to receive treatment at the end of November, a huge 137-fold increase from the count of 1,398 in October 2019. This is the highest monthly count of patients that have waited this long since April 2008.
  • Only 222,810 patients were admitted to a bed for consultant-led treatment in November 2020, 27% less than the 303,193 in November 2019.
Cancer
  • 87% of cancer patients were seen by a specialist consultant within two weeks of urgent GP referral, a 0.9% point increase from October. 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.
  • 75.5% of cancer patients were treated within two months of an urgent GP referral (1% decrease from October), making November the 61st 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 October/November 2020

Emergency departments
  • Demand for care decreased in November – it remains at lower levels than usually expected due to the Covid-19 pandemic.
  • There were 1.49 million attendances at emergency departments in November, a 7% increase from the 1.60 million in October and a 30% decrease from the 2.14 million attendances that occurred last November.
  • The total number of emergency admissions (451,800) decreased relative to the 481,800 that occurred in October; this represents a dramatic 19% decrease from the number last November (560,000).
  • Despite the decrease in attendances and admissions, the proportion of people being admitted, transferred, or discharged within four hours from all emergency departments decreased to 83.8% (down from 84.4% in October and up from 81.4% last November).
  • This compares to 76.8% of patients leaving major (type 1) emergency departments within four hours (down from 77.6% in October).
  • The monthly number of 4-hour trolley waits increased by 4,200 to 71,000 – this is still lower (17% less) than last November’s count of 88,900. 12-hour trolley waits also increased to 2,141, 93% more than (almost double) last November’s count of 1,111.
Referral to treatment waiting list
  • Including estimates for missing data, the elective treatment waiting list increased to 4.44 million in October. This is lower than the 4.45 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 12.0 weeks in September to 11.1 weeks in October; whilst this decrease is good, this is still 3.5 weeks more than the median wait seen last October.
  • Only 65.5% of patients were treated within 18 weeks (an increase from 60.6% in September 2020, but a decrease from 84.7% in October 2019). There has been consecutive improvement to this target since July, which was the worst performance against this target since it started being recorded in 2008.
  • 162,888 patients were waiting over 52 weeks (1 year) to receive treatment at the end of October, a huge 123-fold increase from the count of 1,321 in October 2019. This is the highest monthly count of patients that have waited this long since August 2008.
  • Only 232,487 patients were admitted to a bed for consultant-led treatment in October 2020, 27% less than the 317,992 in October 2019.
Cancer
  • 87.9% of cancer patients were seen by a specialist consultant within two weeks of urgent GP referral, a 1.7% point increase from September. 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.
  • 74.5% of cancer patients were treated within two months of an urgent GP referral (0.2% decrease from September), making October the 60th 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.