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: Monday 19 July 2021
NHS Structure Article Illustration

April and May 2021 analysis

New activity data for April and May 2021 keenly illustrates 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 May 2021, there were:

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

Long waits for specialist treatment skyrocket

The overall median waiting time for treatment decreased to 10.8 weeks in June 2021, and the total number of patients waiting over 18 weeks for treatment also decreased to 1.73 million.

The number of patients waiting over one year for treatment further decreased in May to 336,733 from 385,490 in April.

The recent falls in waiting times are positive considering the consistent growth since the outset of the pandemic until March 2021.

Nevertheless, this still represents 13-fold the number waiting more than a year for treatment in May 2020 and 326-fold the number waiting in May 2019.

This 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 June 2021 data again shows increases in admissions and attendances, virtually reaching pre-pandemic levels and the highest since January 2020. This month saw record-high attendances in major emergency departments. 

Long waits have also increased, following a slight improvement in previous months. For June, the number of patients waiting over 12 hours in corridor trolley beds for admission has almost doubled last month’s figures to 1,289.

This compares to 462 in June and 416 in May 2019.

The number of four hour waits also increased, hitting 66,619 - an increase compared to May (57,307) and higher than the 57,671 seen pre-pandemic in June 2019.

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

June 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

May saw an improvement in performance against a number of cancer waiting time targets, despite the decline seen last month.

The proportion of patients being seen rapidly still remains lower than what would be expected, 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 increased in May, following declining performance in recent months, and performance still remains significantly higher than in the summer of 2020.

However, 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 second peak.

 

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

Key indicators for May/June 2021

Emergency departments
  • Demand for care increased again in June and is now at pre-pandemic levels, with A&E attendances exceeding the levels seen in January 2020.
  • There were 2.16 million attendances at emergency departments in June, a 3.8% increase from the 2.08 million in May and exceeding June 2019 levels.
  • The total number of emergency admissions has decreased slightly (535,175) compared to May (543,754); and is a 1.2% increase on June 2019 levels.
  • The proportion of people being admitted, transferred, or discharged within four hours from all emergency departments further decreased, to 81.3% (down from 83.7% in May and 92.8% in June 2020).
  • This compares to 73.2% of patients being admitted, transferred, or discharged from major (type 1) emergency departments within four hours (down again from 76.5% in May).
  • After falling in April, the monthly number of 4-hour trolley waits continue to increase in June, by 9,312 to 66,619 (compared to 61,507 in May and in 57,671 June 2019).
  • 12-hour trolley waits also massively increased, to 1,289 compared to the to the 694 in May and the 462 in June 2019.
Referral to treatment waiting list
  • Including estimates for missing data, the elective treatment waiting list increased to 5.3 million in May – a record high.
  • The median wait for treatment decreased again, to 10.8 weeks. Though this is still 3.1 weeks higher than pre-pandemic May 2019.
  • 67.4% of patients were treated within 18 weeks (an increase on 64.6% in April, but far lower than the 86.9% in May 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.
  • 336,733 patients were waiting over 52 weeks to receive treatment at the end of May, an important decrease of almost 50,000 compared to April – but still 326-fold higher than the number waiting in May 2019.
Cancer
  • 87.5% of cancer patients were seen by a specialist consultant within two weeks of urgent GP referral in May, an increase from 85.4% in April. The 93% target was met last in May 2020 – though performance is improving.
  • 73% of cancer patients were treated within two months of an urgent GP referral - a 2.4% decrease compared to April. May was the 67th consecutive month that the Government target for 85% of patients to receive treatment 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 April/May 2021

Emergency departments
  • Demand for care increased again in May and is now virtually at pre-pandemic levels, with A&E attendances reaching their highest level since January 2020.
  • There were 2.08 million attendances at emergency departments in May, an 11% increase from the 1.86 million in April and hitting 99% of May 2019 levels.
  • The total number of emergency admissions (543,754) increased compared to April (510,150); and represents 95% of May 2019 levels.
  • The proportion of people being admitted, transferred, or discharged within four hours from all emergency departments further decreased, to 83.7% (down from 85.4% in April and 93.5% in May 2020).
  • This compares to 76.5% of patients being admitted, transferred, or discharged from major (type 1) emergency departments within four hours (down again from 78.8% in April).
  • After falling in April, the monthly number of 4-hour trolley waits increased in May, by 8,588 to 57,307 – compared to 61,507 in May 2019.
  • 12-hour trolley waits also increased, to 694 compared to the to the 523 in April and the 416 in May 2019.
Referral to treatment waiting list
  • Including estimates for missing data, the elective treatment waiting list increased to 5.12 million in April – a record high.
  • The median wait for treatment decreased again, to 11 weeks. Though this is still 3.8 weeks higher than pre-pandemic April 2019.
  • 64.6% of patients were treated within 18 weeks (a small increase from 64.4% in March, but far lower than the 86.5% in April 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.
  • 385,490 patients were waiting over 52 weeks to receive treatment at the end of April, an important decrease of over 50,000 compared to March – but still 368-fold higher than the number waiting in April 2019.
  • 223,780 patients were admitted to a bed for consultant-led treatment in March, an increase on the 220,349 admitted in March, but significantly fewer than the 280,209 in April 2019.
Cancer
  •  85.4% of cancer patients were seen by a specialist consultant within two weeks of urgent GP referral in April, a decrease from 91.2% in February. The 93% target was met last in May 2020 – though performance is improving.
  • 75.4% of cancer patients were treated within two months of an urgent GP referral - a 1.5% increase from March.

    However, April was the 66th consecutive month that the Government target for 85% of patients to receive treatment 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 March/April 2021

Emergency departments
  • Demand for care increased again in April and is now nearing pre-pandemic levels, with A&E attendances reaching their highest level since February 2020 and nearly doubling the number of attendances seen in April 2020.
  • There were 1.87 million attendances at emergency departments in April, a 10.5% increase from the 1.69 million in March and hitting 88% of April 2019 levels.
  • The total number of emergency admissions (510,150) increased compared to March (503,913); and represents 95% of April 2019 levels.
  • The proportion of people being admitted, transferred, or discharged within four hours from all emergency departments decreased, to 85.4% (down from 86.1% in March and 90.4% in April 2020).
  • This compares to 78.8% of patients being admitted, transferred, or discharged from major (type 1) emergency departments within four hours (down from 80.1% in March).
  • The monthly number of 4-hour trolley waits decreased again, by 2,153 to 48,719 – compared to 15,720 last April and 66,933 in April 2019.
  • 12-hour trolley waits also fell again, decreasing to 523 compared to the to the 688 in March and the 3,825 in January 2021 – this is still significantly higher than April 2019 levels (442), however.
Referral to treatment waiting list
  • Including estimates for missing data, the elective treatment waiting list increased to 4.95 million in March. This is higher than the 4.24 million people that were waiting in March 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 12.6 weeks in February to 11.6 weeks in March; 2.7 weeks more than the median wait seen in March 2020.
  • 64.4% of patients were treated within 18 weeks (a small decrease from 64.5% in February, but a drastic one from 79.7% in March 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.
  • 436,127 patients were waiting over 52 weeks to receive treatment at the end of March, a 378-fold increase from the count of 1m154 in March 2019. This is the highest monthly count of patients that have waited this long since August 2007.
  • 220,349 patients were admitted to a bed for consultant-led treatment in March, a significant increase on the 152,642 admitted in February, but nearly 28% fewer than the 285,918 in March 2019.
Cancer
  • 91.2% of cancer patients were seen by a specialist consultant within two weeks of urgent GP referral in March, an increase from 90.33% in February. The 93% target was met last in May 2020 – though performance is improving.
  • 73.9% of cancer patients were treated within two months of an urgent GP referral - a more than 4% increase from February. However, March was the 65th consecutive month that the Government target for 85% of patients to receive treatment 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.