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: Tuesday 18 January 2022
NHS Structure Article Illustration

November and December 2021 analysis

Activity data for November and December 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 November 2021, there were:

  • 4.22 million fewer elective procedures
  • 29.14 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 demonstrate improvements across referral and waiting time targets. The overall median waiting time for treatment has remained high in November 2021, at 12 weeks, as did the total number of patients waiting over 18 weeks for treatment, at 2.07 million.

The number of patients waiting over one year for treatment has slightly decreased in November to 207,000 from 312,665. The number of patients waiting more than year is still relatively enormous and is 220-fold the number waiting in November 2019.

Despite the progress against these targets, the total waiting list currently sits at an alarming, record high 6.00 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 remains relatively high, but have decreased very slightly this month.

However, 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 12,986 - an increase of nearly 2,340 compared to the 10,646 waits in November 2021.

However, the number of four hour waits slightly decreased once more after having increased for six consecutive months reaching record levels in October 2021.

In December, there were 120,218 people spending over 4 hours in A&E – a small decrease compared to 120,749 in November but substantially higher than in December 2019 (98,461).

Altogether, this shows continued high demand and a concerning decline in performance. Worryingly, if attendances and A&E pressures continue to grow, this trend may worsen.

Mixed cancer waiting time performance

November saw some small improvements in performance against a number of cancer waiting time targets, though slight decline against others.

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 percentage of patients receiving their first treatment within two months of attending a screening service decreased slightly to 73.80% from 73.20% in October - this remains significantly higher than in the summer of 2020.

The percentage of patients receiving cancer treatment within two months of an urgent GP referral hit record-low levels, falling to 67.50% - far lower than the safe standards set at 85%.

Activity remains low compared to 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 November/December 2021

Emergency departments
  • Demand for care across all A&E departments remained high in December, and performance against the four and 12 hour waiting time targets has again suffered badly.
  • There were 1.88 million attendances at emergency departments in December, with a marginal decrease from November.
  • The total number of emergency admissions in December (499,325) has fallen since November (506,238); and is now lower than December 2019 levels.
  • The monthly number of 4-hour trolley waits has again dropped after increasing for the six consecutive months, to 120,218 (compared to 120,749 November and 98,461 in December 2019).
  • 12-hour trolley waits reached record-high levels, to 12,986- an increase of 2,340 compared to the 10,646 waits in November. This is significantly higher than the 2,356 waits seen in December 2019.
Referral to treatment waiting list
  • Including estimates for missing data, the elective treatment waiting list increased to 6.00 million in November – a record high.
  • The median wait for treatment remains steady at 12 weeks. Though this is still 4.3 weeks higher than November 2019.
  • 65.5% of patients were treated within 18 weeks (a very small decrease from 66.6% in November, but far lower than the 84.4% in November 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.
  • 306,996 patients were waiting over 52 weeks to receive treatment at the end of November, a decrease of 5,669 compared to October – but still 220-fold higher than the number waiting in November 2019.
Cancer
  • Performance against the two week wait target from GP urgent referral to first consultant appointment decreased from 81.3% to 77.4% (compared to 87.0% in November 2020).
  • The number of people receiving their first cancer treatment within two months of an urgent GP referral remains worryingly low and has decreased from 67.8% in October to 67.5% this month.
  • The percentage of patients receiving a first treatment for cancer after being seen by a national screening service has increased slightly to 72.8% compared to 73.2% in October.
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 2021

Emergency departments
  • Demand for care across all A&E departments remained high in November, and performance against the four and 12 hour waiting time targets has again suffered badly.
  • There were 2.04 million attendances at emergency departments in November, with a marginal decrease from October.
  • The total number of emergency admissions in November (506,238) has fallen since October (517,062); and is now lower than November 2019 levels.
  • The percentage of people being admitted, transferred, or discharged within four hours from all emergency departments is 74%.
  • The monthly number of four hour trolley waits has now marginally dropped after increasing for the six consecutive months, to 120,749 (compared to 121,251 in October July and 88,992 in October 2019).
  • 12-hour trolley waits reached record-high levels, to 10,646 - an increase of 3,587 compared to the 7,059 waits in October. This is significantly higher than the 1,111 waits seen in October 2019.
Referral to treatment waiting list
  • Including estimates for missing data, the elective treatment waiting list increased to 5.98 million in October – a record high.
  • The median wait for treatment decreased again, to 12 weeks. Though this is still 4.4 weeks higher than October 2019.
  • 65.6% of patients were treated within 18 weeks (a small decrease from 66.5% in September, but far lower than the 84.7% in October 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.
  • 312,665 patients were waiting over 52 weeks to receive treatment at the end of October, an increase of 12,099 compared to September – but still 237-fold higher than the number waiting in October 2019.
Cancer
  • Performance against the two week wait target from GP urgent referral to first consultant appointment decreased from 84.1% to 81.3% (compared to 87.9% in October 2020).
  • The number of people receiving their first cancer treatment within two months of an urgent GP referral remains worryingly low and has decreased from 68% in September to 67.8% this month.
  • The percentage of patients receiving a first treatment for cancer after being seen by a national screening service has increased slightly to 73.2% compared to 70.8% in September.
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 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.

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.