England

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Pressure points in the NHS

a busy hospital

With annual increases in demand for care, the NHS in England is under a growing amount of pressure and has begun to noticeably struggle to meet targets.

As this pressure grows, so too does the importance of highlighting it and lobbying for the government to address this issue.

The BMA will be analysing monthly data releases published by NHS England to shed some light on the massive pressures being placed on an already over-burdened healthcare system.

The BMA has warned that the NHS is likely to endure a 'perfect storm' of pressure and demand this winter. Read our analysis of how the NHS fared last winter.

Read our latest projections

 

Latest updates on 2019/20 winter pressures

Key indicators for the first 5 weeks of winter (2 December - 5 January 2020)

  • A higher average daily number of beds (96,744) were open over the first half of this winter season than in the same time frame in the previous three winters in England. For example, the 5-week daily average for the same period of winter 2018/19 was 95,618.
  • The main increase in total bed numbers can be attributed to a large increase in escalation beds compared to the same period last year - an average of 3,272 escalation beds were open daily in the first five weeks of winter 2019/20. This is significantly higher than the 2,286 figure for the same period in the previous year, representing a year-on 43.1% increase.
  • Despite this increase in bed numbers, average bed occupancy was higher over this period of winter 2019/20 than the same period in the previous three winters. Average daily occupancy across England was 93.5% in this first half of winter 2019/20, contrasting the 91.9% figure from 2018/2019, 93.4% from 2017/18, and 92.7% from 2016/17.
  • Each week of this winter, a larger proportion of trusts had average bed occupancy exceeding the 95% target than in the equivalent 2018/19 winter period. An average of 52% of trusts had average daily bed occupancy exceeding 95% for the five-week period in 2019/20, whereas this proportion was only 38.8% in the 2018/19 period.
  • An average of 744 beds were closed daily across England due to diarrhoea, vomiting, or Norovirus in the five-week period. This is 63% higher than the same figure for the 2018/19 period (average of 456 closures).
  • 500,098 people arrived at A&E via ambulance in the first five weeks of the 2019/20 winter period, a 1.2% increase compared to the 493,952 that arrived in the same period last year.
  • A high proportion of these ambulance handovers were delayed: an average of 11.9% by 30-60 minutes and 4.3% by over an hour. These are larger proportions of delays than seen in the same period of winter 2019/20, where the figures were 8.4% and 2.0%, respectively.
  • There were no A&E closures in England during the first five weeks of winter 2019/20.

 

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

Key indicators for November/December 2019:

A&E (December - excluding 14 trusts piloting new targets)

  • Demand for care continues to rise: there were over 2.18 million attendances at A&E and 560,801 emergency admissions, increases of 6.5% and 2.9% from this time last year (all Trusts).
  • There was a 15-year record low proportion of people being admitted, transferred, or discharged from A&E within four hours (79.8%), a 1.6 percentage point decrease from November 2019 and a 6.7 percentage point decrease from December 2018.
  • Performance within major A&Es (type 1 admissions) also dropped, with only 68.6% of patients leaving major A&E within four hours in type 1 emergency departments, compared to 71.3% in November 2019 and 79.1% in December 2018.
  • There was a record number (98,452) of 4-hour trolley waits. This represents a 11% increase in 4-hour waits from November 2019 and a 65% increase on December 2018.
  • The number of 12-hour trolley waits was also a monthly record: 2,347 people waited over 12 hours on a trolley bed in December 2019. This is over double the number from last month (1,112 waits in November 2019) and over eight times the number of waits last December (284).

Delayed transfers of care (November)

  • There were over 145,800 delayed days as a result of delayed transfers of care, a month-on improvement (4.4% decrease) compared to the 152,522 delayed days in October 2019. However, this is 7.1% more delayed days than the 136,183 that occurred in November 2018.

Cancer (November)

  • 91.3% of cancer patients were seen by a specialist consultant within two weeks of urgent GP referral, a 0.01% decrease from October. The 93% target has been missed in 16 of the last 20 months, and performance is below what it was this time last year (92.5% in November 2018). 
  • • 77.4% of cancer patients were treated within two months of an urgent GP referral (0.3% increase from October), making November the 48th consecutive month that the Government target (treatment of 85% of patients within two months) has been missed.

RTT waiting list (November)

  • Including estimates for missing data, the elective treatment waiting list decreased to 4.42 million people (0.03 million decrease from October 2019). This is the first time in the past ten months in which the waiting list has decreased in size. However, the monthly waiting list sizes for March-November 2019 were all larger than any month since August 2007.
  • The median wait for treatment increased from 7.6 weeks in October to 7.7 weeks this month - this is larger than last November's 6.9-week median wait.
  • Only 84.4% of patients were treated within 18 weeks (a decrease from 84.7% in October 2019 and 87.3% in November 2018), falling well below the 92% target, which has been consecutively missed monthly since March 2016. This is the worst performance against this target since September 2008.

 

BMA analysis

The latest data from NHS England yet again reveal a health system on the brink of collapse as it endures its worst winter yet. Despite Trusts increasing the number of beds available, patients are having to wait longer than ever for treatment. Clinical staff are struggling amidst spiralling workloads, expected to provide adequate care in insufficiently resourced settings. This is impacting on doctors’ ability to do what they do best: keep patients safe.

In what has now become a normalised decline in the standard of care that doctors are able to provide, A&E wait times have once again reached their highest levels since records began – over one in five people waited over four hours in A&E this December. Pressure in major A&Es was even worse, with more than a quarter of people waiting more than four hours. Five NHS Trusts saw less than half of their A&E attendances four hours – no Trusts had wait times this long in December 2018. Overall, this month hails the worst performance against the Government’s four-hour wait target since its inception nearly 16 years ago.

More people are waiting long periods of time on corridor trolley beds than ever before; a staggering 98,452 people waited over 4 hours to be transferred to an actual ward bed. 2,347 people waited over 12 hours in this supposedly ‘temporary’ setting in December 2019; this is a higher number of 12-hour trolley waits than there were in the past eight Decembers combined. An unprecedented number of patients are being left in unsafe and uncomfortable conditions, being denied access to much-needed urgent care.

The increase in the number of beds open compared to previous winters is welcome. However, this increase is mostly attributable to an increase in escalation beds, not core beds. Whilst escalation beds are an important measure to help cushion increased demand over winter, they are not a long-term solution to the current level of pressure the NHS is under. These beds are additional to the permanent bed stock and are brought in to service for limited periods of time, either in temporary or re-purposed wards, or added to existing wards, to provide extra capacity. The extremely high bed occupancy rates from the first half of this winter (more than half of trusts had average daily occupancy exceeding 95%) demonstrate that further increases to bed numbers are needed beyond the short-term escalation bed solution.

The large amount of bed closures during the first half of winter due to diarrhoea, vomiting, or Norovirus are likely to only increase as the truly cold months arrive. Altogether, these figures reflect unacceptably high levels of system-wide pressure within and beyond A&E – reduced hospital bed numbers, staff shortages and lack of capacity in both GP surgeries and social care all contribute to the undue strain being put on the NHS. Combined with this, senior doctors are being prevented from working additional shifts due to punitive pension tax rules. These data suggest that the NHS is now in the throes of an exceptionally arduous winter, with little sign of relief in January (or even in spring) without increased investment across the board.

 

Data from previous months

  • November / December 2019

    A&E (November - excluding 14 trusts piloting new targets)

    • Demand for care continues to rise: there were 2.14 million attendances at A&E and 559,556 emergency admissions, increases of 5.2% and 2.6% from this time last year (all trusts). 
    • There was a 15-year record low proportion of people being admitted, transferred, or discharged from A&E within four hours (81.4%), a 2.2 percentage point decrease from October 2019 and a 6.2 percentage point decrease from November 2019. 
    • No NHS trusts met the four-hour wait target this month - the first time that this has happened since the target was set. 
    • Only 71.3% of patients in major A&Es were admitted, transferred or discharged within four hours, compared to 74.5% in October 2019 and 81% in November 2018. 
    • There was a record number (88,923) of 4-hour trolley waits. This represents an 11% increase in 4-hour waits from October 2019 and a 63% increase on November 2018. 
    • The number of 12-hour trolley waits also hit record highs: 1,112 people waited over 12 hours on a trolley bed in November 2019, a 53% increase from October 2019 and a 329% increase from October 2018. 
       

    Delayed transfers of care (October)

    • There were 152,500 delayed days as a result of delayed transfers of care, the highest monthly figure since March 2018.

    Cancer (October)

    • 91.4% of cancer patients were seen by a specialist consultant within two weeks of urgent GP referral, a 1.3% increase from September. This represents an improvement; however, the 93% target has still been missed in 15 of the last 19 months, and performance is below what it was this time last year (92.3% in October 2018). 
    • 77.1% of cancer patients were treated within two months of an urgent GP referral, making October the 47th consecutive month that the Government target (treatment of 85% of patients within two months) has been missed.

    RTT waiting list (October)

    • Including estimates for missing data, the elective treatment waiting list grew to its highest level since records began, reaching 4.6 million people. October was the 9th consecutive month in which the waiting list has increased in size. 
    • The median wait for treatment decreased from 8.0 weeks in September to 7.6 weeks this month. Although this represents a month-on improvement, median wait time is longer now than it was in October 2018 (7.0 weeks). 
    • Only 84.7% of patients were treated within 18 weeks (compared to 87.1% in October last year), falling well below the 92% target, which has been consecutively missed since March 2016. This is the worst performance against this target since 2008. 

     

  • September/ October 2019

    A&E (October - excluding 14 trusts piloting new targets)

    • 83.6% of people were admitted, transferred or discharged from A&E within four hours, a 5.5% decrease from last year and a record low for the past 15 years.
    • The decrease in four-hour wait performance was even larger in major A&Es, down by 8.6% to 74.5%. These figures for both all and major A&Es are the lowest recorded in the month of September over the last decade. Demand for care continues to rise: there were 2.17 million attendances at A&E, and 563,079 emergency admissions, increases of 4.4% and 3.1% from this time last year (all trusts).
    • There were 80,092 trolley waits of over four hours. There were over 30,000 more trolley waits over four hours this October compared to the same month last year.
    • 726 patients waited on trolleys for over 12 hours, an increase of over 230% from last October.

    Delayed transfers of care (September)

    • There were 149,384 delayed days, the highest figure since March 2018.

    Cancer (September)

    • 76.9% of cancer patients were treated within two months of an urgent GP referral (1.6% increase from August), making September the 46th consecutive month that the Government target (treatment of 85% of patients within two months) has been missed.
    • 90.1% of cancer patients were seen by a specialist within two weeks of urgent GP referral, a 0.7% increase from August. This represents a slight improvement; however, the 93% target has still been missed in 14 of the last 18 months. 

    RTT waiting list (September)

    • The waiting list for treatment grew to its highest level since records began, reaching 4.57 million people (including estimates for missing data). Compared to last September, there are an additional 245,024 people waiting for treatment, a rise of 5.67%.
    • The median wait for treatment remained eight weeks, the highest it has been since January 2008.
    • Only 84.8% of patients were treated within 18 weeks, falling well below the 92% target, which has been consecutively missed since March 2016. This is the worst performance since 2008.

  • August/ September 2019

    A&E (September - excluding 14 trusts piloting new targets)

    • 85.4% of people were admitted, transferred or discharged from A&E within four hours, down from 88.9% last year.
    • The fall in four-hour wait performance was even bigger in major A&Es, down to 77.0% from 83.0%. Both figures are the lowest recorded in the month of August by some distance. 
    • Demand has continued to increase at an accelerated rate; there were 2.14 million attendances at A&E, and 529,900 emergency admissions, increases of 6.9% and 3.8% (All trusts).
    • Trolley waits of over four hours were up by 45.6% on last September to 64,900. This is the largest increase between consecutive Septembers since 2013/14 (All trusts).

    Delayed Transfers of Care (August)

    • There were 148,900 delayed days, the highest figure since March 2018.

    Cancer (August)

    • 78.5% of cancer patients were treated within two months of an urgent GP referral, making August the 44th consecutive month that the Government target - to treat 85% within two months - has been missed.
    • 89.4% of cancer patients seen by a specialist within two weeks of urgent GP referral. The 93% target has now been missed in 15 of the last 17 months. For the second consecutive month, more patients than ever before (21,191) waited over two weeks to be seen by a specialist. 

    RTT waiting list (August)

    • The waiting list for treatment grew to its highest level since records began, reaching 4.56 million people (includes estimates for missing data). Compared to last August, there are an additional 35,400 people waiting for treatment, a rise of 0.8%.
    • The average wait for treatment was eight weeks, while only 85% of patients were treated within 18 weeks, falling well below the 92% target. This is the worst performance since 2008.
  • July / August 2019

    A&E (August - excluding 14 trusts piloting new targets)

    • Only 86.3% of people were admitted, transferred or discharged from A&E within four hours, down from 89.8% last year.
    • The fall in four hour wait performance was even bigger in major A&Es, down to 78.3% from 83.9%. Both these figures make August 2019 the worst August on record and are comparable to some of the worst winters on record.
    • Following on from July being the busiest month ever, there were 2.1 million attendances at A&E in August. 1.3 million of those were at major A&E departments. This makes this month the busiest August on record for A&E departments. (All trusts)
    • Trolley waits of over four hours were up an enormous 40.5% on last August to 56,500. Trolley waits of over 12 hours more than doubled to 372, compared with last August. Comfortably the worst August on record. (All trusts)

    Cancer (July)

    • 77.6% of cancer patients were treated within two months of an urgent GP referral, making July the 43rd consecutive month that the government target - to treat 85% within two months - has been missed. More than two thirds (69.9%) of providers missed the target. 3,300 patients waited over two months to start treatment, the second highest figure on record.
    • 90.9% of cancer patients seen by a specialist within two weeks of urgent GP referral. The 93% target has now been missed in 14 of the last 16 months. Over a third of all providers (38.6%) missed the target. More patients than ever before (20,200) waited over two weeks to be seen by a specialist.
    • Both these figures make this July the worst July since records began in October 2009.

    RTT waiting list (July)

    • The waiting list for treatment grew to its highest level since records began, reaching 4.52 million people. Compared to last July, there are an additional 200,000 people waiting for treatment, a rise of 4.6%.
    • The average wait for treatment was 7.3 weeks in July 2019.
    • Only 85.8% of patients were treated within 18 weeks, falling well below the 92% target. This is the worst performance since January 2009.
  • June / July 2019

    A&E (July - excluding 14 trusts piloting new targets)

    • There were 2.3 million attendances at A&E in July, making it the busiest month on record for A&E departments. 1.4 million of those were at major A&E departments, also the highest figure on record. (All trusts)
    • Only 86.5 per cent of people were admitted, transferred or discharged from A&E within four hours, down from 89.4 per cent last year.
    • The fall in four hour wait performance was even bigger in major A&Es, down to 78.9 per cent from 83.3 per cent. Both these figures make July 2019 the worst July on record.
    • Trolley waits of over four hours were up an enormous 34.7 per cent on last July to 57,700. Trolley waits of over 12 hours almost tripled to 436 compared with last July. Comfortably the worst July on record. (All trusts)

    Cancer (June)

    • 76.7 per cent of cancer patients were treated within two months of an urgent GP referral, making June the 42nd consecutive month that the Government target, to treat 85 per cent within two months, has been missed. More than three quarters (75.2 per cent) of providers missed the target.
    • 90 per cent of cancer patients were seen by a specialist within two weeks of an urgent GP referral. The 93 per cent target has now been missed in 13 of the last 15 months. Almost half of all providers (46 per cent) missed the target.
    • Both these figures make this June the worst June since records began in October 2009.

    RTT waiting list (June)

    • The waiting list for treatment grew to its highest level since records began, tipping over 4.5 million people for the first time on record. Compared to last June, there are an additional 197,500 people waiting for treatment, a rise of 4.6 per cent.
    • The average wait for treatment was 7.5 weeks in June 2019.
    • Only 86.3 per cent of patients were treated within 18 weeks, falling well below the 92 per cent target. This is the worst performance since January 2009.

    Cancelled operations (quarter one 2019/20)

    • There were 20,000 cancelled operations in the quarter to June 2019. This is up 6 per cent on the same quarter last year. This is the highest figure for this quarter (Apr-Jun) since 2001.
    • 1,025 urgent operations were cancelled.
    • May / June 2019

      A&E (June - excluding 14 trusts piloting new targets)

      • Only 86.4 per cent of people were admitted, transferred or discharged from all A&E within four hours, down from 90.9 per cent last June.
      • The fall in four hour wait performance was even bigger in major A&Es, down to 78.8 per cent from 85.5 per cent. Both these figures make June 2019 the worst June on record.
      • Trolley waits of over four hours were up 71 per cent on last June to 57,800. (All trusts)
      • 471 trolley waits of over 12 hours were recorded, a 376 per cent increase compared with last June. (All trusts)

      RTT Waiting List (May)

      • The waiting list for treatment grew to its highest level since records began, reaching 4.5 million people in May 2019 (includes estimates for missing data). Compared to last May, there are an additional 220,000 people waiting for treatment, a rise of 5.2 per cent.
      • The median wait for treatment grew to 7.7 weeks in May 2019.
      • 86.9 per cent of patients were treated within 18 weeks, falling well below the 92 per cent target (a small of improvement of 0.4 percentage points from April).

      Cancer (May)

      • 90.8 per cent of cancer patients seen by a specialist within two weeks of urgent GP referral. This is a small improvement from April (0.9 percentage points). The 93 per cent target has now been missed for three consecutive months.
      • 77.5 per cent of cancer patients were treated within two months of an urgent GP referral (down by 1.9 percentage points), making May the 41st consecutive month that the government target, to treat 85 per cent within two months, has been missed.
    • April / May 2019

      A&E (May - excluding 14 trusts piloting new targets)

      • Only 86.6 per cent of people were admitted, transferred or discharged from A&E within 4 hours, down from 90.3 per cent last May.
      • The fall in 4 hour wait performance was even bigger in major A&Es, down to 79.1 per cent from 84.7 per cent. Both these figures make May 2019 the worst May on record.
      • Trolley waits of over 4 hours were up 57 per cent on last May to 61,500. (All trusts)
      • Trolley waits of over 12 hours almost tripled to 415, compared with last May. (All trusts)

      Cancer (April)

      • 89.9 per cent of cancer patients seen by a specialist within 2 weeks of urgent GP referral. Falling below 90 per cent for the first time on record. The 93 per cent target has now been missed in 10 of the last 12 months. Almost half of all providers (46 per cent) missed the target.
      • 79.4 per cent of cancer patients were treated within 2 months of an urgent GP referral, making April the 40th consecutive month that the government target, to treat 85 per cent within 2 months, has been missed. 63 per cent of providers missed the target.

      RTT Waiting List (April)

      • The waiting list for treatment grew to its highest level since records began, reaching 4.41 million people in April 2019. Compared to last April, there are an additional 215,000 people waiting for treatment, a rise of 5.1 per cent.
      • The average wait for treatment grew over 7 weeks in April 2019.
      • Only 86.5 per cent of patients were treated within 18 weeks, falling well below the 92 per cent target. This is the worst performance since January 2009.
    • March/ April 2019

      A&E

      • Only 85.1% of people were admitted, transferred or discharged from A&E within 4 hours, down from 88.6% last year.
      • The worsening of performance against the 4 hour wait target was even greater in major A&Es, down to 77.2% from 82.3%. These figures make April 2019 the worst April on record.
      • 304,000 patients waited over 4 hours in major A&Es. This is up 38% on last April.
      • Trolley waits of over 4 hours up 39% on last April to 67,000. Trolley waits of over 12 hours rose by 24% to 442, compared with last April. The worst April on record.
      • Demand continues to grow with a 6.6% increase in total A&E attendances compared to last April, rising to 2,100,000. There was a similar rise in emergency admissions to 535,000.

      Waiting list and cancellations

      • The waiting list for treatment continued to rise in March 2019, reaching 4.34 million people. Compared to last March, there are now an additional 241,500 people waiting for treatment, a rise of 5.7%. The waiting list has only been higher than this once on record.
      • Almost 22,000 elective operations were cancelled between January and March 2019. While this is down on last year, it represents the 5th worst quarter since records began in 1994.
      • 347 urgent operations were cancelled in March 2019.

      Cancer waits

      • 91.8% of cancer patients seen by a specialist within 2 weeks of urgent GP referral in March 2019. Falling back under the 93% target. This target has now been missed in 10 of the last 12 months. It was only missed once in the previous year.
      • 79.7% of cancer patients were treated within 2 months of an urgent GP referral, making March 2019 the 39th consecutive month that the government target, to treat 85% within 2 months, has been missed.
      • Both these figures make this the worst March since records began in 2009.
      • These figures confirm that winter 2019 (Jan-Mar) was the worst winter on record for cancer waits, with 43,000 having to wait over 2 weeks to see a specialist and almost 9,000 waiting over 2 months for their first treatment.
    • February / March 2019

      • There were 2.17m attendances at A&Es in March, an increase of 116,500 from the previous March.
      • 555,500 emergency admissions were recorded, a worrying 6% increase from March 2018.
      • Performance against the four-hour wait target at major A&Es was 79.5% last month, a slight improvement on February's historic low.
      • There were 59,500 trolley waits of four or more hours, making it the second worst March on record.
      • Including estimates for missing data, the waiting list for elective treatment rose to 4.31m in February.
      • There were 127,300 delayed days recorded in February, a 6% fall from last month.
    • January / February 2019

      • There were 1.95m attendances at A&Es in February, an increase of 133,800 from the previous February.
      • 505,700 emergency admissions were recorded, a 28,900 increase from February 2018.
      • Performance against the four-hour wait target at major A&Es deteriorated by 0.4 percentage points from January, reaching 75.7% last month. This is 1.2 percentage points less than the previous February which represents another historic low.
      • There were 70,800 trolley waits of four or more hours, which is 2,100 more than February 2018.
      • Including estimates for missing data, the waiting list for elective treatment was 4.26m in January. The median wait of 7.8 weeks to begin treatment was the highest figure recorded since May 2008.
      • There were 135,700 delayed days recorded in January, a 6,300 increase from December.
    • December 2018 / January 2019

      • There were 2.1m attendances at A&Es in January an increase of 111,500 from the previous January.
      • 563,800 emergency admissions were recorded, a 37,700 increase from January 2018. 
      • Performance against the four-hour wait target at major A&Es deteriorated by 3.2 percentage points from December, reaching 76.1% last month. This is 1.1 percentage points lower than the previous January (and an historic low).
      • There were 83,500 trolley waits of four or more hours, which is 2,290 more than January 2018.
      • Including estimates for missing data, the waiting list for elective treatment was 4.28m in December. The median wait of 7.6 weeks to begin treatment was the highest figure recorded since May 2008. 
      • There were 129,400 delayed days recorded in December, the lowest figure since June 2014.
    • Further resources