NHS pressures - what is the issue?
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.
Letter to Prime Minister
BMA council chair wrote to the Prime Minister about the unacceptable pressures on the NHS on 18 January 2018.
Read the letter (PDF)
With the arrival of colder weather, these pressures are being exacerbated, leading to an unprecedented burden being placed on trusts across England. The effect of sustained increases in demand often entails massive, systemic difficulties at trust level, meaning long delays across the NHS, from general practice to emergency care.
These pressures have already manifested themselves in a dramatic way this winter, with dangerously high bed occupancy, long waits for elective care, patients stuck in ambulances at A&E or in hospital beds waiting to be discharged.
The BMA will be analysing the weekly, trust-level data (the winter situational reports) published by NHS England, to shed some light on the massive pressures being placed on an already over-burdened healthcare system. Further down the page you can find the analysis of the monthly A&E and waiting list data which gives a broader overview of the problems facing the NHS .
Read our news story, Winter pressures overwhelm NHS.
The latest data
The winter situational report (08/01/18 – 14/01/18)
- Average bed occupancy across England was 94.9%, 0.1% lower than the previous week.
- Occupancy peaked on the Tuesday at 95.7%, the second highest figure recorded so far this winter.
- Helping to arrest the rise in bed occupancy was the fact that trusts were forced to close fewer beds due to factors such as norovirus. An average of 621 beds were closed every day, 323 fewer than the week before.
- A&E diverts were down compared with the previous week with seven recorded.
- There were 12,559 ambulance handover delays recorded (of which 9,939 were 30-60 minutes, and 2,620 were over an hour). This is over 4,100 fewer than the previous week, thanks in large part to a reduction in the number of patients arriving by ambulance (3,700 fewer).
Monthly data on A&E, waiting list and delayed transfers of care
Key indicators for November-December 2017:
How much longer will patients have to wait in the next three years?
View our projections
- There were just over 2m attendances at A&E in December, about 70,000 more than December 2016.
- Performance against the four wait target was the worst on record (data available from 2010 onwards). 85.1% of patients were admitted or discharged from all A&Es in December, which means that 300,000 patients waited over 4 hours. At major A&Es, just 77.3% of patients were seen within four hours (also a historic low).
- 69,071 patients experienced trolley waits of over four hours, 7300 more than December of last year. During the whole of 2017, there were just over 565,000 instances, which is more than were recorded in the whole of 2012, 2013 and 2014 combined.
- Emergency admissions also reached a historic monthly high of 520,000, more than 22,000 than December 2016.
- Delayed transfers of care continued to fall (latest data from November). 155,000 delayed days were recorded, the lowest since December 2015.
- The waiting list for elective treatment fell slightly to 4.0m In November, down from 4.1m. It’s worth noting that these figures predate more recent policy related to cancellations of elective procedures.
These visualisations show a worsening trend of the key indicators over a number of years and include the latest data. Scroll through all five graphs* and click on the double-edged arrow in the bottom-right to see larger versions.
All data is from NHS England
December’s data confirms that the crisis in the NHS this winter is one of the worst on record, with services under unprecedented strain as a result of a lack of long term investment. Alarmingly, this deterioration in performance coincided with measures intended to tackle pressures at A&E, including the cancellation of a massive number of elective procedures.
This decision was taken with a view to addressing extremely high bed occupancy, but despite attempts to reduce planned admissions and delayed transfers of care (as well as opening up over 5,000 escalation beds in the new year) occupancy exceeded 95% during the first week of January. One reason for this is almost certainly the record high number of emergency, unplanned admissions, which broke the previous record (set earlier in 2017) by almost 7,000. NHS staff are doing everything they can to cope with these pressures, but are being put in a position where they do not have the resources to provide the level of care they want to.
The implications of having the vast majority of beds occupied include much longer waits at other points in the system, which also meant that more patients than ever before have been waiting for more than four hours to be seen in A&E, as well as the second highest number of trolley waits ever recorded.
Perhaps most disconcertingly of all, January often proves to be even busier than December. Unless immediate action is taken, the NHS could once again find itself breaking records for all the wrong reasons. The devastating impact on patients and on the NHS’s incredibly hard working and dedicated staff cannot be underestimated.
Performance of key indicators in previous months
The key indicators for November 2017 are:
- November saw 1.9m attendances at A&E, an increase of 4.4% compared with November 2016. Despite this increase, there was a small improvement against the four hour wait target, meaning that 88.9% of patients were discharged or admitted in four hours or less, half a percent more than November of the previous year.
- Emergency admissions remained high last month, with 513,000 instances during November, an increase of 4% compared with 2016. Trolley waits also maintained a consistent upward trend, exceeding 48,000.
- The waiting list for elective treatment remains steady at 4.1m. Generally speaking, the number of patients on the waiting list tends to fall towards the end of summer, before rising again at the end of winter. However, this fall is yet to materialise this year, meaning that an almost record number of patients remain waiting for treatment.
- Delayed transfers of care remained fairly stable in October compared with the previous month, reaching 171,000 delayed days. This is a significant improvement from 2016 however, which saw delayed transfers reach a historic high of over 200,000 delayed days.
The key indicators for October 2017 are:
- Despite a particularly busy month at A&Es (141,000 more attendances than September) there was a small improvement against the four hour wait target. Trusts achieved an average of 90.1%, an improvement of 1% compared with October 2016. The 95% target has now been missed for 27 consecutive months.
- The number of emergency admissions exceeded 510,000 for the first time ever; consequently, the number of trolley waits increased by more than 3,000 from September. There have been 448,000 trolley waits so far in 2017, 24,000 than took place in the first ten months of 2016.
- Including estimates for those trusts that did not return data this month, the waiting list for elective treatment has increased in eight consecutive months. It now stands at 4.1m, just 100,000 short of exceeding the highest ever recorded figure. The proportion of patients treated within 18 weeks reached its lowest level (89.1%) since February 2011.
- Delayed transfers of care fell from both the previous month, and compared with September 2016. There were 28,000 fewer bed days lost to delayed transfers of care than in September 2016, the lowest total in a year and a half. However, the number of delayed days so far this year still exceeds the figure from the first 9 months of 2016 by 77,000.
The key indicators for September 2017 are:
- Despite a small decrease in attendances from 2016 (25,000 fewer this year), performance against the four hour wait target was almost a full percent worse (89.7% discharged, transferred or admitted within four hours this year, compared with 90.6% in September 2016).
- Trolley waits of four hours or more reached a new high in 2017-18 of 42,000, 6,500 higher than in September 2016. Having decreased slightly from 2016-17 prior to September, the average number per month is now 1,000 higher in 2017-18. This is presumably in part due to the increase of over 11,500 emergency admissions compared to September last year.
- Including non-reporters (i.e. trusts that did not return data this month, but including their last known reported figures as an estimate), the latest RTT (referral to treatment) waiting list reached 4.1, just shy of the highest ever reported total (4.2m in August 2007).
- There was an improved performance with regard to delayed transfers of care, which fell by 1,800 delayed days compared with July 2017, and by 16,500 compared with August 2016. Patients awaiting care packages in their own home remains the most frequently cited reason for delays (responsible for 11,000 more delayed days than any other reason).
The key indicators for August 2017 are:
- In the first four months of 2017-18, the proportion of patients waiting more than 18 weeks to begin their treatment was 9.9%. This is an increase of 1.5% from 2016-17, and is the highest figure for these months since 2009-10.
- So far there have been just under 10m attendances at A&Es in 2017-18, an increase of just about 85k from the same period in 2016-17. There were just under 2.5m emergency admissions, an increase of about 70k.
- The average proportion of patients waiting over four hours at A&E was roughly the same in the first five months of 2017-18 (9.7%) as it was in the same period the year before (9.6%).
- There was a small fall in the number of twelve-hour trolley waits (444 in 2017-18, down from 557 the year before) while the number of four-hour trolley waits plateaued (183k in both years).
- The number of days on which patients experienced delayed transfers of care increased by 19k between 2016-17 and 2017-18. Social care has been responsible for an average of 37.6% of those days in 2017-18, compared with 32.6% of the delayed days a year earlier.
- The DH (Department of Health) set a target of 75% for ambulances arriving at the most serious incidents within 8 minutes. This target has not been met for over 2 years.