Three-quarters of finance directors surveyed in our latest quarterly monitoring report (QMR) say that they are concerned or very concerned about meeting either the A&E four-hour or 18-week referral-to-treatment waiting time standards by the end of this financial year (2016/17).
While this would be the third consecutive full year the A&E standard has been missed, it will be the first year in which the elective waiting time standard has not been met (using the current referral-to-treatment waiting time standard) in any month. This is despite an added incentive for hospitals to meet the performance standards in order to receive their allocation of the Sustainability and Transformation Fund.
To briefly review recent history. While performance against the 18-week waiting time standard improved following its introduction in April 2012, since mid-2013 – albeit with some variation – the proportion of patients waiting more than 18 weeks from referral to begin treatment has been growing (Figure 1). Previous attempts to reduce the number of long waits have not proved effective.
December 2016 saw more than 10 per cent of patients waiting more than 18 weeks to begin treatment (against a standard of 8 per cent). This was the worst performance against this standard since it was introduced. Added to this, more than 1,200 patients are still waiting to begin treatment more than a year after referral; the Secretary of State for Health’s ambition is for the number of patients waiting this long to be as close to zero as possible.
Figure 1: Per cent still waiting 18 weeks to begin treatment / having waited more than six weeks for diagnostics
With admissions not increasing as fast as referrals, the size of the waiting list has grown. When the current 18-week standard was introduced in April 2012 the total waiting list was around 2.48 million patients. In December 2016, however, it has increased to 3.66 million, or more than 1.17 million additional patients. Furthermore, the waiting list could be as high as 3.8 million patients according to NHS England, once the small number of non-reporting trusts begin submitting their data again.
So what could be done to remedy the situation? The waiting list could be reduced by increasing the volume of activity in hospitals, though clinical commissioning groups may struggle to pay for this. In any case, referral growth is competing with other demands on hospital capacity: an increase in attendances at and particularly admissions from A&E; a dramatic rise in the number of delayed transfers of care; and bed occupancy levels that are running at above 90 per cent.
When we look at waiting times data in more detail it is clear that the longest waits are for surgical specialties. To alleviate some of this pressure the NHS can (and does) outsource some of these surgeries to the private sector, and there is evidence (£) that this is happening more. However, there are limits to what the private sector can do, both in terms of capacity and the complexity of patients – many smaller independent sector hospitals are not equipped to deal with more complex cases with multiple co-morbidities. How much activity to outsource to the private sector has always been a contentious issue.
The increasing challenges to referral-to-treatment performance highlight the competing pressures local health systems are under. While reducing elective work in providers may benefit A&E performance by allowing more emergency patients to be admitted, it also results in longer waiting times for elective care, missed national targets, and reduced income for providers. Increasing capacity to the levels required to meet the referral-to-treatment standards, on the other hand, could result in more outsourced work, more pressure on clinical commissioning group budgets, and reduced capacity to meet the four-hour A&E standard.
Recent media attention has focused on A&E departments and funding of social care, with rather less attention on patients waiting to begin elective care. Meanwhile, the waiting list and waiting times continue to grow. Difficult choices lie ahead.