Although this way of looking at the world provides simplicity and clarity, most national targets are blind to how long patients wait once the target is missed – after all, the A&E target has been equally missed whether a patient waits for four hours and five minutes in A&E or seven hours and five minutes. So as most of the media attention and national focus in the NHS remains on measuring how many patients are missing the target and wondering when (or if) the NHS can once again hit its targets, we may be losing our focus on how long patients are actually waiting for care.
If we go back to 2012/13, 95.9 per cent of patients spent four hours or less in A&E departments, meeting the ‘95 per cent’ standard. By 2016/17, performance had fallen to only 89.1 per cent, but perhaps more worrying was what happened to the 95th percentile – the actual time by which 95 per cent of patients are seen in A&E departments. Figure 1 shows that although there has been relatively little change in the average (‘median’) time spent in A&E departments, in December 2017 95 per cent of patients were seen within 8 hours and 49 minutes – far above both the target of four hours and the average levels of a few years ago. The same data set shows that the number of patients waiting more than 12 hours in A&E departments has also ballooned from 66,000 in 2012/13 to 262,000 by 2016/17.
Source: NHS Digital
While this detailed A&E data comes with health warnings over its quality and coverage, a similar pattern of lengthening long waits is evident from separate national data on ‘trolley waits’ – the time patients spend in A&E after a decision has been made to admit them to hospital, until they are actually placed in a hospital bed. Twelve-hour trolley waits happen to fewer than 0.1 per cent of emergency patients admitted to hospital, but these waits were once considered anathema (and colloquially referred to as ‘P45 waits’ for their ability to lose managers their jobs) and yet the number of people experiencing this type of delay has exploded from 129 in 2011, to nearly 2,800 in 2017. In January 2018 alone 1,043 patients experienced a 12-hour trolley wait – the highest number on record and comparable to the number of these waits we used to see over an entire year.
Source: NHS England (December 2017). Notes: From December 2015 onwards, data on trolley waits was revised to include patients who are transferred to another provider. NHS England estimates that up to 9 per cent more patients per year may be brought into the data collection due to this change.
If we turn to the target for 92 per cent of patients to be seen within 18 weeks of referral, the news is only marginally less worrying. We already know the target has not been met since February 2016 but looking at the target another way we can see the 92nd percentile (the number of weeks by which 92 per cent of patients are seen) has lengthened from 16.2 weeks in December 2012 and is now 21.3 weeks, with reports of older patients already enduring longer and painful waits for urgent hip operations.
For patients on hospital waiting lists, the longest waits can last more than a year. Fewer than 0.05 per cent of patients wait this long for care, but both the recent February 2018 NHS planning guidance and an August 2014 speech by the Secretary of State for Health and emphasised a zero tolerance approach to year-long waits for routine treatment. In his 2014 speech Jeremy Hunt noted, ’A year is a very long time to wait if you are immobile, in discomfort or in pain… I want this number of people waiting more than a year for their operation to be not in the thousands, not in the hundreds, but as close to zero as possible’. However, this has not stopped the number of patients waiting more than 52 weeks from rising from hundreds to thousands, and reaching levels we haven’t seen for more than five years (Figure 3).
Source: NHS England (December 2017)
So, what are we to make of all this? First, the story of lengthening waiting times in the NHS is not a uniform one in which everyone equally waits ‘just a little longer’ to receive care – we have seen sharp increases in the longest of the long waits for A&E and routine consultant care as services struggle to cope with increasing demand, austere funding and chronic workforce challenges.
And second, there has been a variable national focus placed on tackling these figures for people who have waited a long time – and we know that what gets measured matters. Renewed efforts have been made to tackle year-long waits for routine care, and the ambulance service has moved to measuring both average waiting times and the 90th percentile as part of wider moves to address ‘hidden waits’ for care. But the four-hour ‘pass or fail’ target remains king in A&E departments, with efforts to focus on treating people who have waited longest failing to gain traction and relatively little focus placed on how long patients wait for care in other time-critical areas such as medical assessment units. We know these delays are not simply inconvenient but potentially dangerous, with the Royal College of Emergency Medicine noting risks to patient safety from long waits in emergency departments.
This combination of factors poses an increasing risk as national targets increasingly become rules more honoured in the breach than the observance – the most recent NHS planning guidance expects the four-hour A&E standard will only be met once again in the course of 2019, and the document does not even include the words ’18 weeks’ when discussing referral-to-treatment standards. The NHS Constitution was established in 2012 to clearly and publicly set out the rights patients can expect on accessing timely NHS care. Unfortunately, we now seem further away from these commitments than at any point in the past five years.