What we think
While rising demand for services means that the NHS is treating more people than ever, even before the Covid-19 pandemic patients were waiting longer for the care they need. Many of the flagship national standards have not been met for several years, eroding improvements that had been made over more than a decade and breaching commitments made to patients in the NHS Constitution. Covid-19 has substantially contributed to growing waits for routine care, with many services paused or operating at reduced capacity because of the pandemic.
The five-year NHS funding deal announced in 2018 was not enough for performance to recover against these standards while also developing new and better services. Taken alongside staffing shortages, this means there was little prospect of performance being restored across the board, before the pandemic struck. It will be several years before access targets are met again so trade-offs are inevitable. Politicians and national leaders must decide which areas to prioritise and be honest with the public about the knock-on effects on the care they can expect to receive.
Current waiting time standards are mainly focused on acute hospital services, although access standards for some mental health services were introduced in 2015. Waiting times standards are currently under review, but while this review will result in changes to the current targets – A&E, planned hospital care and cancer treatment – it is unlikely to fundamentally change their focus and will not address the underlying issues that have led to people waiting longer. More broadly, as the current standards focus on access to acute hospital services they are not suited to measuring whether care is properly co-ordinated; measures need to be developed to better reflect performance across the whole system.
The NHS has some of most ambitious waiting time standards in the world. These set out the maximum amount of time most patients should have to wait to access ambulance, cancer, some mental health, planned hospital care and A&E services. Many of these standards were introduced under the Labour government (1997–2010) to provide a greater focus on performance and to capture the anticipated improvements from the increased levels of investment in the NHS at the time. Since their introduction, a number of standards have been enshrined as pledges and rights in the NHS Constitution.
Waiting time standards can sometimes create perverse incentives by focusing attention on a limited number of services and measures. However, they can be an important tool to measure and improve NHS performance and provide accountability to patients and the public, and they remain popular with the public.
However, key waiting time standards were routinely being missed all year round even before the Covid-19 pandemic, leaving people waiting longer for care. The prolonged funding squeeze on the NHS since 2010, together with growing demand for care and staffing shortages, led to significant deterioration in performance across the board; it is now more than four years since the 18-week referral-to-treatment standard for planned care was last met, more than five years since the national four-hour A&E standard was met and more than six years since the 62-day cancer treatment standard was met.
During 2020, many routine NHS services were paused during the peaks of the Covid-19 pandemic. Even with substantial efforts to restart services in periods of lower pressure from the pandemic, waits for care have continued to grow. By December 2020, there were more than 220,000 people waiting more than a year for routine planned care, compared to only 1,500 people in December 2019.
The new five-year funding settlement for the NHS, and additional funding given to health services to respond to Covid-19 by procuring extra capacity from the independent hospital sector, will go some way to relieving pressures on the service. But because of the scale of the backlog of care and continued workforce shortages, it will take several years before access standards are routinely met again. This means difficult trade-offs between priorities will continue to be made.
A clinical review of the main NHS access standards is currently under way. The interim report proposed changes to how waiting times for A&E, routine hospital, cancer and mental health services will operate in future. Following testing in some parts of the NHS, proposals for new measures of A&E performance are now undergoing public consultation, though new measures for other areas of care will remain under development.
Other aspects of NHS performance have also suffered as of a result of constrained budgets and staff shortages in recent years. There is evidence that access to and quality of primary care and parts of community and mental health services have deteriorated, but the absence of similar targets in these areas means the decline in performance has been less visible. As health and care services and policy evolve, and the scale of the restoration and recovery effort following Covid-19 becomes clear, national standards will need to be examined regularly to ensure they are the best reflection of performance and ambitions for high-quality, co-ordinated care for patients.