Ahead of the general election on 8 June, we examine the big issues around health and care.
What’s the issue?
The NHS has some of the most challenging performance standards in the world. These standards cover a range of services including ambulance response times, new measures on access to certain mental health services and waiting times for diagnostic tests as well as the more high-profile waiting times on A&E and on referral for elective treatment and cancer services.
The data for 2016/17 shows that performance was below the set standard for many of these indicators, while data over a number of years shows that, in general, performance has been deteriorating across the board. The performance standard for ambulances responding to the most critical calls has not been met for the past 21 months, the A&E four-hour standard for 20 months and the 62-day cancer standard for more than three years.
What’s behind this?
Access to NHS services has improved greatly over the past two decades, in part due to the introduction of these standards but also due to investment and reform in the early 2000s. For example, before this it was common for many patients to wait more than a year for elective treatment.
The NHS Constitution sets out principles and values for the NHS, which includes the right for patients to access certain services within maximum waiting times. The list of services made under this pledge includes three high-profile standards: for A&E waits and for referral for elective treatment and cancer services.
Accident and emergency
The current A&E standard is for no less than 95 per cent of patients attending A&E to be admitted, transferred or discharged within four hours. This standard was met in 2012/13 (95.9 per cent) and 2013/14 (95.7 per cent) but has been missed for the past three years, with performance deteriorating each year to 89.1 per cent in 2016/17. For major A&E departments (those providing 24/7 consultant-led care), performance was worse, with only 83.7 per cent of patients spending less than four hours in A&E.
While performance has been slipping, activity in A&E departments has been increasing. Between 2012/13 and 2016/17 the number of attendances at A&E departments increased by more than 1.6 million (7.5 per cent) and the number of emergency admissions from A&E increased by more than 481,000 (12.7 per cent).
Combined with increasing demand, delays in admitting and transferring patients have been affected by a squeeze on hospital resources; bed occupancy rates have increased while the number of hospital beds has decreased, which affects how quickly hospitals can admit and treat patients. Delays within the NHS and cuts to social care funding have also had an impact on how quickly hospitals can discharge some patients
The Next steps on the five year forward view prioritises meeting the A&E standard over the 18-week elective treatment standard in 2017/18. To access the sustainability and transformation funding money in 2017/18, hospitals must improve A&E performance; the intention is for the NHS in England to achieve an aggregate A&E performance of 90 per cent by September 2017, with the majority of trusts meeting the 95 per cent standard by March 2018.
Elective care: 18-week referral-to-treatment
Since April 2012, the standard for elective care is for at least 92 per cent of patients to begin treatment within 18 weeks of referral. The standard was met from 2012/13 to 2015/16, though performance worsened. The NHS missed the standard for the first time for the full year 2016/17.
The number of patients receiving elective treatment has grown from around 14.2 million in 2012/13 to 15.7 million in 2016/17, an increase of 11 per cent. The total elective waiting list in April 2012 was 2.5 million; by March 2017 this had increased to 3.7 million, an increase of 51 per cent.
The increase in activity is affected by changes in clinical practice, not just increased demand. The number of on-the-day surgical cases has increased in recent years, which reduces the need for overnight admission and allows more patients to be treated.
Recognising the pressures on the service, NHS leaders have acknowledged that the service cannot currently meet the standards for both elective and emergency care. The 18-week elective treatment standard has effectively been downgraded. The government’s current mandate to NHS England does not specify performance standards for elective care in 2017/18, and Next steps on the five year forward view notes that the average waits for routine care may now increase.
Cancer: 62 day wait for first treatment for cancer, following an urgent GP referral
There are a number of standards for accessing cancer treatment. The most prominent of these is the standard that at least 85 per cent of patients should begin treatment for cancer within 62 days of an urgent referral from their GP. From its introduction in 2009/10 to 2013/14 this standard was met; however, it has been missed every year since. Performance has deteriorated each year, and in 2016/17 was at its lowest ever with 82 per cent of patients beginning first treatment within two months.
Since 2012/13 the number of patients beginning cancer treatment within two months has increased, from around 103,000 in 2012/13 to around 120,000 in 2016/17, an increase of 16 per cent.
The King’s Fund view
Key performance measures for hospital services are being missed on a regular basis. The NHS is treating more patients than ever before, with activity increasing across the board.
Waiting lists for elective care, and the number of patients who have not been treated in A&E within four hours or received cancer treatment within 62 days from GP referral, have increased. But the volume of elective care and the number of patients who have been treated within the cancer treatment standard has also increased, reflecting the overall increase in demand for NHS care.