In a speech ahead of the Autumn Budget on 22 November, the Chief Executive of NHS England, Simon Stevens, has warned that without extra funding the improvements made in reducing waiting times for patients over the past decade will be reversed and the waiting list for elective treatment could increase to 5 million people by 2021. We examine the big issues and recent NHS performance on waiting times.
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 for elective treatment, A&E and cancer services.
The latest data for 2017/18 shows that performance remains 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 18-week referral-to-treatment standard for planned care has not been met since February 2016, the A&E four-hour standard since July 2015 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.
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. However, the NHS missed the standard 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 August 2017 this had increased to 4.1 million – this is the highest level for the waiting list since 2007.
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 it cannot currently meet the standards for both elective and emergency care. The 18-week referral-to-treatment standard has effectively been given lower priority. The government’s current Mandate to NHS England does not specify performance standards for elective care in 2017/18, and Next steps on the NHS five year forward view notes that average waiting times for routine care may now increase. In his speech to the NHS Providers 2017 annual conference, Simon Stevens suggested that the right in the NHS Constitution for patients to access elective treatment within 18 weeks may have to be abolished unless more funding is provided.
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. Over the second quarter (July to September) of 2017/18, 90.1 per cent of patients were seen within four hours, a slightly worse performance than the same period last year. For major A&E departments (those providing 24/7 consultant-led care), performance was worse, with only 85.2 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 (12.8 per cent). Between September 2016 and September 2017 emergency admissions to hospital increased by more than 3 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 to their highest ever recorded rates 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 NHS five year forward view prioritises meeting the A&E standard over the 18-week referral-to-treatment standard in 2017/18. To access sustainability and transformation funding money in 2017/18, hospitals must improve A&E performance; the intention was 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. The first of these milestones was missed by a small margin, with 89.7 per cent of patients seen within four hours in September 2017. Our recent quarterly monitoring report found only 28 per cent of NHS trust finance directors were very or fairly confident that the next performance milestone for March 2018 would be achieved.
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 level with 82 per cent of patients beginning first treatment within two months, and performance continues to be challenged in 2017/18.
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
The NHS is treating more patients than ever before, with activity increasing across the board. But key performance measures for hospital services are now being missed throughout the year. These pressures are being felt in all areas of care with general practice, mental health and community services also under strain.
The implications of the funding squeeze and rising demand on patients’ access to care are clear. The dramatic improvements achieved over the previous two decades are slipping away. Unless additional funding is provided, patients will wait longer to access the urgent and routine clinical care they need.