While the NHS has increased the number of people it treats each year, the percentage of patients treated within waiting time standards continues to get worse for both elective (non-urgent care) and cancer treatment, and the waiting list for elective care continues to grow, according to today’s report by the National Audit Office.
The NAO has found that while increased demand and funding constraints affect the entire system, other factors that are linked to declining waiting time performance include NHS staff shortages for diagnostic services, a lack of available beds and pressure on trusts from emergency care.
The elective care standard aims for 92% of patients to be seen by a consultant within 18 weeks after referral. This was last met nationally in February 2016. In 2012-13, 94% of patients waited under 18 weeks after referral, but by November 2018 this had fallen to 87.3%.
The elective care waiting list grew from 2.7 million to 4.2 million between March 2013 and November 2018, while the number waiting more than 18 weeks grew from 153,000 to 528,000. During this period, the number of people treated each month increased from 1.2 million to 1.3 million.
Standards for cancer care were introduced to help improve early diagnosis of cancer and cancer survival rates – most of these standards were met until 2017-18. However, a key standard, that 85% of patients are treated within 62 days of an urgent GP referral for suspected cancer, has not been met since the end of 2013. In November 2018, only 38% of NHS trusts met this standard and between July and September 2018, 78.6% of patients were treated within this timescale.
Waiting time performance varies significantly across England. In 2017-18, the number of patients waiting less than 18 weeks for their elective care varied between 75% and 96% across clinical commissioning groups (CCGs). For cancer, between October and December 2018, the percentage of patients treated within 62 days following a GP referral differed across CCGs from 59% to 93%.
Elective care waiting times standards are being met for some specialties, such as general medicine, but not others, such as surgical specialties. For cancer, performance for lung, lower gastrointestinal, and urological cancers was significantly lower than other cancers.
The NHS’s inability to keep up with the growing number of referrals means that more people must wait longer for their treatment after being referred. Between the 12 months to March 2014 and the 12 months to November 2018, the number of annual referrals for elective treatment increased by 17%. Between 2010-11 and 2017-18, the number of patients referred urgently for suspected cancer increased by 94%. For the majority of months since April 2013, the NHS has treated fewer elective care patients than the number of patients referred.
A growing and ageing population only accounts for a relatively small proportion of the increase in referrals for elective care and cancer. For cancer, the major factor is likely to be NHS England’s policy of encouraging more urgent referrals to improve early cancer diagnosis. However, the reason behind the increase in elective referrals is less well understood by the NHS.
Constraints on capacity, including lack of finance, staff and beds, is linked with the decline in waiting times performance. The NAO found that there have been persistent staff shortages in diagnostic services and a widening gap between demand for these services and the number of staff working in these areas.
Despite increasing bed occupancy rates, the number of beds in the NHS has reduced by 7% (8,000) since 2010-11. While reducing excess beds may create efficiencies, after a certain point the capacity challenges this will introduce will impact on other resources such as staff and theatre usage.
Increases in the number of urgent referrals has improved early diagnosis of cancer. The proportion of all cancer patients diagnosed through urgent referrals increased from 31% in 2010 to 38% in 2016. Areas that are urgently referring more patients tend to have better survival rates. However, they are more likely to perform worse against the two-week waiting standard.
Given their clinical urgency, the Department of Health and Social Care and NHS England have chosen to focus on emergency care and cancer services more than elective care. In February 2018, NHS England and NHS Improvement asked trusts to ensure that in March 2019 their waiting lists for elective care would be no larger than at the end of March 2018, rather than explicitly requiring them to meet the 18-week standard as in previous years. A current clinically-led review provides an opportunity to improve the NHS’s approach to waiting times standards. The NAO estimates that it would cost the NHS an extra £700 million to reduce the waiting list to March 2018 levels, based on current trends.
Since almost 40% of clinical negligence claims are brought because of delays in diagnosis or treatment, there is a risk that longer waiting times may lead to increasing future claims. The NHS’s understanding in this area is limited.
The NAO recommends that NHS England and NHS Improvement should set out how they will address declining waiting time performance. They should also do research to better understand variations in performance, the impact of delays on patients and how performance is related to hospital capacity constraints such as bed capacity, and its links to other variables such as staff numbers and theatre usage.
“The NHS’s actions to increase the number of urgent cancer referrals are a positive step. They have helped to diagnose more patients at earlier stages, leading to better outcomes, even though this has meant that waiting times commitments for cancer care are no longer being met. “However, there has been insufficient progress on tackling or understanding the reasons behind the increasing number of patients now waiting longer for non-urgent care. With rising demand for care as well as constraints in capacity, it is hard to see how the NHS will be able to turn around this position without significant investment in additional staffing and infrastructure.”
Amyas Morse, the head of the NAO