Key points
- While the pandemic’s full impact on access to elective care in England is still emerging, this long read uses routine data on 18-week waiting times for consultant-led elective care to look at what we know so far.
- Before the pandemic, meeting the 18-week standard would have required the NHS to treat an additional 500,000 patients a year for the next 4 years – an unprecedented increase in activity, which looked unrealistic before COVID-19 and looks even harder now.
- The number of people waiting for consultant-led elective care was 4.2 million in August 2020, around 196,000 less than at the end of 2019 (4.4 million). But this is only the case because the 32% reduction in the number of elective care pathways completed was exceeded by the 34% reduction in the number of new pathways being started.
- From January to August 2020, the specialties with the greatest reductions in new pathways were oral surgery, trauma and orthopaedics, and ophthalmology (42%, 42% and 40% lower respectively than in the same period in 2019).
- The impact of COVID-19, and the response to it, have been felt across the UK but more acutely in some parts of the country. Similarly, while the pandemic has already had a stark effect on the waiting list at national level, there are signs that access to elective care has been better in some parts of England than others. This includes regions with lower rates of the virus after the initial peak, which may have also faced fewer difficulties in restarting routine hospitals services.
- With returning to the ‘old normal’ unlikely to be enough, more radical options are now under consideration. This includes giving full consideration to the role the independent sector can play, while acknowledging the sector is unlikely to be a suitable option for all patients in all regions of England.
- Every day that activity lags behind demand, the backlog will continue to grow. With the government due to announce the results of a Spending Review, the impact of postponing elective care on millions of people, the extent of the backlog the NHS will face, and the new measures needed to address it, should all be taken into account when making decisions about future NHS funding.
The first factor is the rate at which clinical pathways are completed and patients are removed from the waiting list – usually when a definitive treatment is carried out, a clinical decision is made that treatment is not required or the patient declines treatment. During the initial peak of the pandemic, the number of completed pathways fell substantially. From January to August 2020, a total of 7.6 million admitted (inpatient and day case) and non-admitted (outpatient) pathways were completed – 3.5 million fewer than the 11.1 million completed in the same months in 2019. By any standard, a substantial reduction in activity – but, given the circumstances, continuing this volume of treatment was a major achievement. Had hospitals been overwhelmed by COVID-19, the reduction would have been even larger.
The 18-week standard covers all consultant-led elective care, with procedures reported at specialty level. Figure 2 shows the specialties with the largest slowdowns in the number of new pathways so far in 2020, as well as those with the smallest reductions. From January to August 2020, the greatest reductions were in oral surgery, trauma and orthopaedics, and ophthalmology – 42%, 42% and 40% respectively lower than January to August 2019. The smallest reductions in completed pathways were in dermatology (24%), neurology (17%) and thoracic medicine (21%).
Figure 2:
The second factor that determines the size of the waiting list is the rate at which new pathways are started and patients are added to the waiting list – usually via a referral made following a GP appointment. With many hospital services closed to all but urgent referrals, the number of patients starting new pathways also fell sharply during the initial peak of the pandemic. From January to August 2020, 8.9 million new pathways were started – 4.7 million fewer than the 13.6 million started in the same months in 2019.
Figure 3 shows the specialties with the largest slowdown in the number of new pathways so far in 2020, as well as those with the smallest reductions. The biggest reductions were in the same specialties where completed pathways fell the most – oral surgery (43% lower than the same months in 2019), trauma and orthopaedics (42% lower) and ophthalmology (41% lower). The smallest reductions in new pathways were in thoracic medicine (29%) cardiothoracic surgery (29%), neurosurgery (29%) and urology (28%).
Figure 3:
Prior to the pandemic, the waiting list had grown steadily from 3.3 million at the end of 2015 to 4.4 million at the end of 2019. In simple terms, this is because new patients were added to the list faster than those already waiting were being treated. So far in 2020, however, the waiting list is slightly smaller than at the end of 2019 – but only because the reduction (32%) in the number of pathways completed was exceeded by the reduction (34%) in the number of new pathways being started.
This situation is unlikely to last. Patients on the waiting list are already experiencing delays caused by the pandemic – 1,959,684 (46.4%) of those waiting had already exceeded the 18-week standard by the end of August, almost three times more than August 2019. The specialties with the highest percentage of patients who had waited over 18 weeks were oral surgery (68.0%), ophthalmology (58.2%) and ear, nose and throat (56.2%). In total, 111,026 patients had waited longer than 52 weeks – compared with just 1,236 in the same month in 2019. In parallel, the most plausible reason for the sharp drop in new pathways is that the pandemic has created new barriers to accessing elective care, which has been the fastest growing area of NHS activity for the past two decades.
The health concerns that would, in normal circumstances, have prompted people to seek care and be referred to a specialist have not simply disappeared. The Care Quality Commission (CQC) has highlighted the ‘huge pent-up demand’ caused by the pandemic. The big unknown is how much of this demand will return and when. Most new pathways start with a referral made following a GP appointment. GP services remained open throughout the pandemic, but – with most routine hospital services suspended – GPs were unable to refer as many patients as normal. This means GP practices were forced to either hold onto referrals until services reopened, or ask patients to wait and get back in touch later if a referral was still needed.
There is also some evidence that fewer people used GP services during the pandemic. Our public polling with Ipsos MORI, conducted in May, found one in five people felt uncomfortable about using local GP services during the pandemic, mostly due to concerns about catching COVID-19. NHS Digital has also reported a reduction in appointments in general practice, although this may be something of an underestimate as data quality was affected by the shift to remote appointments.
If the ‘missing’ 4.7 million new pathways are added onto the current waiting list of 4.2 million, the prediction of 10 million by Christmas suddenly does not look so farfetched. At least some of this suppressed demand is likely to return – as more services reopen to referrals, as more people go back to their GP, or if people present in A&E because their condition has deteriorated for lack of treatment. Depending on when and how that happens, the waiting list could start growing very quickly.
In the initial phase of the pandemic, the number of patients in hospital with COVID-19 peaked in April. Although London bore the initial brunt of the first outbreak, the London region had by far the smallest reduction (50%) in completed pathways in April 2020 compared with the same month in 2019. Other regions experienced reductions ranging from 55% in the South East and North East, to 58% in the South West, 60% in the Midlands, East of England and North West. Pathways commissioned by NHS England had the smallest reduction in April with 37% fewer completed pathways compared with April 2019.
Similarly, during the year to date, all regions experienced a comparable reduction in the number of new pathways being started compared with 2019. Figure 5 shows the lowest reduction (29%) was in the South West, which reported relatively lower levels of COVID-19 cases and hospitalisations. Elsewhere, the reduction in new pathways ranged from 33% to 37%. Pathways commissioned by NHS England saw the smallest reduction with 37% fewer new pathways than 2019.
Figure 5:
Substantial progress has been made in reopening services since April, although activity remains well below the level prior to the pandemic. The South West and East of England are the regions closest to returning to pre-pandemic levels of activity. In the South West in August, the number of completed pathways was 31% below the same month in 2019 and the number of new pathways was 26% lower. In the East of England, completed pathways were 31% lower and new pathways just 18% below the level reported in August 2019.
The North West and South East were the regions furthest away from returning to pre-pandemic levels of activity by August, with completed pathways 38% below those reported in August 2019 and new pathways 32% below. London and the Midlands were the regions next furthest away from pre-pandemic numbers of new and completed pathways. In August 2020, pathways commissioned by NHS England saw a greater reduction than any of the regions with a 43% reduction in complete pathways and 38% reduction in new pathways.
While the majority of independent sector providers of acute care are rated ‘Good’ (78%) or ‘Outstanding’ (9%) by the CQC, many providers have focused on winning high volumes of common procedures for lower risk NHS-funded patients. This was highlighted as a common, albeit not universal, business strategy in a 2014 review of the private health care market by the Competition and Markets Authority. This means independent sector providers may not all be equipped to treat more complex patients or to deliver the full range of procedures performed in NHS hospitals.
A further consideration is the geographical distribution of independent sector providers. Of the 144 non-NHS providers registered with the CQC as hospitals, 89 (62%) are located in the South East, South West, London and East of England. The South East and South West made the greatest use of independent sector providers in 2019, with the sector accounting for more than 10% of the pathways completed in both regions. Location alone, however, does not fully account for regional differences in the use of the independent sector prior to the pandemic. The least use of the independent sector was in London, which may be partly due to the capital having more providers aiming to attract privately-funded patients rather than those referred by the NHS. While there are independent sector hospitals in every part of England, the providers willing and able to take publicly funded patients are unlikely to be distributed evenly across the country.
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