The data also show that people are being added to the elective waiting list faster than the NHS can treat them. The total number of people on the waiting list is now over 4.5 million, having grown steadily from 2.5 million in April 2010.
Why have waiting times risen?
Waiting times are not the only dimension of quality but they do represent a barometer of broader pressures on the NHS and other services such as social care. The rise in waits reflects a mismatch between the resources that have been put into the NHS and the population’s need for such services, which has grown faster than funding over the past decade or so. This includes social care, which has experienced real-terms cuts: government spending on adult social care in England fell from an average of £346 per person in 2010/11 to £324 in 2017/18.
This increase in need has been felt in different ways in different parts of the service. It has been acute in general practice because the number of full-time, qualified permanent GPs and practice nurses fell between March 2016 and March 2019 (by 5% for GPs and 2% for practice nurses). Evidence suggests that the rate of consultations has grown faster than the population. The population has grown by 1% between June 2016 and June 2018.
Some of the population have more complex needs. The Health Foundation has estimated that over 14 million people now have more than two long-term conditions (such as diabetes or depression), affecting older people and younger age groups from more deprived areas: 28% of people aged 65–74 in the most-deprived fifth of England had four or more conditions, compared with 16% in the least-deprived fifth. Being able to see the same GP is essential for these groups, and can reduce emergency hospital admissions, but has become harder because of the pressure on general practice.
This increase in ill health has also been felt at the front door of hospital emergency departments. Health Foundation analysis has found that one in three patients admitted to hospital as an emergency in 2015/16 had five or more health conditions, compared with just one in ten in 2006/07.
The increase in the proportion of sicker patients arriving at emergency departments who subsequently need admission is one factor in longer A&E waiting times. Other factors include a greater range of tests performed than in the past and higher bed occupancy within the hospital, which in turn reflects the pressure on social care and NHS services in the community. However, unlike general practice, there has been an increase in emergency care doctors over time (a 21% increase in full-time emergency medicine consultants between March 2016 and March 2019). But the continuing waits suggest that the workforce growth has not been enough.
Pressures in emergency departments have affected waiting times for non-urgent care in hospitals, while some of the increases in waiting times for cancer are also the result of shortages of diagnostic equipment and in the associated workforce.
What has been the impact of longer waiting times?
It is difficult to tell from NHS data what impact longer waiting times has had on the health of patients. International studies on overcrowding in emergency departments have pointed to risks of increased errors, poor patient satisfaction and worse outcomes, including increased mortality.
In relation to cancer and non-urgent care, the Public Accounts Committee rebuked the national leadership of the NHS earlier this year for failing to collect data on the potential harm to patients caused by increased waiting times, observing that they ‘lack curiosity’. Although some hospital trusts collect data on potential harm, it is not captured centrally.
There is also limited information about services which are not subject to waiting time targets, for example mental health services for children and young people. Although there is a target for young people with eating disorders, set in 2016, other mental health services have variable waiting times (some of them long) and limited data to assess the impact on patients. A 4-week waiting time from referral to assessment is now being piloted.