This long read was produced during the 2019 General Election.
- Essential parts of the NHS in England are experiencing the worst performance against waiting times targets since the targets were set. This includes the highest proportion of people waiting more than four hours in A&E departments since 2004, and the highest proportion of people waiting over 18 weeks for non-urgent (but essential) hospital treatment since 2008.
- The target for treating cancer patients within 62 days of urgent GP referral has not been met for over 5 years, and survey evidence suggests more people are experiencing lengthening delays in getting GP appointments.
- Longer waits are a symptom of more people needing treatment than the NHS has the capacity to deliver. This reflects a decade of much lower than average funding growth for the NHS and workforce shortages, coupled with growing and changing population health needs. These pressures are exacerbated by cuts to social care and public health budgets, which make it harder to keep people healthy outside hospitals.
- It will take sustained investment in the NHS and social care to reverse lengthening waits. This will include filling existing staff vacancies and growing the workforce, investment in buildings and equipment, and stabilising the social care sector.
- If the NHS is to achieve its long-term vision of a service that can prevent ill-health, better manage long-term conditions, and treat people earlier, NHS staff will need time, space and skills to make change at all levels of the health and care system.
NHS waiting time performance has dominated public and political debate since the late 1990s. In 1999, more than 50,000 people were waiting more than a year for hospital treatment – it is now just over 1,000. It was the 1999 death of a 38-year-old patient in the north of England, on a waiting list for cardiac surgery, that galvanised the Labour government to inject more money into the NHS, at growth rates not repeated since.
Essential parts of the NHS in England are experiencing the worst performance against waiting times targets since the targets were set. While it is important to look at other aspects of the quality of care beyond waiting times, the persistently downward trend against these targets is a barometer of the wider pressures the health and social care system is facing. It is a signal that the NHS is unable to meet patient needs with the resources it has available.
The current picture
The NHS features prominently in news headlines at election time, with waiting times a key aspect of debate. This long read takes a closer look at the performance of the NHS in England against key waiting times targets from 2010/11. We aim to put the performance into some context, pointing to data and research on why waiting times have increased and what effect this might be having on patients.
Fixing long waiting times to see a GP was one of the first promises made by Boris Johnson when he became Prime Minister, stating, ‘My job is to make sure you don’t have to wait 3 weeks to see your GP.’ It is not clear how long patients wait for GP appointments. A survey of 900 GPs earlier this year suggested average waits for non-urgent appointments were now over 2 weeks, but there are no national data to show change in waiting times for the nearly 7,000 GP practices across England.
Until very recently, there has not been data on the volume of appointments taking place in general practice. In December 2018, the NHS began publishing data collected directly from some GP IT systems. This does not capture all the activity within general practice but gives a rough picture of the volume of appointments. According to the most recent data for September 2019, there were 26 million appointments in that month, of which 41% took place on the day they were booked, 7% on the next day, a further 34% within 2 weeks and another 13% within between 2 weeks and 1 month.
These data cannot tell us whether patients wanted to be seen within the times they had booked for them (some may have wanted later appointments). The next best source of information is the annual GP patient experience survey, which collects views from over 770,000 people, including a sample of registered patients from every practice in England.
The chart below shows how responses to selected questions from the GP patient survey have changed over time. Most people (83%) report a good overall experience (down from 88% in 2012), but the survey also shows evidence of increased problems getting appointments, with more people reporting problems contacting their GP practice, lower likelihood of seeing their preferred doctor and poorer overall experience of making an appointment. This is consistent with the thousands of patient experiences from across England recorded by Healthwatch.
The picture for hospital care is clearer than for general practice. Data are collected on waiting times because the NHS is required to treat both urgent and non-urgent patients within a range of target time limits.
The number of people waiting longer than the target time in A&E has steadily increased since 2010/11. The chart below shows that the target to admit, discharge or transfer at least 95% of people within 4 hours of arriving in A&E has not been met since the second quarter of 2014/15. Performance fell to a record low of 83.6% in October 2019, before the anticipated pressures of winter and seasonal flu set in. What is notable about this year’s data is that the normal ‘recovery’ of performance over the summer has not taken place, suggesting pressure has not alleviated within the year.
This chart also shows a substantial increase in the number of attendances at A&E departments since 2011. A total of 24,826,981 people visited A&E departments in England in 2018/19 – up from 21,481,402 in 2011/12. Not all the growth in A&E attendances has been driven by major (type 1) A&E departments, with minor (type 3) A&E departments having seen a higher relative growth in footfall. Over 99% of people were seen within the 4-hour target time in minor (type 3) A&E departments in 2018/19, in comparison to 81.4% in major (type 1) A&E departments.
For cancers, waiting time targets have been progressively rolled out since the mid-2000s, designed to speed up the process of diagnosing (or ruling out) cancer after a GP referral and beginning treatment.
The chart below shows that the principal target that at least 85% of people should begin treatment within 62 days of being referred with suspected cancer has not been met since 2013/14. In 2018/19, performance hit a record low with only 79.1% seen within the target time. This is on course to fall even further in 2019/20. The number of people being treated within target times has increased since 2010/11, but so has the number waiting longer.
The number of GP referrals for people with suspected cancer has grown. Where GPs suspect cancer, at least 93% of people should see a specialist within 14 days of the referral. In 2018/19, 2,245,524 people were referred on this pathway, an increase of 125% from the 999,038 referred in 2010/11. Capacity has not kept pace with this increase in demand and performance against the 14-day target was 92% last year.
Beyond emergency and cancer care, there are targets for other kinds of non-emergency consultant-led care.
Under the NHS Constitution, patients have a legal right to start treatment within 18 weeks of a GP referral unless they choose to wait longer or there is a clinical reason for doing so. At least 92% of people waiting for elective care are expected to have waited for 18 weeks or less from being referred by a GP. At the end of 2018/19, 86.7% of people had been waiting for 18 weeks or less (see chart below) – down from 94% in 2012/13 when this version of the 18-week target was set.
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.
Most similar countries either do not have waiting time targets or, if they do, they are not comparable. International data collected on waiting times for certain types of surgery show that the UK is not an outlier: it was 6th out of 16 OECD countries for knee replacement and 8th out of 16 for cataracts in 2017.
Waiting times and access to treatment are one important dimension of quality, but not the only one. It is not possible to give a full description of quality in this long read, but comparisons with other developed countries give a mixed picture (Figure 5), with some better performance (for example, rates of flu vaccinations in older people or fewer hospital admissions for diabetes) and worse than average in others (for example, admissions for asthma).
Priorities for the next government
Recovering performance against targets will require initial investment to stabilise staff numbers, increase the workforce in key services, and increase investment in buildings and equipment.
For general practice, staff shortages of GPs and practice nurses need to be reversed. Setting rigid waiting time targets is unlikely to be the right approach as patients need a combination of continuity and quick access, and this varies by area. Investment in the workforce will need to happen alongside investment in buildings and premises. It is vital to ensure resources reach those general practices where need is greatest.
Improving emergency hospital waiting times will require a sustained focus on multiple parts of the system, including staffing within A&E but also the management of patients across hospital departments, particularly services to enable patients to leave hospital safely. This, in turn, needs an urgent solution to social care services, which are understaffed, unstable and unable to meet the needs of older and younger adults.
Longer-term solutions to keeping people well, preventing deterioration of illness and finding more efficient ways to manage patients’ journeys through the NHS do exist. However, these will require hospital staff and managers to have the time and skills to stand back and find ways to redesign services, so patients avoid long delays and are prevented from reaching crisis points that require hospital admissions.
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