78-week waiters: the story so far

Background

In January this year, our analysis looked at the progress systems had made to eliminate the number of people waiting for elective care of over 78 weeks and assessed the potential to reduce this number to zero by April. Since then, trusts have made substantial progress, although the figure for the end of March 2023 is 10,737.

A new data release on 11 May also broke the data down into ‘reason’ for delay. It shows that 21 per cent of the remaining patients had been offered a choice of another provider but did not take this up, or had chosen to wait longer than 78 weeks for ‘social’ reasons.

19 per cent are highlighted as ‘complex’, for whom it would not be clinically safe to move to another provider or for whom the procedure is clinically complex and can only be done on that site or by that clinician, while 2 per cent are waiting for a corneal transplant and directly affected by the global shortage of corneas.

The remaining 59 per cent do not fall into these categories and the reason is noted as ‘capacity’.

In September 2021, there were an estimated 124,911 patient pathways that extended over 78 weeks for treatment. The figure is now reported at 10,737, having been cut considerably from the 20,101 reported week ending 19 March. The above chart shows the trajectory of the two datasets we have available (the standard, referral-to-treatment dataset and the supplementary data that has been available on an ad-hoc basis).

We have spoken to some of our members about the recent work. In the latest release, Nottingham University Hospitals’ number of patients waiting over 78 weeks was 122, having been at 754 at the end of December, and 674 week ending 5 February, showing there had been a big push through 2023. The chief executive, Anthony May, told us:

At University Hospitals of Leicester, there have also been significant challenges. We heard from Richard Mitchell, chief executive at University Hospitals of Leicester, where the newly released number is 837 for 78-week pathways, having been as high as 3,500 last summer and still over 3,000 in January:

As highlighted in the quotes above, the amount of activity is not simply the reduction in the number of people already waiting more than 78 weeks. Systems must also treat people on pathways that are approaching the threshold to avoid them rising above 78 weeks. This represents a significant amount of activity to simply maintain the status quo.

The chart below shows how many pathways have tipped over the 78-week threshold each week since the end of January. At that point, the task wasn’t in the mid-40,000 range (the total number of 78 week waiters), and was actually in the 90,000-100,000 range needing to meet NHS England’s zero target by the end of March. This shows the significant amount of work in 2023 to now have the number at less than 11,000.

Mitigating factors

There have been a number of constraints on progress despite the progress made by systems.

One impediment was the particularly challenging A&E performance across December and January, meaning beds or staff sometimes needed to be diverted away from electives to tackle urgent and emergency care pressures. This has been exacerbated by challenges discharging patients, with high bed occupancy rates and a lack of capital investment over the last decade hampering abilities for the service to tackle the backlogs.

A second challenge has been case mix. Data showing the mix of patients to be treated is not available publicly, only the split of specialty, which does not indicate complexity. However, we know there was a significant drive to validate the waiting list and book outpatient appointments before the end of January, with outpatient appointments and treatments completed before the end of March. Remaining pathways are therefore likely to have had higher levels of acuity, with the potential to have risen since they were originally booked in.

The below chart uses the figures for case mix for the end of February, as there are some inaccuracies with the March 2023 'incomplete commissioner' data:

From publicly available data, it is hard to identify the exact impact of industrial action on the target, but we do know that over 57,000 operations have had to be cancelled and over 426,000 outpatient appointments due to strikes since December, with services having experienced disruption. In addition to reduced activity, industrial action will have had a wider impact on costs, productivity and resources which can affect subsequent recovery activity.

The burden of 78-week waiters is also not even. In the latest supplementary data release, we can see that 21 per cent of providers reported zero patients at the end of March, as per the target, while 69 per cent of providers (95 of the 137 in the data) had less than 50.

Conclusion

While the target has not yet been met, it is clear systems have made significant progress in treating those waiting the longest for care. That hard work should be celebrated especially alongside mitigating circumstances such as challenging case mix, emergency pressures, an uneven burden and disrupted services following industrial action, and noting the considerable volumes of patients tipping over 78 weeks during 2023 to date.

There are more challenges to come, too. The ambition is to eliminate waits of over 65 weeks by March 2024, and then 52 weeks by March 2025. The latter represents 4.9 per cent of the overall waiting list at the moment and these large cohorts may produce an even greater challenge, despite concerted efforts to eliminate 78-week waits helping to make inroads.