Analysis: NHS performance leading into winter

Overview 

Analysis

A&E attendance and admission 

A&E attendance and admission data can be very illustrative of the pressures in the wider healthcare system.  

...it seems likely that there will be a lot of pressure on emergency departments even if there weren't any seasonal peaks.

Looking first at A&E attendance, there were 2.36 million attendances at A&Es (all types) in October 2024. This is compared with 2.22 million in 2023 and 2.19 million in 2022, so notably higher than both. Indeed, October 2024 was the busiest October on record and was 5.9 per cent higher than October 2023, suggesting that A&Es are already seeing intense demand. Moreover, it is possible that it is not solely attendance figures that will put A&Es under significant strain this winter. Our members have highlighted that the aforementioned political pressure on improving category 2 ambulance response times could be detrimental to patient care in A&E departments. If a department is struggling to cope with this increased pressure, it may find that solutions such as increased corridor care are the only possible response.  

In terms of the A&E attendance trends over winter, there are not notable spikes in attendances in this time period. Indeed, with the exception of December 2022, winters in both 2023/24 and 2022/23 saw fewer attendances than the following spring of those years (March to May). 

When looking at emergency admissions, there were 567,000 in October 2024, compared with 547,000 in October 2023 and 507,000 in October 2022. Since the start of 2023, the trend has been an overall increase in admissions. October was the second highest number of emergency admissions on record, second only to March 2024. This, therefore, paints a picture of intense pressure in emergency departments.  

Similarly to A&E attendance, however, there is no notable trend for starkly increased admissions over the winter period in comparison with the surrounding months. However, it is possible that a pattern is masked by to the overall trend of increased attendances over time. It is noted that both 2022/23 and 2023/24 saw increased emergency admissions between October and January compared to the months around them, with September and February having lower admissions. However, given that the attendance figures are so high going into winter, it seems likely that there will be a lot of pressure on emergency departments even if there weren’t any seasonal peaks.  

Ambulance response times 

Ambulance response times are a key metric for NHS performance. We will focus on ambulance response times for two categories of calls: category 1 (life-threatening injuries and illnesses, such as cardiac arrest) and category 2 (emergency calls, such as stroke patients) as these constitute the highest priority responses.  

In October, category 1 calls were responded to in 8 minutes and 38 seconds. In October 2023 this was 8 minutes and 41 seconds, and in October 2022 it was 9 minutes and 56 seconds. This suggests that the NHS is in a better position going into winter than it has been in previous years, in terms of response times to category 1 calls. However, it is important to note that this response time remains above the target time of 7 minutes.  

In October 2024, category 2 calls were responded to in 42 minutes and 15 seconds. In October 2023 this was 41 minutes and 43 seconds, and in October 2022 it was 61 mins and 19 seconds. Although October 2024 was therefore a little slower than 2023, it was notably faster than 2022. It remained, however, considerably longer than the constitutional standard time of 18 minutes and the interim target of 30 minutes. 

Looking at the previous two winters, we can see that average response times for both categories were notably slower in December than in October or November, especially for category 2. The response times then improved again in January and February.  

Cancer waiting times

There are three key cancer performance metrics: 

Of the three targets above, the 28-day target is the only one which has ever been met. Since January 2024, this has been met six out of months months. Regarding the other targets, the average values since this data was first published in April 2022 is 90.8 per cent for the 31-day, and 65.3 per cent for the 62-day. This suggests that the 62-day figures are, on average, further from their target of 85 per cent than the 32-day target of 96 per cent.  

The most recent data on cancer performance is from September 2024. For the 28-day target, this figure was at 74.8 per cent, compared with 69.7 per cent in September 2023 and 67.0 per cent in 2022. While it has not met the 75 per cent target, this shows progress in comparison to previous Septembers. For the 31-day target, the most recent September figure is 90.6 per cent, compared with 89.5 per cent in September 2023 and 90.7 per cent in 2022. This shows that there has been relatively little variation for this metric over the years. For the 62-day trend, the September 2024 figure was 67.3 per cent, compared with 63.5 per cent in September 2023 and 64.2 per cent in September 2022. Similarly to the 28-day target, this shows improvement when compared with previous Septembers and suggests a positive position going into winter but remains a long way from its target.  

Looking at previous winters, it is interesting to note that each of the targets has had a different trend. The 28-day target has historically increased in the months from September leading to December, then dropped in performance in January, which was then followed by an increase in February which surpassed the figures from the pre-winter period. The 31-day target, however, while also seeing the drop in performance in January, saw the February figures largely in line with those from November. The 62-day target also sees this drop in January, with a small increase in February which then increased to a peak in March.  

Community waiting lists  

Community health services play a key role in the health and care system. They keep people well at home and in settings close to home, supporting people to live independently. These services include falls prevention services, sexual health centres and specialist nurses. Services are generally delivered in people’s homes but can also be in settings such as schools or community centres.  

When looking at waiting lists for community health services, it is only possible to compare September 2024 with September 2023, as the data only started in January 2023. In September 2024 there were 1.10 million people on the community waiting list (75 per cent of which were adults, 25 per cent were children). In September 2023, this figure was 1 million, showing an increase of nearly 100,000 people in this time, a 9.9 per cent increase. In fact, each month saw an increase of somewhere between 7.5 per cent and 14.6 per cent compared to the same month the previous year. This shows that, worryingly, the waiting list is growing longer in 2024.  

However, it is interesting that the waiting list from November 2023 to January 2024 was notably lower than the months surrounding them. Indeed, November’s waiting list was 4.2 per cent lower than October’s, and February’s was 4.0 per cent higher than January’s. It will be interesting to see if winter 2024/25 follows the same trend. If it does, this would go some way to mitigate the pressure seen by the monthly increases to the waiting lists seen throughout 2024 so far.  

Diagnostics 

When examining performance in diagnostics, a key statistic is the percentage of patients waiting longer than six weeks for diagnostic tests.  

In September 2024, the number of patients waiting longer than six weeks was 22.7 per cent. In September 2023 this figure was 26.3 per cent, and in September 2022 this was 29.8 per cent. It therefore looks like the NHS is in a much better position in terms of diagnostic testing than it was in previous winters.  

On examining previous winter trends, we can see that following September 2022 and 2023, October and November both saw a smaller proportion of patients waiting longer than six weeks. This then increased over December and January, before dropping to below November-levels in February. We can therefore expect to see a similar pattern over the coming months. 

GP appointments

To also explore demand for primary care services, the number of appointments in general practice (GP) was also examined. However, an important factor to consider when looking at this data is that GP collective action has been in place since August 2024. This means that although GP surgeries are still open and seeing patients, some work may be reduced and therefore there could be fewer appointments available.  

In October 2024, the estimated total number of GP appointments in England (which takes account of practices not included in the data) per working day was 1.68 million – the highest figure on record. In October 2023, this figure was 1.56 million and in October 2022 it was 1.53 million, showing a clear increase in the demand for GP appointments.  

...it is unknown what impact collective action will have...

While this already shows a challenging picture going into winter, collective action is expected to increase over the coming weeks, including the capping of appointment numbers and termination of unfunded specialised services and tasks (ie onward referrals). This is likely to affect the wider healthcare system. The experiences of NHS healthcare services data (available here) showed that of the patients who were unable to contact their GP, 7.4 per cent contacted 111, 6.8 per cent visited a pharmacy and 1.9 per cent visited A&E. It is therefore likely that services such as 111 and pharmacies will see increased demand over winter if there is more demand for GP appointments than there are appointments available.  

Looking at the winter trends for the number of GP appointments, the past two winters have not shown a spike in appointments over the winter months, even when accounting for bank holidays. In fact, localised peaks were instead seen in October, and a localised low point in December. It is not known if this decrease in December is down to a decrease in demand (with patients being away from home and thus away from their GP practice), or due to a lack of supply (with GPs themselves being away and thus not working).  

Although previous Octobers have seen an increase in GP appointments, and thus this increase is not unexpected, the peak seen in 2024 is notably higher than that seen in previous years. While previous years’ trends would suggest that the next few months will see fewer GP appointments per day than the 1.68 million in October 2024, it is unknown what impact collective action will have on this.  

Referral to treatment waiting lists ¹  

The referral to treatment (RTT) waiting list data contains information on the waiting times for consultant-led elective care. An RTT pathway refers to the length of time that a patient waited from referral to start of the treatment. If they haven’t already started treatment, it is referred to as an ‘incomplete pathway’ and is the length of time that the patient has waited from referral so far. Each pathway refers to an individual referral, rather than an individual patient, as a single patient can have more than one referral.  

The most recent data for RTT is for September 2024, when there were 7.57 million incomplete pathways. This was lower than the previous month and reversed a trend – between March and August 2024 when this number had increased each month. When looking at previous Septembers, September 2023 had the highest waiting list on record (7.77 million pathways), and September 2022 had 7.14 million. The figure for September 2024 therefore falls in between these two figures. 

Examining the previous two winters, in 2022/23, the waiting list increased a little between September and February, from 7.14 million to 7.22 million (equivalent of a 1.1 per cent increase). Conversely, in 2023/24, the waiting list appeared to decrease from 7.77 million to 7.54 million (equivalent of a 3.0 per cent decrease) (see the graph below). As a result, it is difficult to predict what will happen over winter 2024/25, but we can see that the waiting list is not currently at record levels and has improved from September last year. Moreover, it is possible that some elective activity could be postponed if there is extreme pressure on UEC services elsewhere in the system, which is yet another factor that complicates predicting the waiting list over winter. 

Conclusion 

This article has aimed to examine whether the NHS on a national level is in a better or worse position going into winter than it was last year. The answer to this question is nuanced buthere are some indicators that suggest the NHS is in a better position, such as diagnostics. Others, however, are in a worse position and indeed are cause for concern, such as A&E attendance. In fact, there is a fairly even split in the metrics examined here between improved, worse and generally consistent trends compared to the last two winters.  

Moreover, some areas experienced seasonal peaks in demand or performance over the previous two winters, such as category 2 ambulance calls, whereas others have not, such as the RTT waiting list. This is important because a large increase in demand over the winter months could have a large impact on performance in certain areas, even if their performance in autumn was reasonable. Further, due to the highly interconnected nature of the healthcare system, even if an area does not independently experience seasonal peaks in demand, it is likely to be affected by surges in other areas. The drops in performance for cancer and diagnostics, for example, are likely to be affected by pressure across other areas of the system.  

The worst-case scenario in this instance would be a metric that is simultaneously in a worse position to the previous two winters and also experiences seasonal peaks. However, this is not the case for any of these metrics. For example, community waiting lists are worse than they were in 2023, but they have previously seen a drop in the waiting lists over winter. Conversely, while the 28-day cancer target performance is better than it was in previous winters, there has historically been a drop in performance over these months.  

Despite the improved metrics in some areas of healthcare, from the trends we see, it appears undeniable that the NHS will face troubling surges in demand over the coming months and is, unfortunately, already facing record levels in some areas. As a result, the main cause for concern identified through this work is twofold: 

These two points of existing pressure, combined with the potential additional challenges caused by stress on ambulance services and GP collective action, could lead to a very difficult few months ahead.