Insight into the target to reduce 78-week waiters to zero

At a glance

• The latest data release showed that 48,961 patients are already waiting over 78 weeks for elective care, as of the end of November 2022. To reach the target of reducing this to zero, the NHS must treat not only this number, but also those people who will have been waiting longer than 78 weeks between the end of November and the April deadline, which could total as many as 218,000.
• An NHS England letter sent on 12 January, asked trusts to ensure all patients in the 78-week cohort without a decision to admit have an appointment booked  before the end of January, and that those with a decision to admit should have a first definitive treatment scheduled before the end of March 2023.
• There are a number of potential constraints to achieving the target. These include industrial action, the uneven distribution of long waiters across the country, emergency care pressures (and their as yet unknown impact over December and January for which data is not published) and ‘unknown’ patients, where the level of care now required may not be known until clinical conversations are held with them this month.
• Yet with the continued extraordinary work of NHS staff, the target currently appears challenging but achievable especially following the latest validation of the lists, the focused work to tackle long waiters and the small exceptions of patients choosing to wait longer or requiring specific complex care.

Background

As set out in the delivery plan for tackling the COVID-19 backlog of elective care in February 2022, the ambition is that the service eliminates waits of over 18 months (78 weeks) by April 2023, and of over 65 weeks by March 2024. This followed the 104-week target from the 2021/22 planning guidance, which was largely met with some exceptions for patients who chose to wait longer.

More recently, NHS England asked organisations to book appointments for their 78 week cohort (patients who will breach by April) by the end of January, via a letter on 12 January. This (largely administrative) process aims to ensure that all outpatient appointments and admitted treatments are completed before the end of March.

This period, where a concerted push to treat long waiters is required, comes during a period of extreme pressure, with an emergency care crisis, huge challenges with hospital flow and industrial action. Yet NHS staff have been doing extraordinary work to tackle the elective and diagnostic waiting list alongside this crisis, achieving the first reduction in the absolute numbers on the waiting list in November.

In this article, we look specifically at long waiters and what will be required to meet the 78-week target by April, what the latest data reveals and what our members are telling us about the challenge.

How many people does the NHS need to treat in total?

Data released on 12 January 2023 (covering the period up to the end of November 2022) showed an estimate of 48,961 patients already waiting over 78 weeks, a marginal reduction from the end of October (50,124). However, this does not tell the full story.

The total number of people who need to be treated and come off the waiting list to meet the target by April could be as high as 218,617 (as of 30 November). This includes both the figure above (just under 50,000 patients) who have already waited over 78 weeks, and those will have waited that long by April. From 30 November, 18 weeks takes us to early April, meaning patients waiting 60 weeks or more fall into the cohort.

The chart below shows the cumulative effect of patients tipping over the 78-week threshold and therefore the total number of patients the NHS must treat to eliminate the number of people waiting more than 78 weeks by April:

What will it take to meet the target?

The elective activity required by trusts to reduce 78-week waiters at any one time depends on the rate at which people were joining the list in the period being targeted, i.e. 78 weeks previously. The rate of joining is not consistent so the size of the challenge can appear to vary depending on when you look at the waiting list.

For instance, looking at the task last year, headlines reported the NHS had slashed 78-week waiters from over 120,000 to 50,000, from September 2021 to mid-2022. However, this was as much timing as target activity - 18 months before 30 September 2021 takes you to the end of March 2020, during the first COVID-19 lockdown when numbers joining the waiting list were lower. Indeed, in the first 11 months of 2019/20 the average number of new joiners per month was over 1.72 million, but this fell to approximately 1.28 million in March 2020 and bottomed out at 536,751 in April. The result was that a much smaller number of patients needed to be treated to make inroads into the total cohort of 78+ week waiters in the middle of 2021 - in the month with the biggest reductions (October 2021), the numbers tipping over 78 weeks during the months were approximately 7,076, compared to 24,685 during November 2022.

The picture now, as we approach the deadline for achieving the target, is more challenging. The temporal advantage does not apply and the service is having to treat considerably higher numbers of patients to just tread water on the target. When the NHS made late progress to run through the backlog of 104-week waiters, there was the timing advantage to support meeting the initial target (also joiners at the onset of the pandemic in March 2020, versus a deadline in early 2022). Roughly, with as many as 218,617 patients to treat to reduce the cohort to zero (from the end of November), a rate of over 50,000 patients every month would be required to be treated.

Will the target be met?

Treating over 50,000 patients every month in this cohort until April appears to be a significant amount of targeted activity. However, there are some factors on trusts’ side. One is the impact of validating lists, which will be happening alongside the work to book appointments for the remaining patients. NHS England’s previous estimate is that on average, as many as 15 per cent of total removals from the waiting list could be ‘validation removals’ which are for reasons other than for treatment. This includes patients who may have had treatment already, no longer want to be treated, or were booked in twice. 15 per cent represents potentially over 32,000 who could be removed (based on the latest data) by simply validating their entry on the waiting list. This percentage could also be higher due to the added time patients have been waiting for care and the potential for changes in circumstances.

Furthermore, the expectation is the majority of 78-week waiters require only outpatient appointments. Data as of 30 November showed that just over a third of the relevant cohort (those already waiting 60 weeks or more) had a decision to admit. That is not insignificant but slightly better than the profile of 60+ week waiters at the end of June 2022, 41 per cent of who had a decision to admit, based on commissioning data. This suggests that the remaining cohort of patients could still be treated at relatively low levels of complexity. Alongside the drive to book in appointments for all long waiters, we believe the target remains challenging but within reach of being achieved.

Other factors to consider

The strike action so far has meant both outpatient and inpatient activity being rescheduled. With much still to deliver and only a small margin for error, industrial action could potentially affect the service’s ability to meet the target. The NHS Confederation is asking the government to come to the negotiating table to resolve this dispute as quickly as is possible.

Following the most recent round of strikes on 18/19 January 2023, there had been nearly 53,000 outpatient and over 10,200 inpatient cancellations. The average Royal College of Nursing strike day has seen fewer than 12,000 outpatient appointments rescheduled per day. For context, in 2021/22 the service delivered 122.3 million outpatient appointments and broadly (not allowing for the fact more activity takes place on a working day) over 335,000 appointments per day. Cancellations are concerning for the patients involved, but in terms of meeting the target, this disruption does not appear very significant, especially as many of the rescheduled appointments may not be for long waiters and they will likely be seen before the cut off of the target.

Where concern is warranted is for the small number of trusts who are facing a number of challenges simultaneously. They are struggling to deliver the target, are affected by the strike action and seeing intense operational pressures. A member in the north of England reported that the extreme pressure faced by some trusts at the start of this year resulting in Operations Pressure Escalation Levels (OPEL) 4 had led to cancelled elective appointments and lost ground against the target.

And another factor is the uneven distribution of 78-week waiters across the country. The latest release of provider data showed over 21,000 of the 48,000+ concentrated in the ten trusts with the most long waiters, meaning some NHS organisations will be under considerably more pressure than others. We have heard from our members, for instance in the north west and East Midlands, that alternative sites had been set up to mitigate this problem and allow earlier care for some patients but they were finding many patients unwilling or unable to travel out of their local area.

Our members have also flagged that the target has influenced decision making and could result in patients in the middle of the waiting list having to wait longer as longer waiters were prioritised. Certain specialties also have more long waiters than others (15.8 per cent of the 60 week+ waiters are in trauma and orthopedics compared to 11.3 per cent of the overall waiting list, and 10.6 per cent ear nose and throat, compared to 7.8 per cent of the overall waiting list, for example). One member told us the most challenging specialties require additional weekend theatre lists to ensure the target is met.

Conclusion

The target currently appears achievable and the positive elective performance in November is a testament to the hard work of the NHS workforce going into a difficult winter. We will need to wait to see the next set of official statistics to understand the impact of the deterioration in emergency performance on the elective recovery, and there are some unknowns in terms of whether the impact of strike action may increase the pressure on individual NHS organisations who have more long waiters and waiting list management issues.