What the latest data tells us about progress against targets

The targets

A range of NHS targets were set in the 2022/23 Priorities and Operational Planning Guidance and the Delivery Plan for Tackling the COVID-19 Backlog of Elective Care. To take stock of progress and in light of this month’s performance statistics release (published 16 June 2022), in this article we review several of the key milestones.

To begin, we look at elective care, including the service’s most immediate target to eliminate 104-week waiters by July; metrics on the effort to return waits for cancer care back to pre-pandemic levels; as well as the overall waiting list. We also look at the numbers around diagnostics and ensuring those who need it get started on a pathway to care.

Finally, we look at challenging urgent and emergency care environment and targets as a backdrop against which services are being asked not only to ramp up activity but achieve efficiencies along the way.

Electives: Eliminate waits of over 104 weeks as a priority by July 2022 and maintain this position through 2022/23 (except where patients choose to wait longer)

A key milestone in both the COVID-19 delivery plan for tackling the backlog of elective care, published in February, and planning guidance for 2022/23, was the ask for systems to eliminate waits of over 104 weeks (two years) as a priority by July 2022 and maintain this position through 2022/23 except where patients choose to wait longer. Last month, we showcased some of the  work our members have been doing to cut the numbers of long waiters. So what does the latest data show?

7,533 patients are waiting over 104 weeks as of the latest supplementary information released up until week ending 5 June. From a high of 23,778 at the end of January, this figure represents a decrease of over two thirds (68.3 per cent). Based on the January statistics from NHS England, by early June 53,276 patients would be waiting 104 weeks or more, meaning systems have treated over 45,000 patients to get this number down to 7,533.

Given the challenge of delivering this target at a system level (all trusts in a patch must have achieved it), as of the start of June few have already completely eliminated 104-week waiters (as of the latest data, this is three). There is a considerable amount of variation here: of the 42 integrated care systems (ICSs), nine have less than ten, 25 less than 100 but four systems have over 500. Trusts and systems have made huge strides in reducing the numbers but a small amount are unlikely to meet the July target without major intervention.

It is understandable that the systems for who the greatest challenges remain have larger trusts and more complex cases. However, these are also those making the largest inroads. The bulk of the reductions have been in the areas with trusts serving large populations and therefore lists.

The chart below shows the estimated number of patients to be treated before July (based on the supplementary information and referral to treatment waiting times data from NHS England). It shows 2,500 patients would be due to tip over the 104-week threshold before the start of July. This, added to the 7,533 patients already waiting over 104 weeks totals over 10,000 would need to be treated by early July to eliminate 104-week waiters. By the end of July to maintain this, the total goes up to 15,484. By the start of October this figure is nearly 40,000.
 

Our members have told us they have confidence in maintaining the low number of 104-week waiters after July but that it will require continued effort and focus. One common issue is the complexity of patients’ needs. As trusts reduce the number of 104-week waiters, the small cohort left is more likely to be patients who need highly specialist and complex procedures. This kind of care can take more time and has more scarce resource able to deliver it.

Cancer: Return the number of people waiting for longer than 62 days to the level in February 2020 (based on the national average in February 2020)

As of week ending 1 May 2022 (the latest data available), the national average of patients waiting over 62 days following an urgent referral is 27,083. This rose from 21,823 week ending 3 April, which means more people are waiting, up 95.9 per cent from the average before the pandemic in February 2020.

The national average of patients waiting over 62 days following an urgent referral from and including week ending 2 February 2020 to week ending 1 March 2020 was 13,825 per week. This rose as high as 34,050 in week ending 24 May 2020.

In February 2020, 74 per cent of patients treated following an urgent GP referral were seen within 62 days. In the latest data, this was 8,437 out of the 12,932 who had a first treatment, 65.2 per cent.

The service has worked hard to see more people, with demand for primary care extremely high and seeing ‘greater acuity’ with people presenting later with more complex issues. This is a trend reflected in cancer care, with the number of first appointments with consultants following urgent GP referrals increased significantly in 2021/22. Across 2019/20, 198,901 patients had their first appointments in an average month whereas the average for 2021/22 is 223,248. April was the highest on record with 204,818 people seen.

One member in the north of England highlighted that people not attending their cancer appointments (DNAs) were causing a big problem as they worked through their backlog of patients waiting, which they were looking to rectify. Another trust in the south east flagged that the complexity the treatment required for cancer patients was increasing, with some patients referred late in their pathway. Other members meanwhile highlighted successes with innovations such as state of the art mobile screening units, allowing systems to provide care to their local communities and catch lung cancer earlier than it would otherwise be caught in at risk populations such as current and ex-smokers.

Electives: The ambitions for patients are supported with a clear plan, aimed at delivering around 30 per cent more elective activity by 2024/25 than before the pandemic

Elective activity in April 2022 was 13.8 per cent lower than the pre-pandemic 2019/20 average, at 1.18 million completed pathways compared to 1.36 million (this average includes lower than average activity in March 2020 at the onset of the pandemic). A considerable rise in activity will be required to meet the target of an additional 30 per cent on top of 2019/20 levels.

In April 2019, there were 1.33 million completed pathways, with April’s number 11.3 per cent down on that. Although the fewer working days in April 2022 may have had an impact, this still represents a significant month-on-month reduction from March which saw 1.43 million completed pathways. Although it is complex to judge, we would expect activity to be increasing if we were seeing the ‘missing’ patients who did not present during the pandemic.

Based on the number of completed pathways, it is unsurprising to see an increase in the overall elective waiting list from 6.36 million to 6.48 million. New joiners to the waiting list stood at 1.5 million compared to 1.18 million who came off the list. The additional variance is down to ‘validation removals’ such as data issues or patients who should have already come off the waiting list.

Increase diagnostic activity to a minimum of 120 per cent of pre-pandemic levels across 2022/23 to support these ambitions and meet local need

In the first month with data available for this target, diagnostic activity is not yet where it needs to be, still at around pre-pandemic levels. However, this looks to be improving and there are good prospects for the target to be achieved over the next 11 months with the diagnostic waiting list falling and as new community diagnostic centres and other new initiatives are established.

By our calculations, the average number of diagnostic tests per month across 2019/20 was 1.94 million. Specifically, in April 2019, the figure was 1.92 million. By comparison, the April 2022 figure was 1.85 million, 95.5 per cent of the 2019/20 average. In April 2022, there were only 19 working weekdays compared to 23 in March (and 20 in April 2019), which could explain this variance.

Encouraging signs that diagnostic capacity will be able to recover and meet the target is that last month, March 2022, total activity surpassed 2 million for only the second time since the onset of the pandemic. Further, the number of people on the diagnostic waiting list fell from 1.57 million to 1.55 million this month.

The graph below shows where activity would be against a 19/20 average or 120 per cent of the equivalent month in 2019/20 based on 2021/22 too.

Urgent care: Systems are asked to reduce 12-hour waits in EDs towards zero and no more than 2 per cent

The total number of 12-hour waits is not available but figures for 12 hour waits from decision to admit to admission are reported and can give an indication of performance, although a much smaller part of the overall figure. In May 2022, this fell to 19,053 having been a record 24,138 in April. For context, in May there were considerably more A&E attendances than April, so to see a small improvement is testament to the excellent efforts of staff.

Although this shows some progress, prior to the pandemic, it had never been over 3,000 in an individual month (2,847 in February 2020) and there were just 332 in April 2019 or 356 in the equivalent month in 2018.

People waiting for over four hours in A&E can also illustrate levels of demand and pressure for the service. This month the number of attendances over four hours was 525,681, with 487,481 of those were type 1 (major emergency departments). This means 60.2 per cent of type 1 attendances were seen within four hours. At system level, the variance is considerable ranging between 75.2 per cent and 41.8 per cent.

To put this in context of demand, the number of type 1 attendances was the sixth highest on record and the total attendances (including type 2, type 3) the second highest on record. Yet this high demand cannot be seen as the sole reason for challenging performance. Type 1 attendances were just 0.4 per cent higher than May 2021, or 2.4 per cent higher than May 2019. Overall attendances were 0.8 per cent higher than 2019. Yet compared to May 2019, the number of patients waiting more than 12 hours from decision to admit to admission was nearly 46 times higher, and four hour waits over twice as high.

Both internal flow issues, and capacity in the care sector are contributing to the problems, and the COVID-19 pandemic clearly has not helped, but in December 2019 the percentage of all A&E patients seen in four hours slipped below 80 per cent for the first time (68.6 per cent in type 1). The service is at 73 per cent (60.2 per cent in type 1) now but this is not a new problem.

Urgent care: Systems are asked to improve against all ambulance response standards, with plans to achieve category 1 and category 2 mean and 90th percentile standards

Ambulance response times did improve in May compared to April: the mean fell from 9 minutes and 2 seconds to 8 minutes and 36 seconds, for category 1 incidents, the most severe incidents. These are classified as life threatening and needing immediate intervention (standard 7 minutes). The average in 2019/20 was 7 minutes and 17 seconds.

For category 2 this average was 39 minutes and 58 seconds, down from 51 minutes and 22 seconds in April and having been over an hour in March. The standard is 18 minutes, which since records began has only been met when there were reduced callouts at the onset of the pandemic (May and June 2020). Across 2019/20, the average was 23 minutes and 44 seconds.

The regional variation is also considerable – category 1 average response times varied from 7 minutes to 10 minutes 44 seconds across the NHS England regions, while category 2 mean responses varied between 27 minutes 57 seconds and 56 minutes and 15 seconds.

Achieving the mean standards therefore seems particularly challenging, and although we don’t have up-to-date publicly available information on ambulance handover delays (contained within the urgent and emergency care sitrep), we know ambulance handover delays and patient flow issues were restricting the ambulance services’ ability to quickly respond to call outs.

Performance against the 90th percentile standards are also challenging, especially for category 2 incidents. 90 per cent of category 1 call outs were responded to within 15 minutes and 15 seconds (standard 15 minutes), while the 90th centile for category 2 incidents was 1 hour 25 minutes and 52 seconds (standard 40 minutes). The NHS England region difference ranged from over 2 hours in the worst case, to 56 minutes 15 seconds for May.

NHS Confederation viewpoint

• The service is struggling to meet elective targets while battling all time poor performance in urgent and emergency care, with patient flow issues resulting in long A&E waits and meaning ambulances are waiting at the front door, unable to respond quickly to call outs.
• Social care does not account for all of the patient flow issues the NHS is experiencing, although issues with capacity in the care sector are adding to these concerns. In order to improve discharge, there needs to be greater, longer-term investment in social care and community care services – particularly to support recruitment and retention where the issue is most acute.
• Workforce remains a constraining factor across both health and care and a long-term workforce solution is needed to support with meeting the targets outlined in this piece.
• There has been great progress in some areas, such as 104-week waiters, but there is still work to be done to achieve and maintain  this performance across systems. As this work progresses and deadlines for targets approach, the system and its regulators must remain aware of and seek to counter the unhelpful unintended consequences of focusing on one area of delivery to the detriment of others.