Delays to treatment
The primary reasons for delays to treatment are too few staff, too few beds, and a lack of equipment. The overarching reason for a delay to a patient’s treatment is the chronic underfunding of the NHS over the 14 years of the Conservative government.
The NHS now has record waiting lists for elective surgery, mental health services, and non-hospital based routine procedures, plus long delays in A&E, and long waits to see a GP.
Worst performance since records began
In October 2023, NHS England once again reported the worst performance on record. The most recent NHS England statistics show the numbers in the queue for elective treatment has now topped 7.75 million - with 8,998 waiting longer than 18 months for treatment.
Within this there is a large and growing number of children waiting for hospital treatment; the number has risen to a record high of 423,500. Of those, 23,396 have been forced to wait over a year for their appointment.
The waiting list covers elective surgery and hospital services. In August 2022, the HSJ revealed that there is also a hidden one million-strong additional waiting list for even more poorly-resourced community health services, among them:
- 75,000 children waiting to access community paediatric services, “including children needing help with developmental delay, long-term health conditions and additional needs”;
- 74,300 young people waiting for speech and language therapy.
- 321,000 adults waiting for musculoskeletal services, mostly physiotherapy;
- And 120,000 waiting for podiatry.
A&E waits
The statistic that makes the headlines more than any other is the wait in A&E: there is a national target that no more than 5% of people should wait more than four hours in A&E. Over the years of Conservative government the percentage of patients that have had to wait longer than 4 hours has risen steadily. In September 2023, 28% of people attending A&E spent more than four hours from arrival to admission, transfer or discharge, with performance moving away from the objective of 24% by March 2024.
Trolley waits (the time between a decision to admit a patient and them being admitted) of over four hours hit almost 126,000 in September, the poorest performance since March 2023.
Source: Nuffield Trust, September 2023
Trolley waits of over 12 hours increased from almost 28,900 in August 2023 to over 33,100 in September. In September 2019, there were 458 instances of waits this long.
Source: Nuffield Trust, September 2023
Waiting a long time to be seen in emergency departments is costing lives.
In November 2023, HSJ conducted an analysis of the data on long waits in A&E departments and concluded that they have caused around 30,000 ‘excess deaths’ 2022-23, up from 22,175 in 2021-22, and 9,783 related deaths in 2020-21.
The data suggests the rate of excess deaths from 2022-23 has so far continued into 2023-24.
The analysis used a methodology in a peer-reviewed study published in the Emergency Medicine Journal, which found delays to hospital admission for patients of more than five hours from time of arrival at A&E were associated with an increase in all-cause mortality within 30 days.
A paper published in the BMJ in April 2021 found that the risk of death in the month following A&E attendance was 16% higher for those who waited over 12 hours than those seen within four. Based on this paper and additional data, John Burn-Murdoch's analysis in the FT in August 2022 concluded that the collapse of emergency healthcare in England may be costing 500 lives every week due to excess waiting times. For June 2022, Burn-Murdoch's analysis found 2000 excess deaths associated with waiting so long for urgent care or admission.
Successive warnings have been given, but ignored, and in August 2022, Emergency medicine consultants were once again warning that NHS England’s latest A&E performance figures mean “we are seeing the sharp demise of the health service.”
The delays was largely due to lack of beds, which in turn has been worsened by delays in discharging people who no longer need hospital care due to the lack of social care and community health services.
A Royal College of Emergency Medicine (RCEM) statement noted that these figures are merely the tip of the iceberg of delays in A&E since the numbers waiting over 12 hours from time of arrival in A&E is many times higher. The RCEM noted that in a sample of hospitals in 2021 it was calculated that these delays were 14 times higher than the official recorded 12-hour waits.
It is therefore likely that the 30,000 figure recorded in July 2022 translates into more than 400,000 patients across England waiting more than 12 hours on trolleys in July from arrival in an Emergency Department to being given a bed on a ward.
Source: Nuffield Trust, August 2022
Also bear in mind that the figures for delays does not include the additional delays due to ambulances queuing for many hours outside A&E departments to hand over “emergency” patients, and the thousands more who suffer falls or heart attacks and wind up waiting hours on end for ambulances to arrive.
The crisis in A&E, and the failure of NHS trusts to make any headway in stemming or reducing the waiting lists are not because of an increase in demand for emergency care, as the latest NHS England figures show that A&E admissions are down on 2019, but due to a chronic shortage of front line general and acute beds, which was worsened by the pandemic, but pre-dates it and remains a major problem.
The most recent quarterly figures show that there were 630,000 (23%) fewer of the most serious Type 1 A&E attendances in April-June 2022 compared with the same quarter in 2019: and there were 125,000 (8%) fewer emergency admissions.
The key difference is that there are 3,300 fewer general and acute beds occupied than in the equivalent period of 2019, and fewer of the reduced number of beds are available for emergency admissions.
Ambulances miss targets
In December 2023, coroners wrote damning warnings to the government over persistent crises in the NHS after multiple inquests into patient deaths following ambulance delays and insufficient mental health beds.
Three coroners sent prevention of future deaths (PFD) reports to health secretary Victoria Atkins in the wake of six deaths.
Two of the coroners warned that severe ambulance delays could return this winter.
One PFD report covered three deaths linked to ambulance delays affecting the South West Ambulance Service( SWASFT), with an eight-hour wait for an ambulance in one case and a 13-hour wait in another even though an ambulance would normally have been expected to arrive within 20 minutes.
Data released in October 2023, showed that there was an average response time of 8 minutes 40 seconds to Category 1 incidents (life-threatening conditions, such as cardiac or respiratory arrest), missing the seven-minute target. One in 10 people waited over 15 minutes 28 seconds, which means the 15-minute target was missed.
Response times to Category 2 incidents (emergency conditions such as stroke or heart attack) deteriorated by four minutes in October, with an average response time of 41 minutes 40 seconds. This is far from the mean target of 18 minutes.
Source: Nuffield Trust, November 2023
Source: Nuffield Trust, November 2023
Behind these figures are some truly harrowing stories of long waits. In August 2022, BBC Radio Cornwall published photos of a shelter that was built to protect an 87 year old man following a fall. He had to wait 15 hours for an ambulance with seven broken ribs, two fractures to his pelvis and an arm wound.
A Guardian investigation in November 2023 analysed data from NHS England that found that in 2022 almost 8,000 people were harmed and 112 died as a direct result of enduring long waits for an ambulance or surgery.
The fatalities included a man who died of a cardiac arrest after waiting 18 minutes for his 999 call to be answered by the ambulance service and was dead by the time the crew arrived.
They show that patient deaths arising directly from care delays have risen more than fivefold over the last three years, from 21 in 2019 to 112 in 2022. The number of people who came to “severe harm” has also jumped from 96 to 152 during that period.
Mental health - long delays for therapy
Although the prevalence of mental health disorders has risen, increases in investment and capacity in services has not kept pace. Recent data released by NHS England in November 2023 on waiting times for community mental health services shows a shockingly high number of children and young people having to wait almost two years before being seen.
HSJ analysis of this data puts the figure at more than 24,000 children and young people waiting almost two years to be seen. With 19,000 adults with a serious mental illness waiting for longer than 18 months for a second contact with community mental health services.
In total, almost 240,000 children and young people were waiting for treatment from community mental health services in August 2023, as well as more than 192,000 adults.
Data released in August 2022 show that the service failed to meet its goal of getting 1.6 million patients into “talking therapy” services, also called IAPT, which are aimed at treating people with mild to moderate depression. Only 1.2 million started sessions last year.
Other targets not met include, access and recovery rates for black and minority ethnic patients in the past year in IAPT and providing services to psychosis patients that meet quality standards.
The waiting list for mental health services is estimated to be 1.8 million in 2023, but in reality much higher as the 1.8 million figure does not include those waiting for inpatient care and other services. In late 2021, the official waiting list stood at 1.6 million people and NHS Providers estimated that there are around eight million people in England that are denied access to mental health services because they do not have severe enough symptoms to get put onto a waiting list.
The eight million figure is based on the known prevalence of mental health conditions and the thresholds dictating who gets access to treatment; NHS England considers it an accurate figure for the number of people who are missing out on care because services are not adequate. So the true figure of people waiting for mental health services is around 10 million.
There are long delays for children needing mental health treatment and support, including the rising number requiring specialist treatment for eating disorders. In August 2022, NHS England published its quarterly data on children and young people with an eating disorder waiting times for the first quarter 2022-23. The findings show that of the 230 children and young people currently on the waiting list for urgent treatment, 44% have been waiting for more than 12 weeks.
An analysis of mothers waiting for mental health care published in September 2023 found a sharp increase in waiting times, with one woman found to have waited 319 days for a first appointment.
Amid rising demand for perinatal mental health services, during the period from August 2022 to March 2023 the numbers of women waiting rose by 40%. Over that same period, the numbers who accessed support also rose, but only by 8%.
In December 2021, the Independent revealed waits for a mental health bed were increasing in London, with 50 patients a week waiting more than 12 hours for a bed, compared with 35 during the same period in 2020. However, sources told the paper that the true length of A&E waits are often hidden, with many waits measured in days. One senior director in London, speaking anonymously with The Independent, said they’d seen a child wait 60 hours for a bed earlier this month, while another emergency care doctor said patients in their A&E were waiting for 18 hours.
Targets missed for cancer treatment
In August 2023, Nuffield Trust's performance tracker found 37% of patients who had their first treatment for cancer following an urgent GP referral waited longer than two months. Although this was the best performance seen since March 2023 it is still very far away from the target of only 15% of patients waiting this long.
The number of patients who waited longer than two months from an urgent GP referral to a first treatment for cancer was 5,940 in August 2023. When the 15% threshold target was last met in December 2015, only 1,704 patients waited more than two months for their first cancer treatment.
The most recent official cancer waiting time figures show how performance has failed to improve over the year.
In August 2022, Figures leaked to the HSJ and shared with BBC’s Newsnight team showed almost a third of a million people (327,000) are on cancer waiting lists in England, almost 40,000 of them waiting for treatment to begin more than 62 days after a GP referral.
Worse still numbers waiting over 104 days have more than doubled in a year, to more than 10,000: in 2018, NHSE said there should be “zero tolerance [of] non-clinically justifiable 104-day delays”.
The BBC report quotes Prof Pat Price from Imperial College London warning that:
“The waits for cancer treatment are the worst they’ve ever been – and they’re getting worse. We have to get on and address this crisis. This is an absolute disaster.”
It has been eight years since services for patients with suspected breast cancer met the target of ensuring 93% receive appointments within two weeks. One month waits for treatment have not been on target since the summer of 2018, and the proportion within target has continued falling despite reduced numbers of patients.
It’s even worse with the 62-day (two month) target, which has not been met since early 2014.
Figures leaked to the HSJ in August 2022 show 10,189 of the 327,395 people on the national cancer waiting list, about 3%, had waited 104 days or more, around double the figure from a year ago, with a further 28,406 having waited between 62 and 103 days as of the end of July.
Delays in primary care inevitable
The Covid pandemic had a massive effect on primary care. GPs were issued Instructions to avoid face-to-face in the early months of the pandemic in 2020 and adopt ‘total triage’.
However, despite this instruction, GPs faced a backlash for reducing face-to-face contacts during the pandemic.
Following the relaxation of rules around GP appointments, GPs have worked hard to prove they are available. And in April 2022 the average waiting time for a non-urgent, face-to-face appointment was 10 days, according to Pulse’s latest GP survey, quicker than before the Covid pandemic. From 2016-2019, the average wait for a non-urgent face-to-face appointment stood at 13-15 days. The average waiting time for a remote, non-urgent appointment meanwhile stands at eight days.
GPs say that this is because there is a greater drive to deal with patients on the day, and triage has enabled practices to be able to use remote consultations or see other healthcare staff where appropriate, which allows for shorter waiting times for patients who need face-to-face appointments.
However, there is a severe shortage of GPs and there is considerable uncertainty over how long GPs will be able to maintain or even improve on these figures for waiting time. See Staffing Shortages.
