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 12 years of 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 August 2022, 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 6.7 million – more than one in eight of the population – with over 350,000 waiting over a year.
Within this there is a large and growing number of children waiting for hospital treatment; the number has risen by almost 50% in a year to a record high of 361,000, and is now increasing at a rate of 10,000 children per month.
The waiting list covers elective surgery and hospital services. In August, 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.
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 July 2022, 29% of people attending A&E spent more than four hours from arrival to admission, transfer or discharge – this compares to 14% of patients in July 2019.
Waiting a long time to be seen in emergency departments is costing lives.
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 official figures for July show almost 30,000 patients were kept waiting over 12 hours in A&E following a decision to admit. The delay 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) press statement points out that 30,000 is “more than 3.5 times the total number of 12-hour waits for the whole of 2019.”
The 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
Data released by the NHS for July 2022 show that ambulances are taking almost an hour to reach patients who have had a suspected stroke or heart attack, more than three times the 18-minute maximum wait. This was the second longest since records began after the one hour, one minute and five second response time to such calls experienced in March 2022.
For category two 999 calls, the second most serious category of incident, ambulance crews in England took an average of 59 minutes and seven seconds. This category includes people suffering from an epileptic fit, major burn or sepsis, which kills 48,000 people a year.
Source: Nuffield Trust, August 2022
The response times to “category one” incidents in which the patient needs immediate medical attention because they are having a cardiac or respiratory arrest or severe allergic reaction, were on average nine minutes and 36 seconds, the joint longest delay on record.
Source: Nuffield Trust, August 2022
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.
Mental health - long delays for therapy
Data released in August 2022 show that the number of people waiting for community mental health care at the end of 2021/22 (March 2022) had risen to 1.2 million, up from 1.08 million at the end of quarter three 2021/22 (December 2021).
The service also 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 is in reality much higher as the 1.2 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.
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 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.”
The most recent official cancer waiting time figures show how far performance has fallen back in the past year, even as the peak of the pandemic has passed.
In the year since April-June 2021 numbers of cancer patients have increased by less than 5% to 676,000: but the number missing the standard for a 2-week maximum wait for a first consultant appointment after an urgent GP referral has rocketed by almost 48%, from 91,000 to 135,000.
Compared to pre-pandemic (April-June 2019) numbers of patients have increased by 15%, but longer than target waits have more than doubled (up 160% from 58,000 to 135,000).
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: in the past year while numbers of patients have increased by 2% to 43,000, numbers waiting longer than 62 days have increased by 71% to 16,000, and performance is falling back, with just 62% treated within the standard time.
The figures leaked to the HSJ 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.