The NHS treats more and more people each year, and patients have a right to expect to receive treatment within the timescales set out by the NHS Constitution.
But more and more patients are being let down by the NHS’s continued failure to meet deadlines for waiting times. The percentage of patients treated within waiting times standards continues to get worse for both elective (non-urgent care) and cancer treatment.
It is unacceptable that less than half of NHS trusts and foundation trusts (trusts) meet the 18-week waiting times standard for elective treatment, and only 38% meet the 62-day standard from referral to treatment for cancer patients.
Like many areas within the NHS, demand for elective and cancer treatments is growing which risks exacerbating this worsening performance. The waiting list for elective care has grown by one and a half million since March 2013 to 4.2 million in November 2018.
NHS organisations are not being sufficiently held to account for ensuring patients’ rights to treatment within maximum waiting times for elective care. The NHS does not yet fully understand what is driving the demand for elective care, undermining its ability to plan services to meet patient needs.
We are also concerned that the national bodies responsible for setting and managing waiting times appear to lack curiosity regarding the impact of longer waiting times on patient outcomes and on patient harm. Improvement is clearly needed to ensure patients get the treatment they need within the waiting times standards the government has set.
The long-term funding settlement for the NHS, the NHS Long Term Plan, and the current review of waiting times standards present an opportunity to get the NHS back on track in meeting waiting times standards.
“It is unacceptable that the proportion of patients being treated within NHS waiting times standards is continuing to spiral downwards; NHS England and the Department of Health & Social Care must regain control.
“The impact on individuals of protracted waiting times cannot be ignored. As one charity told us, the wait for cancer testing is “agonising… it is essential that a definitive answer is given as soon as possible, to either provide peace of mind or to allow treatment to begin at the earliest stage.”
“In a high-pressured healthcare environment in which patient numbers are rising and demand is increasing, we were troubled by the Department’s and NHS England’s approach to waiting times which seems to be characterised by gaps in understanding of: patient harm, hospital capacity and what is driving demand.
“It is no surprise then that we see such variation of waiting times across local areas and, therefore, why it has proved impossible for local trusts to properly map services and deliver sufficient provision.
“NHS England’s review of waiting times is now more crucial than ever. However, this cannot be an opportunity for standards to slip, any changes must protect and improve patient outcomes.
“Ultimately, NHS England must steer waiting times standards back on course to prevent further decline. We call on NHS to outline and commit to a firm timescale and plan for delivering this.”
Conclusions and recommendations
The NHS is failing to meet key waiting times standards for cancer and elective care, and its performance continues to decline. The NHS is treating more people for suspected cancer and elective care than ever before. For example, the number of patients referred for elective care has increased by 17% since 2013-14 and the number of patients referred for suspected cancer has almost doubled since 2010-11. However, the NHS has not met the 18-week waiting times standard for elective care since February 2016. In November 2018, 44% of NHS trusts and NHS foundation trusts (trusts) met this standard. The waiting list for elective care has grown, from 2.7 million in March 2013 to 4.2 million in November 2018. The NHS has not met the 62-day standard from urgent referral for suspected cancer to treatment since 2013, and in November 2018 only 38% of trusts met this standard. In 2015, NHS England committed to us that it would improve performance against the 62-day cancer standard, but performance has further declined since. Between July and September 2018, only 78.6% of patients were treated within 62 days of an urgent referral, down from 83.8% between September and December 2014. Substantial improvement is clearly needed. NHS England and NHS Improvement assert that that they will be in a better position to determine how best to improve performance once local NHS organisations have published their forward plans in September 2019.
Recommendation: NHS England should set out, by December 2019, how, and by when, it will ensure that waiting times standards for elective and cancer care will be delivered again.
The Department of Health & Social Care has allowed NHS England to be selective about which standards it focuses on, reducing accountability. Under the NHS Constitution, patients in England have the right to be treated within maximum waiting times. It is important that Parliament and the public can rely on NHS waiting times standards to hold the NHS to account over patients’ rights to timely access to care. However, in response to rising demand while under increasing financial constraints, the Department has allowed NHS England to prioritise meeting standards for emergency services and cancer care over elective care. NHS England told us that, in recent years, it has removed sanctions and penalties against NHS trusts for failing to meet elective care waiting times standards, as many of the trusts were already in financial difficulties. We welcome the action taken by NHS England to focus on reducing the number of patients waiting 52 weeks and over for elective care, but we are concerned that the Department is no longer holding NHS England to account for the other service standards that are still in place.
Recommendation: The Department of Health & Social Care and NHS England should clarify to the Committee by December 2019:
- how NHS England will be held accountable for achieving waiting times standards now and in the future; and
- what additional support NHS England and NHS Improvement will put in place to help local NHS bodies to meet waiting times standards.
We are concerned that NHS England’s review of waiting times will not be enough to ensure a clear understanding of, and strong accountability over, the performance of the NHS. We welcome NHS England’s current review of standards for accessing NHS services, which includes waiting times standards for cancer and elective treatment. Its interim report, published in March 2019, proposes several changes to cancer and elective waiting times standards. Some stakeholders are concerned that, given the ongoing failure by the NHS to meet the 18-week standard, the review could be used as an opportunity to make the target easier to meet or less appropriate. The review is an opportunity to put patient experience and outcomes at the centre of waiting time standards, but the health bodies involved must ensure that strong accountability for performance remains if standards are being altered. It is also important that the NHS engages with the public regarding any changes that may affect their access rights.
Recommendation: The Department of Health & Social Care should ensure that any changes to current waiting times standards:
- help to improve patient outcomes and patient experiences;
- do not water down current standards to make them easier to meet; and
- are communicated clearly to the public, so that patients understand what they can expect of the NHS.
The national health bodies lack curiosity about the impact for patients of longer waits and how often this leads to patient harm. When waiting times are longer, patients may experience additional pain, anxiety and inconvenience. There is also a risk that longer waiting times may lead to patient harm through, for example, the deterioration of a medical condition. Similarly, outcomes for those who wait for more than six months for treatment can be poorer. The NHS has a very limited understanding of this issue. Although trusts collect data on patient harm through an incident reporting system, which is overseen by NHS Improvement, the data cannot be used easily to help understand the relationship between waiting times and patient harm. Individual trusts may carry out harm reviews due to long waiting times, but these data are not collected at a national level. NHS England is aware that some patients have suffered harm due to long waits and that research on the relationship between patient harm and waiting times is not consistent. NHS England relies on the professional judgement of clinicians to ensure that patients do not come to harm because of longer waiting times but accepts that widespread unwarranted variations in clinical practices exist across the country.
Recommendation: The Department of Health & Social Care, together with NHS England and NHS Improvement, should write to us by December 2019 on how they are going to ensure that the data on patient harm due to long waiting times are going to be routinely collected, reported and acted upon.
Bottlenecks in hospital capacity are having a detrimental impact on how long patients wait for treatment. There are wide variations in performance against waiting times standards across local areas and hospitals. For example, the proportion of patients waiting less than 18 weeks for their elective care varied between 75% and 96% across CCGs in England in 2017-18. Poorer performance in waiting times is related to bottlenecks in hospital capacity, including diagnostics and bed occupancy. We have highlighted the persistent lack of capacity in diagnostics services, including shortages in diagnostics staff, in our previous reports. In terms of access to diagnostics, England compares poorly to other countries that have a similar level of income to England. Hospitals now routinely operate with a bed occupancy rate of more than 90%. This can affect elective patient care as patients may have their elective care treatment postponed because the beds are needed for emergency admissions, resulting in delays to treatment. We are concerned that the number of NHS beds has been reduced over recent years but the NHS does not know what the right level of beds is to meet the growing demand for its services. NHS Improvement told us that there is still room to make better use of existing beds through improving patient pathways which may help meet some of the demand for services.
Recommendation: NHS England and NHS Improvement should evaluate and report back to the Committee on how the NHS plans to ensure that it has the required diagnostic and bed capacity to meet patient demand in the medium to long term. They should also set out, in the short term, how they will support local bodies to improve their patient flow through the health system and reduce unwarranted variation.
The NHS still does not understand sufficiently what is driving demand for referrals for elective treatment. Between the 12 months to March 2014 and the 12 months to November 2018, the number of referrals for elective treatment increased by 17%. Our recent report on NHS financial sustainability, published in March 2019, concluded that the rising demand for NHS services is not sufficiently well understood. The Department asserts that there are three groups of factors which are driving the increase in demand for elective treatment: demography, technology, and patient expectations. NHS Improvement explained that up to 45% of inpatient admissions and 25% of outpatient referrals are due to a growing and ageing population. But the impact of technology and patient expectations on referrals for elective treatment are difficult to quantify and less researched. NHS England expects local commissioners and sustainability and transformation partnerships (STPs) to forecast and develop plans to meet the demand from their local populations. However, we are concerned that each local body carrying out its own analysis will lead to duplication of efforts.
Recommendation: As we recommended in March 2019, NHS England and NHS Improvement should, by September 2019, write to us to set out how they will help local bodies to better understand the demand for care, and to plan their services accordingly to better meet the needs of their local patients.