The NHS frontline is always under considerable pressure over winter. In past years, demand for services has tended to increase significantly as we enter the colder months, but this year we saw the pressure start to build as early as June.
To mark the first weekly Urgent and Emergency Care Daily Situation Report for 2021/22 released by NHS England on 9 December, this article aims to articulate pressures on the system, put them into context and share feedback from our members on how this feels ‘on the ground’.
From now, and throughout winter, this data will be reported weekly, collating daily returns from acute trusts on ambulance handover delays, bed occupancy (including ‘stranded’ patients) and as of this year, a new daily discharge sitrep.
This article combines analysis of the monthly performance stats release for December, which includes datasets for October and November 2021, with the first weekly release. We will publish updated analysis of the winter return every week across the winter period.
At a glance
- Amid record levels of presentation from patients, and in the face of significant overall demand for services in primary care and in hospitals, cancer performance has continued to decline and is of significant concern to members.
- More than 1 in 10 hospital beds were occupied by patients who were medically fit to leave over the last week, reflecting the challenges being seen with the homecare workforce declining sharply.* This, alongside increased demand including months of high demand for emergency care, is leading to an alarming picture at both the back and front doors of hospitals. One member told us this week that “fit patients are in our beds, meanwhile the sick patients can’t get in”; the data shows ambulance handover delays on arrival at hospital, and there are some alarming performance metrics on long A&E stays.
- The waiting list has risen to 5.98 million, with 312,665 52-week waiters and 16,225 104-week waiters by the end of October. Both these long-waiter metrics have risen, but the shift in activity to tackle them in line with H2 planning guidance is more visible. In October, there was a 29 per cent increase in 104-week waiters removed from the waiting list compared to September and 75 per cent more than August. Although the NHS has performed well in tackling 104-week waiters, the statistical bulge in patients who started care two years ago may continue to increase numbers for months to come.
- Primary care saw an estimated 34 million patients in September and continues to support urgent care, with over 40 per cent of appointments taking place on the same day they were booked.
Performance against the standard for two-week waits from GP urgent referral to first consultant appointment was 81.3 per cent in England in October, down from 84.1 per cent in September. This remains short of the 93 per cent operational standard which was last successfully met in December 2018. For context, pre-pandemic in 2019 the average month was 91 per cent.
Performance should be understood against the volume of activity. Over 227,000 patients had their first consultant appointment in October; this is the fourth highest volume of appointments in a month ever, and now eight of the ten busiest months for first consultant appointments on record have been in 2021. The record was 232,136 in March 2021, while the average per month in 2019 pre-pandemic was 198,392.
The chart below shows the increased level of demand and patients being seen, alongside the decrease in performance against the two-week standard:
Performance against the standard for people waiting no longer than two months from GP urgent referral to first treatment for cancer was 67.8 per cent in October, falling further from 68 per cent for September. The operational standard is 85 per cent, last met in December 2015. Across 2019 the average was 77.7 per cent and in October 2019 it was 77.2 per cent.
The amount of people starting their first treatment in October was 13,691, which is near to the average for this year (13,698 per month). This is considerably higher than last year, where the number of treatments started was below average (12,579), but in keeping with 2019 (13,700).
There are a few caveats to the performance against these two standards deteriorating. One is the high levels of presentation – the more people being referred, the more difficult it is to offer them a consultant appointment in time. One acute provider told us that cancer referrals were at 120 per cent of where they are normally, and there have been some delays with patients presenting for myriad reasons including fears regarding COVID-19.
A second caveat is that some patients are being carried over from month to month (for example, a patient who had been waiting two weeks from referral in September is then in October’s figures and has been seen but outside the standard). If performance was 100 per cent this month that could be concerning, as some people waiting longer than the standard such as a carried over patient from September would not have been treated. There were over 23,800 such patients as of week ending 3 October.
Critically, it is important that we recognise the whole system background to increased cancer waiting times. We know that some delays will be driven by patients with symptom awareness, individual activation and persistence, travel distances and fears around COVID-19 stopping some patients presenting. We know that some delays are related to primary care services, with access, appropriate referrals and GP continuity all important in picking up presentation early. Lastly, we know that some delays occur in hospitals, where COVID-19, infection prevention and control and staffing pressures are reducing the normal efficiency around diagnostics and treatment.
There are increasing challenges in moving people through the health and care system. More than 1 in 10 beds were occupied by patients who were medically fit to leave between 29 November and 5 December, as shown in the new COVID-19 daily discharge sitrep.
On an average day, 10,443 patients who remained in hospital no longer met the criteria to reside, while 90,229 general and acute beds were open, so these patients occupied just under 12 per cent of beds. NHS England also note that the 10,443 figure could actually be higher.
Of these patients, an average of over 4,500 per day had been in hospital for over 21 days.
And the number of patients medically fit to leave but occupying beds was actually higher than the amount of patients discharged per day, which averaged 8,608.
These discharge metrics could be interpreted alongside the rapidly deteriorating picture in social care, especially the homecare market, which is emphasised by the ADASS snap survey results, released on 29 November. These showed that nearly 1 in 2 councils had had to respond to a care home closure/bankruptcy in the last six months, 1.5 million hours of commissioned home care could not be provided between August and October because of a lack of staff and that the level of unmet social care need over the summer was almost three times higher than the previous three months.
In the first week of December (week 48 of 2021), there were 19,366 ambulance handover delays of over 30 minutes, which equates to 23 per cent of ambulances. 8,211 of those were over 60-minute delays.
To provide context, 19,366 is higher than any individual week in previous winter sit reps, with the highest weekly number of delays previously being 18,251 between 30 December 2019 and 5 January 2020. In that period, the number of ambulances arriving was 86,100, compared to 83,903 in this week’s figures.
We know that handover delays have been significantly higher over autumn than in previous years, but this data alongside the discharge metrics back up the message we are hearing from within the service, with one member telling us that “fit patients are in our beds, meanwhile sick patients can’t get in”.
Challenges in emergency care remain, in a year where we saw winter pressures begin in summer. 999 calls answered have also been at an unusually high level, and in November there were 879,192 calls answered, a record for the month of November but a decrease from October’s record of over 1 million calls.
Visits at major A&E departments were just below record levels for November, with 1.34 patient attendances compared to 1.37 million 2019. With overall attendance levels comparable to pre-pandemic levels (there were 2.04 million total attendances, compared to 2.14 million 2019), the volume of major A&E attendances presents a challenge against the continued backdrop of COVID-19 and an increasing elective waiting list, as shown by the performance metrics.
A&E waiting times
The operational standard for A&E waiting times remains that 95 per cent of patients should be admitted, transferred or discharged within four hours of their arrival at an A&E department. Although this has not been met since July 2015, prior to 2021 performance had only dropped below 80 per cent once since records began in 2010 (this was in December 2019) and this is the fifth month in a row the figure has been below that.
November’s figure of 74 per cent actually represents a slight stabilisation, however, as the percentage had fallen seven months in a row and was 73.9 per cent in October. In major A&E departments only, this is as low as 61.9 per cent for a second month running.
The number of patients spending 12 hours from decision to admit to admission (12 hour ‘trolley waits’) has increased again, from 7,059 in October to 10,646. This is the highest since records began and the third consecutive month that over 5,000 patients have been waiting more than 12 hours (this had never happened before).
Urgent care demand continues to have an impact across the whole system. For instance, primary care is experiencing high demand for its urgent, same-day appointments. In the latest NHS Digital dataset for October, 40.3 per cent of the 34 million primary care appointments occurred on the same day they were booked. Although data across primary care is not uniform, our members tell us that demand for these appointments continues to outstrip capacity. It’s a challenge for primary care to meet these urgent care needs at the same time as managing their other pressures, such as the ramping up of booster vaccinations.
Pressure point: scaling up booster programme in primary care
Bolton GP Federation outlined to us some of the successes they have had in scaling up their response to the uplift in demand following the government’s announcement on the expanded COVID-19 vaccination booster programme:
- They modelled a 50 per cent uplift in delivery and started to book staff and vaccines early.
- They immediately looked to source a much larger site, and hope to operate in a vacant department store from next week. They already had a dedicated shopping centre site from the summer, which freed up clinical space in previous site.
- They have colleagues from the military starting with them this week, and are hoping to also work with St John Ambulance volunteers.
- They continue to offer mobile delivery via a ‘vaccination bus’ which has delivered over 27,000 vaccinations to under-served areas. They have also administered over 1,000 vaccines in people’s homes and around 4,000 in care homes.
The official waiting list at the end of October has risen to a record 5.98 million, up from 5.83 million in September. There were 1.59 million new referral-to-treatment (RTT) periods or ‘clock starts’ in October. This is still trending below pre-pandemic levels – the figure in October 2019 was over 1.8 million and the average month in 2019 was 1.68 million. We are still not seeing a major uptick in patients joining the waiting list, as many have been, expecting due to the ‘missing’ patients who did not present during the pandemic. The Institute for Fiscal Studies (IFS) explored this in a briefing this week.
This is concerning with the waiting list still rising, as activity would need to significantly increase to start bringing the waiting list down even before the missing patients join the official waiting list. In October’s data, there were 1.28 million clock stops (patients who were removed from the waiting list, many of whom will have started treatment). Although this is figure likely to be slightly higher than evidenced here due to unknown flow off the waiting list (data quality adjustments or removals other than treatment, for example) it still falls short compared to the number of people joining the official queue.
There were 312,665 patients waiting over 52 weeks, an increase of over 12,000 from September’s data, as well as 16,225 waiting 104 weeks, an increase of 3,734.
Although this shows an increase in the overall list, the service is ramping up activity to see as many patients as possible. 4,194 patients waiting over 104 weeks were removed from the waiting list in October, an increase of 29 per cent on the volume in September and 75 per cent on August, when this was around 2,400. This reflects the additional focus on eliminating 104-week waiters outlined in the H2 planning guidance at the end of September can be seen in the data.
Despite the progress being made, one trust told us this week that the elimination of 104-week waiters as targeted in the H2 planning guidance is looking very unlikely for them – and they are actually forecasting an increase in numbers due to capacity constraints, concerns about retaining elective capacity during a difficult winter and the upcoming statistical bulge of patients who were referred two years ago. These patients will be ticking over the 104-week wait threshold between now and March.
This first view of this year’s winter pressures and performance is against a continued backdrop of COVID-19. The continued uncertainty around Omicron and upwards creep of COVID-19-associated hospital admissions week on week is of concern (nationally there has been an almost 6 per cent increase in the admissions per day based on the seven-day rolling average. In the South East this is an increase of 17 per cent, which in real terms is a rolling average of 100 patients being admitted per day, now up to 117). However, the average admissions across England per day sits under 700 in comparison to October when this was as high as 871 in England.
The total number of patients actually in hospital in England with COVID-19 meanwhile has remained relatively flat at 6,053 as of 8 December. The rolling average of just over 5,900 across the last seven days is a fall from early November, when this was over 7,300.
The uncertainty and concern is most pronounced in case rates, however, and if hospitalisations start to increase at a similar rate. The figure of 45,880 cases by date reported on 29 November was the highest since 17 July, with the seven-day average now at over 41,000 per day. This is up from 27,600 in early November.
The overall performance picture is challenging, as outlined in this article, and further needs for infection control and care for more COVID-19 patients is hugely concerning as we head into winter. As such, the NHS Confederation has welcomed the announcement of new measures to help curb the spread of the virus announced yesterday and relaunched the #NotTooMuchToMask campaign this week.
Demand for mental health support continues to be very high. 1.49 million people, including 337,080 children and young people (CYP), were in contact with mental health services in September 2021, which is higher than any point this year to date. There is currently no publicly available national data on waiting times, but we know from NHS England that the waiting list for mental health services was 1.6 million this summer.
Concerns remain about the impact of the pandemic on people’s mental health and whether services have enough capacity. The Health and Social Care Committee published their Expert Panel’s evaluation of the government’s progress against mental health policy commitments today, and while some improvements have been made, the panel found that the government’s progress to improve mental health services ‘requires improvement’.
There were also 178,242 people in contact with learning disabilities and autism services in September 2021, which is up from 172,838 in August 2021. A key concern for this group is the number of people placed, often inappropriately, in inpatient settings, and for long periods of time. In October 2021, according to the Assuring Transformation data, there were 2,070 people with learning disabilities and/or autism in inpatient settings, and over half of these people had a total length of stay of over two years. Alarmingly, in October 2021, 95 people with learning disabilities and/or autism had been in their current inpatient settings for over ten years.
There were 5,608 emergency referrals to crisis care teams for all ages in September 2021, up from 5,255 emergency referrals in August. Most were for adults, but 724 were for CYP. The number of emergency referrals to crisis care teams for CYP, is up from 441 referrals in August 2021.
There were 19,906 urgent referrals to crisis care teams in September 2021, up from 18,332 in August 2021. Most of the referrals are for adults and continue to be higher in this age group compared to pre-pandemic levels with 17,928 urgent referrals in September 2021 compared to 16,056 in December 2019, for example.
How is the NHS performing?
View our analysis of the latest NHS performance figures for a rounded view of how healthcare services are coping under immense pressure.