Progress against the 104-week wait target

As we approach the first milestone to bringing down the elective waiting list, we report on how the NHS is doing.
Joseph Plewes

17 May 2022

The challenge

  • We are soon approaching the first milestone in the journey to elective recovery – the fight to bring down the list of 6.36 million people currently waiting for elective care. 
  • The immediate focus is on those waiting for the longest. The recent COVID-19 delivery plan for tackling the backlog of elective care, published in February, and subsequent planning guidance reflect this. They ask 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).
  • At the time of the elective recovery plan’s publication, the number of people waiting two years or more stood at 22,311 having grown 20 per cent over the winter from 18,585 in December 2021. Eliminating these waits, understandably, has been deemed a tall order.

How are we getting on?

  • The NHS has so far made incredible progress against this first target. Nationally, the number of people waiting more than two years stood at 11,724 in the week ending 1 May, down from 21,149 in the week ending to 6 March, a drop of 45 per cent.
  • Within this national picture, there are examples of NHS Confederation member trusts who have put in outstanding individual performances. NHS England data published outside of the usual monthly cycle showed that of 137 hospital trusts in England where data was available, 33 have already eliminated 104-week waiters and more than 40 have ten or fewer patients.
  • The data shows trusts making huge inroads into their long waiters' lists, with significant activity over winter and big pushes through the early part of this year. Some of the trusts with higher amounts of long waiters such as Manchester University NHS Foundation Trust reduced the numbers waiting over 104 weeks by over 51 per cent in the nine weeks between week ending 6 March and week ending 1 May. University Hospitals Birmingham NHS Foundation Trust reduced their 104-week waiter total by 55 per cent and Barts Health NHS Trust by 66 per cent in this time.
  • This progress has been made under very difficult circumstances. Figures from the final week of the winter sitrep up to the start of April showed over 28,000 staff off work on an average day solely due to COVID-19, while in the same month the number of patients in hospital with COVID-19 in England peaked at over 16,500.  There have also been issues with patient flow including delays in discharging patients – all of which has dramatically reduced the number of beds and space available for planned surgery patients.

What else is required to meet the July target?

  • Looking ahead over the next months to the July deadline, to be able to eliminate two-year waiters, trusts need to treat not only those already over the threshold of 104 weeks but also those who are waiting just under two years and will ‘tip over’ in the intervening period.
  • The chart below maps the journey to July, starting on with the current baseline of 11,724 waiters for the week ending 1 May, then adding the volume of patients due to tip over 104 weeks week by week after that based on validated referral-to-treatment data.
  • By July, if we were to have eliminated 104-week waiters, approximately 19,000 patients would need to have been treated. This number will be slightly lower assuming some patients waiting between 91 and 104 weeks have been treated throughout April.
  • Thanks to the recent surge in activity by trusts in March and April, the target to have zero 104-week waiters by July is becoming more and more achievable, with the bulk of long waiters expected to be treated.
  • Total figures for March show that over 11,000 patients waiting over 104 weeks (11,403 ) started non-admitted or admitted treatment, which equates to over 2,200 long waiters treated per week for five weeks. This level of activity exceeds the c.2,100 patients that would need to be seen per week up to the first week of July to meet the target, which requires approximately 19,000 patients to be treated.
  • The latest data for April shows a slight deceleration of the progress against the target. In the five weeks following the end of March, the service treated the 1,966 patients who tipped over the 104-week threshold in addition to a further 3,215 waiters between week ending 3 April and week ending 1 May. This is down on the month of March where over 10,000 patients were removed from the long waiters list.
  • One consideration beyond just the numbers of people who required treatment, is that the target must be achieved at a system level. Firstly, in terms of complexity, there can be significant variation between trusts within footprints. For instance, Cheshire and Merseyside has the most individual acute trusts within the data with 13, with 104-week waiting lists ranging from over just over 300 to zero patients. In contrast, other areas have just one acute trust and a handful of long waiters.
  • Secondly, some systems face a much larger challenge than others, with seven areas being responsible for over half of the total two-year waiters. These are however also making the biggest difference in eliminating long waits, with Greater Manchester Health and Social Care Partnership and Birmingham and Solihull reducing the overall list by over 2,700 patients between week ending 3 March and week ending 1 May alone.
  • This achievement is particularly outstanding when viewed at a trust level. For instance, in the six months from the start of November 2021 to week ending 1 May, University Hospitals Birmingham NHS Foundation Trust reduced the cohort of patients over, or due to tip over, 104 weeks by July, by over 93 per cent.
  • Other trusts made similarly impressive strides by May. Buckinghamshire Healthcare NHS Trust brought the number of patients waiting over 104 weeks to just four, a decrease of over 99 per cent. The Royal Free London has reduced their cohort by 97.5 per cent and University Hospitals Sussex a 92 per cent reduction. University Hospitals Coventry and Warwickshire also completed significant levels of activity to reduce their number to zero

Is this sustainable?

  • The elective recovery plan and guidance ask systems to not only eliminate waits of over 104 weeks by July 2022, but crucially to maintain this position through 2022/23. This means continuing to treat enough patients waiting just under two years to avoid them breaching the threshold.   
  • The further forward projections go, the harder it is to accurately predict who will still be waiting, and how many people will have been seen, but to broadly estimate the size of the challenge, we can look firstly just at the three months after July, taking us to the end October 2022.
  • As the chart above shows, between now and the end of October approximately 77,333 people will need to be treated to maintain the position of zero two-year waiters. If all 19,000 patients to be seen by July are removed from the list, there are still nearly 60,000 to treat by the end of October.
  • There will be some activity to treat patients approaching the 104-week wait threshold between now and then, so the figure will reduce as we approach October. However, even at the elevated rates of activity delivered in March, this could continue to present a challenge especially as more people joined the queue two years ago in October than at the onset of the pandemic.
  • Our members have told us of other challenges on top of the volume of patients. One operational director told us that even simple procedures were now taking longer as patients have deteriorated on the waiting list. Due to the added complexity, these patients are also less suitable to be moved to other providers including the independent sector. Some patients also understandably want to stay with their current surgeon or within the local area.
  • The ongoing challenges with patient flow including medically optimised patients being unable to be discharged from hospital and pressure in urgent and emergency care are of considerable concern and tying up resource to tackle the elective backlog. This is in addition to ongoing workforce shortages steadily getting worse, and nearly three quarters of staff reporting that there are not enough staff to do their jobs properly in the recent staff survey.