Last week’s data showed a continued rise in people waiting more than 52 and 104 weeks for elective care. With insight from our members, we look at the context and challenges faced in tackling the problem.
This analysis is part of our weekly piece looking at the urgent and emergency care situation report (sitrep) review and the monthly performance statistics analysis.
- NHS organisations have been focusing on the elective backlog, treating large volumes of patients and delivering levels of activity comparable to those before the pandemic, despite the ongoing impact of COVID-19 on capacity.
- Despite this, the volume of long waiters is increasing. The latest statistics showed 23,778 patients waiting over 104 weeks and 311,528 waiting over 52 weeks. In addition, high numbers of patients have been crossing (or are about to cross) those thresholds.
- The delivery plan for tackling the COVID-19 backlog of elective care reset targets for long waiters, with a deadline of eliminating waits over two years by July this year and waiters over a year by March 2025.
- This piece looks at the numbers of long waiters, what NHS organisations are doing to tackle them, the challenges our members are experiencing in delivering this and how the numbers look in the short-term future.
NHS services have increased elective activity following a dip in completed treatments at the onset of COVID-19 and during more recent peaks.
As the pressure on the NHS increased during the pandemic, in April and May 2020, the number of completed elective pathways fell respectively to 43 per cent and 40 per cent of the equivalent months in 2019. This increased so that in November 2021 completed pathways were just below 100 per cent of November 2019 levels and the average across the last six months is now at 91.4 per cent of the activity against the corresponding month in 2019.
This in part is as a result of innovation by the service, including using data and technology to both support patients and increase elective activity. We have seen increased use of clinical prioritisation software allowing organisations to make real-time decisions on scheduling surgery and tackle health inequalities while reducing the elective backlog.
Although NHS elective care is a story of incredible recovery with organisations delivering high levels of care and innovation, the numbers of long waiters nationally have been growing. We have heard from members whose attempts to reduce waits were hampered during November and December by staff leave and sickness as well as high levels of emergency demand. This is reflected in the latest statistics, with figures released last week showing increases in long waiters once again and many of patients crossing the 52- and 104-week thresholds.
This is against the backdrop of NHS England and the government’s elective recovery plan, which set the ambition of eliminating waits over two years (except when it is the patient’s choice) by July 2022.
The most recent performance statistics release showed that of the 6.1 million people on the elective waiting list in December 311,528 (5.1 per cent) were waiting over 52 weeks and 23,778 over 104 weeks, which both increased from 310,813 and 20,065 respectively.
The chart below shows the number of 52-week waiters since records started (August 2007). March 2021, the peak of the pandemic, was 436,127. Looking at the latest waiting list figures over this period demonstrates how significant a shock to the system the pandemic caused - one that is only just starting to be recovered from.
Data recording 104-week waiters is only available since April 2021, but it has risen every month since:
If the NHS is to eliminate 104-week waits by July, this picture presents a challenge. There are some indicators we can use to predict how difficult this is likely to be.
In the data up to the end of December 2021, we could see a number of patients due to ‘tip over’, prior to the rise in January’s data of both 52-week waiters (up 715) and 104-week waiters (up 3,713). 67,604 patients were waiting between 48 and 52 weeks and 9,882 were waiting between 100 and 104 weeks. Significantly, for the latter this represented nearly 49 per cent of the total 104-week waiters in that month, 20,065.
Looking at the number of people waiting just under the thresholds of 52 and 104 weeks, we can estimate the numbers due to ‘tip over’ in the coming months.
The rise in 104-week waiters is likely to continue in next month’s data, with 10,300 due to tip over 104 weeks in February (patients waiting between 100-104 weeks), up on the previous month (9,882). In March an additional 9,063 people are due to tip over. For 52-week waiters, the number between 48 and 52 weeks is also higher than in the previous month (74,973 compared to 67,604 the previous month).
To eliminate 104-week waiters by the end of July 2022, 75,992 patients would need to be treated (approximately 62,280 by the start of July) based on patients waiting between 78 and 104 weeks, on top of the current 104-week waiters:
The following chart then shows the week-by-week breakdown of patients due to ‘tip over’ 104 weeks. This is high in February and March again before sharply dropping: in the four-week period from 4 April to 25 April there are 3,034 patients due to tip over, which is less than one week in February. This is because there were considerably fewer patients joining the waiting list at the onset of COVID-19 two years ago. The below chart shows the distribution of patients waiting between 78 and 104 weeks up to the beginning of August:
126 of the 171 trusts within the provider data available have less than 400 patients over 78 weeks to treat by the end of July, while the ten trusts with the highest amount of long waiters account for over 32,000 of the total. Clearing long waiters down to meet the elective recovery plan targets therefore falls largely to a smaller number of trusts.
Similarly, they are concentrated in certain specialties:
- trauma and orthopaedics - 20 per cent of patients waiting over 52 weeks, rising to 23 per cent of over 104-week waiters
- ear nose and throat - 12 per cent of all 52-week plus waiters and 13 per cent of over 104-week waiters.
Several reasons are emerging as to why it is not simple to treat these long waiters. One trust in the Midlands told us the impact of non-elective demand is continuing to place pressures on their elective capacity, exacerbated by the recent uptick in COVID-19 patients that has once again limited emergency capacity due to infection prevention control (IPC) measures required, even if higher numbers of patients are not in hospital with COVID-19 as the primary cause. Operational directors have also highlighted the added constraints of ageing estates can have on this, with limited side rooms meaning little flexibility.
One member noted that they were finding normally simple procedures were taking longer and were seeing increased complexity as patients’ conditions had deteriorated while on the waiting list. Another operational director recently explained that they were able to move some patients around or have them cared for in the independent sector where they needed routine procedures, but the ‘majority’ of their waiting list was filled with complex patients who cannot be passed on to outsourced care, or want to stay with trusted surgeons within their local area.
Members have also cited that waiting list management and the way in which lists are collated is not standardised across the NHS. It is becoming evident that roles e in the specific skill and experience of waiting list management are moving to general administration roles. This can mean waiting lists are not wholly accurate if consistent data is not being captured.
Finally, our members have also highlighted the long-term challenges in meeting productivity targets without a fully costed whole system workforce plan which addresses staff vacancies, absence and turnover. One operational director told us that workforce needed to be “front and centre” before we even talked about backlog strategy.