Performance Tracker 2022: Hospitals

By any reasonable measure, hospitals are in crisis. The proportion of people waiting more than four hours at A&E is the highest on record, ambulances are taking longer to respond to calls than at any time since the NHS started publishing data, the waiting list for elective care is the highest it has ever been (and not expected to start coming down until 2024), and the number of outpatient appointments and diagnostic tests done in hospitals has still not returned to pre-pandemic levels.

The pandemic forced the NHS in England to suspend much of its normal hospital work and encourage people to actively stay away from hospitals. Beds that would have been used for routine activity were repurposed for Covid patients as hospitals struggled to meet the demands of each successive wave of the virus. As a result, the number of outpatient appointments, diagnostic tests and elective procedures all declined sharply in 2020/21.

The NHS attempted to return to normal operations in 2021/22 and has become better at ramping up and down its Covid capacity as required, but is still struggling with the effects of the pandemic, which continue to reduce hospital productivity. ²⁵³ Coyle D, Dreesbeimdieck K and Manley A, Productivity in UK healthcare during and after the Covid-19 pandemic, The Productivity Institute, February 2021, p.21, www.bennettinstitute.cam.ac.uk/wp-content/uploads/2020/12/Productivity_in_UK_Healthcare.pdf However, factors outside of Covid – namely pre-pandemic trends of declining bed numbers, an overstretched workforce, increasing numbers of workforce vacancies and delays in discharging patients into social care – all continue to contribute to the immense pressure that hospitals are under.

The coming winter is likely to be a difficult one for the NHS. The yearly peak in demand – which has in effect become an ‘annual winter crisis’ – coincides with an ongoing and worsening staffing situation, with almost 10% of NHS roles vacant at the end of June 2022. ²⁵⁴ NHS Digital, NHS Vacancy Statistics England April 2015 – June 2022 Experimental Statistics, 1 September 2022, retrieved 29 September 2022, https://digital.nhs.uk/data-and-information/publications/statistical/nhs-vacancies-survey Covid has also not gone away and will continue to divert NHS resources away from regular activity. The government and the NHS have attempted to address some of these issues with the release of two plans (‘Next steps for urgent and emergency care’ ²⁵⁵ NHS England, Next steps for urgent and emergency care letter and framework, 12 August 2022, retrieved 29 September 2022, www.england.nhs.uk/publication/next-steps-for-urgent-and-emergency-care and ‘Our plan for patients’ ²⁵⁶ Department of Health and Social Care, Our plan for patients, 22 September 2022, retrieved 29 September 2022, www.gov.uk/government/publications/our-plan-for-patients/our-plan-for-patients ), but while both accurately diagnose some of the problems in the service, neither come close to laying out a sufficiently clear, ambitious or well- resourced set of steps to solve them.

This chapter discusses NHS acute and specialist trusts in England, which provide specific short-term treatments, including diagnostic services, outpatient treatment and services, emergency treatments – such as ambulances and A&E – and surgeries. As data relating solely to acute and specialist trusts is not always available, in some places we analyse corresponding data for all NHS trusts.

Spending increased by 10.4% in 2020/21, but much of this was Covid-related

Spending on NHS providers – which includes NHS acute trusts, ambulance, community and mental health services – increased by 10.4% in real terms between 2019/20 and 2020/21. This was the biggest single-year spending increase since 2009/10 and brings the total increase in spending since then up to 38.6% in real terms. However, 2020/21 was also the first year of the pandemic and it should be expected that the NHS would increase spending to match the increased pressure imposed on hospitals.

Unfortunately, it is not possible to determine how much of the spending in that year was Covid-specific, but overall spending should either fall or grow less slowly in the coming years as Covid spending is rolled back, ²⁵⁷ The King’s Fund, ‘The NHS budget and how it has changed’, 3 February 2022, retrieved 28 April 2022, www.kingsfund.org.uk/projects/nhs-in-a-nutshell/nhs-budget though it is likely that there will be continuing Covid-related spending in the medium to long term.

Another key area where spending increased was on staffing, which rose 8.7% between 2019/20 and 2020/21. This increase was driven by a mixture of higher spending on recruitment in line with ambitions in the NHS Long Term Plan (LTP) ²⁵⁸ NHS England, The NHS Long Term Plan, 7 January 2019, www.longtermplan.nhs.uk/wp-content/uploads/2019/08/nhs-long-term-plan-version-1.2.pdf and emergency spending on staffing due to Covid.

The increase in spending on hospitals since 2019/20 comes in the wake of a period of historically low spending increases for the service. Spending on hospitals increased by 1.6% per year in real terms between 2009/10 and 2014/15 – compared to an average of 6.3% per year in the decade to 2009/10. ²⁵⁹ The Health Foundation, ‘How funding for the NHS in the UK has changed over a rolling ten year period’, 31 October 2015, retrieved 28 April 2022, www.health.org.uk/chart/chart-how-funding-for-the-nhs-in-the-uk-has-changed-over-a-rolling-ten-year-period

Hospitals will continue to incur Covid costs

Hospitals face continuing spending pressures from preventing the spread of Covid to responding to outbreaks of different variants. The National Audit Office (NAO) estimates that the government spent £89bn between March 2020 and June 2022 to support health and social care services through the pandemic. ²⁶⁰ National Audit Office, ‘COVID-19 cost tracker’, (no date), retrieved 22 June 2022, www.nao.org.uk/covid-19/cost-tracker Estimating future cost, though, is more difficult. It is unclear how frequently Covid waves will occur and also difficult to accurately differentiate Covid costs from business-as-usual costs. ²⁶¹ Institute for Government interview.

In addition, the emergence of new variants might require the reintroduction of ‘mass vaccination and testing’ ²⁶² Prime Minister’s Office, 10 Downing Street, ‘Prime Minister sets out plan for living with COVID’, 21 February 2022, press release, www.gov.uk/government/news/prime-minister-sets-out-plan-for-living-with-covid measures that would entail an expansion of NHS spending. There are, however, reasons to believe that the emergence of another variant would not require the same extent of funding as previous variants. According to interviewees, the NHS has become more efficient at responding to Covid, taking less time – and therefore spending less money – to increase Covid capacity. Despite this, a joint report by NHS Confederation and NHS Providers, which uses survey data from 54% of NHS providers, estimates that the NHS will need to spend an additional £4–5bn per year on Covid-related costs “for some years to come”. ²⁶³ NHS Confederation and NHS Providers, A reckoning: the continuing cost of COVID-19, 2 September 2021, www.nhsconfed.org/system/files/2021-09/A-reckoning-continuing-cost-of-COVID-19.pdf

Hospitals found some efficiencies during the pandemic

The pandemic encouraged the NHS to develop new ways of working. Some proved to be effective and could lead to longer-term – though not transformative – savings across the NHS. These innovations can be grouped into three categories.

First, more efficient use of existing resources. For example, hospitals expanded the use of ‘mutual aid’ – the sharing of resources such as vaccines ²⁶⁴ NHS England, Mutual aid and the transfer of COVID-19 vaccines between NHS vaccination sites, 30 September 2021, retrieved 19 July 2022, www.england.nhs.uk/coronavirus/documents/mutual-aid-and-the-transfer-of-covid-19-vaccines-between-nhs-vaccination-sites and staff between different NHS providers – to reduce wastage and improve productivity.

Second, measures designed to keep people away from hospitals. Examples include the use of virtual wards ^{265 Institute for Government interview.   266 Walton H and Fulop N, ‘Virtual wards and Covid-19: An explainer’, Nuffield Trust, 14 March 2022, www.nuffieldtrust.org.uk/resource/virtual-wards-and-covid-19-an-explainer#what-are-virtual-wards} (in which hospital staff remotely monitor patients who stay in their own homes), increasing the number of virtual outpatient appointments ²⁶⁷ Nuffield Trust and the Health Foundation, ‘The remote care revolution during Covid-’, (no date), retrieved 22 June 2022, www.nuffieldtrust.org.uk/files/2020-12/QWAS/digital-and-remote-care-in-covid-19.html#5 and carrying out acute services in the community. ^{268 NHS Cambridge University Hospitals, ‘Outpatient phlebotomy/blood tests’, (no date), retrieved 21 June 2022, www.cuh.nhs.uk/our-services/outpatients/outpatient-phlebotomyblood-tests   269 Ibid.} There were 53 virtual wards providing 2,500 virtual beds in February 2022, ²⁷⁰ NHS England, 2022/23 priorities and operational planning guidance, 22 February 2022, p.22, www.england.nhs.uk/wp-content/uploads/2022/02/20211223-B1160-2022-23-priorities-and-operational-planning-guidance-v3.2.pdf and the NHS has an ambition to increase this capacity to “40–50 virtual beds per 100,000 population”. ²⁷¹ Ibid. This would equate to approximately 23,000–28,000 virtual beds ²⁷² Office for National Statistics, ‘England population mid-year estimate’, 25 June 2021, retrieved 20 May 2022, www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationestimates/timeseries/enpop/pop – or around a quarter of the currently available general and acute beds. Virtual wards are still, however, a relatively new innovation and there is not enough evidence to evaluate their effectiveness. ²⁷³ Walton H and Fulop N, ‘Virtual wards and Covid-19: An explainer’, Nuffield Trust, 14 March 2022, www.nuffieldtrust.org.uk/resource/virtual-wards-and-covid-19-an-explainer#what-do-staff-and-patients-think-of-covid-19-virtual-wards In addition, while not physically being in a hospital, staff still need to monitor the status of patients in virtual beds, ²⁷⁴ Best J, ‘The virtual wards aiming to ease hospital pressures’, the BMJ, 6 July 2022, www.bmj.com/content/378/bmj.o1603 which may prove difficult given current staffing issues (more on which below).

Finally, hospitals have attempted to reduce unnecessary activity. One lever for this is the introduction of ‘patient initiated follow-up’ (PIFU), ²⁷⁵ NHS England, ‘Patient initiated follow-up’, (no date), retrieved 27 June 2022, www.england.nhs.uk/outpatient-transformation-programme/patient-initiated-follow-up-giving-patients-greater-control-over-their-hospital-follow-up-care which places the onus on patients to arrange follow-up appointments when they think they are necessary.

This has the potential to free up capacity in the NHS; follow-up appointments accounted for 67.8% and 69.7% of attended outpatient appointments in 2019/20 ²⁷⁶ NHS Digital, Hospital Outpatient Activity 2019–20: Main procedure or intervention, 8 October 2020, https://digital.nhs.uk/data-and-information/publications/statistical/hospital-outpatient-activity/2019-20 and 2020/21 ²⁷⁷ NHS Digital, Hospital Outpatient Activity 2020–21: Main procedure or intervention, 23 September 2021, https://digital.nhs.uk/data-and-information/publications/statistical/hospital-outpatient-activity/2020-21 respectively. The NHS hopes that its target of “moving or discharging 5% of outpatient attendances to PIFU pathways by March 2023” ²⁷⁸ NHS England, 2022/23 priorities and operational planning guidance, 22 February 2022, p. 13, www.england.nhs.uk/wp-content/uploads/2022/02/20211223-B1160-2022-23-priorities-and-operational-planning-guidance- v3.2.pdf will help it to achieve its wider target of reducing outpatient follow-up appointments by 25% by March 2023. ²⁷⁹ Ibid. There remain questions about this approach, however. There is still little evidence that PIFU reduces unnecessary appointments and concerns that it could contribute to health inequalities. ²⁸⁰ Reed S and Crellin N, ‘Patient-initiated follow-up: will it free up capacity in outpatient care?’, Nuffield Trust, 4 August 2022, www.nuffieldtrust.org.uk/research/patient-initiated-follow-up-will-it-free-up-capacity-in-outpatient-care

Hospital activity has not returned to pre-pandemic levels

Hospital activity dipped during the pandemic and has not returned to trend levels. The NHS conducted 22.9 million diagnostic tests (including tests carried out in non- hospital settings) in 2021/22, compared to 23.4 million in 2019/20, and 121.2 million compared to 124.9 million outpatient appointments in the same two years. These outcomes represent a decline of 1.4% and 3% respectively. Concerningly for the NHS’s ability to clear the backlog, the number of elective procedures fell from 16.4 million in 2019/20 to 15.2 million in 2021/22.

There are two key reasons for this decline. First, the pandemic has made it harder for the NHS to carry out routine procedures in hospitals. ²⁸¹ Nuffield Trust, ‘Diagnostic test waiting times’, 4 May 2022, retrieved 7 June 2022, www.nuffieldtrust.org.uk/tesource/diagnostic-test-waiting-times Spikes in Covid cases cause higher bed occupancy and greater infection control requirements – for example, having at least one vacant bed space between each occupied bed – meaning that there is less space available for procedures. ²⁸² Coyle D, Dreesbeimdieck K and Manley A, Productivity in UK healthcare during and after the Covid-19 pandemic, The Productivity Institute, February 2021, p. 16, www.bennettinstitute.cam.ac.uk/wp-content/uploads/2020/12/Productivity_in_UK_Healthcare.pdf Second, increased staff absences and vacancies make it difficult for hospitals to return to pre-pandemic levels of activity. ²⁸³ Ibid. These pressures have not gone away despite the return to post-pandemic normality elsewhere in the country; hospitals are still dealing with Covid and expect to for the foreseeable future.

High bed occupancy is limiting NHS capacity

Another drag on hospital performance is patients staying in beds longer than needed. ²⁸⁴ Curry N and Fisher E, ‘Chart of the week: What’s happening to hospital discharges?’, Nuffield Trust, 2 February 2022, www.nuffieldtrust.org.uk/resource/chart-of-the-week-what-s-happening-to-hospital-discharges On average between 29 November 2021 and 31 August 2022 (the time period covered by the Daily SitRep data ^{285 NHS England, ‘Urgent and emergency care daily situation reports 2021–22’, 7 April 2022, retrieved 1 July 2022, www.england.nhs.uk/statistics/statistical-work-areas/uec-sitrep/urgent-and-emergency-care-daily-situation-reports-2021-22} ), 21,124 patients per day no longer met the criteria to reside in hospital. On average more than half (57.7%, 12,179) of this number remained in hospital at the end of the day. With 98,016 general and acute beds available across all acute trusts in July 2022, this means that 12.4% of bed capacity on an average day was occupied unnecessarily.

The data for patients in hospitals for more than 21 days is worse. Between 29 November 2021 and 3 April 2022 (the time period for which this data is available), 6,143 patients per day remained in a bed 21 days or more after being eligible for discharge. Of these the vast majority (5,479 patients, 89.2%) continued to occupy a bed at the end of the day, mostly due to a lack of appropriate places to discharge them to. Beyond the unnecessary occupancy of limited bed capacity, delayed discharge also uses up clinical resource, as staff have to care for patients that remain in hospital, diverting attention away from those more in need of care.

After a decline at the beginning of the pandemic, occupancy of general and acute (G&A) beds has increased steadily and has been above 90% every month since August 2021, reaching a high of 93.1% in July 2022, the most recent month for which we have data. ²⁸⁶ NHS England, ‘Critical care and general acute beds – urgent and emergency care daily situation reports’, (no date), retrieved 1 July 2022, www.england.nhs.uk/statistics/statistical-work-areas/bed-availability-and-occupancy/critical-care-and-general-acute-beds-urgent-and-emergency-care-da… This high occupancy is concerning for the performance of hospitals as it makes it difficult to admit patients.

Unfortunately, following the suspension of the Delayed Transfer of Care dataset in February 2020, there is no longer official data on the cause of these delayed discharges. ²⁸⁷ NHS England, ‘Delayed transfers of care’, (no date), retrieved 1 July 2022, www.england.nhs.uk/statistics/statistical-work-areas/delayed-transfers-of-care But interviews point to several reasons. First, limited staffing, both among social workers in local authorities who carry out assessments for care, ²⁸⁸ Curry N and Fisher E, ‘Chart of the week: What’s happening to hospital discharges?’, Nuffield Trust, 2 February 2022, www.nuffieldtrust.org.uk/resource/chart-of-the-week-what-s-happening-to-hospital-discharges and in care workers, reduces the number of available care places into which hospitals can discharge patients. Second, there is a lack of available NHS community care that is preventing hospitals from discharging patients in a timely manner, increasing the reliance on social care. ²⁸⁹ The Association of Directors of Adult Social Services, ADASS Spring Budget Survey 2022, 19 July 2022, p. 2, www.adass.org.uk/media/9389/adass-spring-budget-survey-2022-key-messages-docx-final-no-embargo.pdf This was likely worsened at the beginning of 2022 by the redeployment of community care staff to the vaccination programme. ²⁹⁰ Limb M, ‘Delayed discharge: how are services and patients being affected?’, the BMJ, 17 January 2022, www.bmj.com/content/376/bmj.o118 Third, hospitals themselves can cause delays due to a lack of intermediate care – for example, reablement and rehabilitation services – needed to facilitate a patient’s discharge from hospital. ²⁹¹ The King’s Fund, ‘Delayed transfers of care: a quick guide’, 4 January 2018, retrieved 15 July 2022, www.kingsfund.org.uk/publications/delayed-transfers-care-quick-guide

In September 2022, the government announced a £500m Adult Social Care Discharge Fund, with the aim of making it easier for hospitals to discharge patients into social care. ²⁹² Department of Health and Social Care, Our plan for patients, 22 September 2022, retrieved 23 September 2022, www.gov.uk/government/publications/our-plan-for-patients/our-plan-for-patients However, this does not appear to be additional funding and is unclear whether it will substantially improve the rate at which hospitals discharge patients.

While bed occupancy increased during the pandemic, the shortage of beds pre-dates Covid. The number of overnight general and acute beds per 100,000 people has declined steadily since 2010/11, from a high of 210.0 beds per 100,000 people in the first quarter of 2010/11 to 176.1 by the first quarter of 2022/23 – a decline of 16.1%.

Fewer open beds means that the NHS is less well equipped to deal with Covid surges and elective and emergency activity. This worsens hospital performance in these areas, as explored below. However, increasing bed capacity by itself – as outlined in the operational resilience plan for the winter of 2021/22 ²⁹³ NHS England, Next steps in increasing capacity and operational resilience in urgent and emergency care ahead of the winter, 12 August 2022, retrieved 15 August 2022, www.england.nhs.uk/next-steps-in-increasing-capacity-and-operational-resilience-in-urgent-and-emergency-care-ahead-of-winter – is not sufficient to improve NHS performance; without extra staff to work on those beds, there is a risk of overburdening current staff.

Staff numbers are increasing, but poor retention is hampering progress

The number of nurses and doctors increased again in 2021/22, by 4.5% and 2.0% respectively, between May 2021 and May 2022. Since 2019/20, the number of nurses and doctors has increased by 4.2% and 3.4% per year respectively. This compares to a rate of 1.3% and 1.5% respectively between January 2010 and January 2019. This follows the launch of the LTP ²⁹⁴ NHS England, NHS Long Term Plan, 7 January 2019, www.longtermplan.nhs.uk/wp-content/uploads/2019/08/nhs-long-term-plan-version-1.2.pdf in that year, which included ambitions to increase the number of nurses and doctors ²⁹⁵ Ibid., p. 79. through improved recruitment and retention.

After a decline in vacancies during the first year of the pandemic, the proportion of unfilled roles in the NHS workforce has increased. In the quarter to the end of June 2022, nursing, medical and total vacancies in NHS providers rose to 11.8%, 7.3% and 9.7% respectively. This total figure is the highest level of vacancies since at least June 2017, when the time series started.

However, these rates hide variation between specialities. For example, in February 2022 the Royal College of Anaesthetists estimated that there was a shortfall of 1,400 anaesthetists across the NHS ²⁹⁶ Royal College of Anaesthetists, ‘Stark figures show impact of shortage of anaesthetists on patients awaiting surgery in the NHS’, press release, 23 February 2022, www.rcoa.ac.uk/news/stark-figures-show-impact-shortage-anaesthetists-patients-awaiting-surgery-nhs – representing an 8.7% vacancy rate, well above the 5.6% vacancy rate for ‘medical roles’ in that quarter (ending March). This is concerning for hospital productivity; anaesthetists are vital for carrying out operations and the same report puts the number of missed operations due to lack of anaesthetists at 1 million per year. ²⁹⁷ Royal College of Anaesthetists, The Anaesthetic Workforce: UK state of the nation report, February 2022, retrieved 9 May 2022, p. 14, www.rcoa.ac.uk/sites/default/files/documents/2022-02/State-Nation2022.pdf

Nursing vacancies are the highest among staff groups, despite increasing numbers of nurses across the service. After dipping before and during the early stages of the pandemic, vacancy rates rose above 10% in 2021/22, reaching a high of 11.8% in June 2022. Overall, the Health and Social Care Committee estimates that there is currently a shortage 50,000 nurses and midwives in England; its figure for doctors is 12,000. ²⁹⁸ House of Commons Committee of Health and Social Care, Workforce: recruitment, training and retention in health and social care: Third report of the session 2022–23, (HC 115), The Stationery Office, p. 3, https://committees.parliament.uk/publications/23246/documents/171671/default/

Persistently high NHS vacancy rates are in part due to record levels of voluntary resignations. These grew to 139,862 in 2021/22, up from 98,878 in 2020/21 and 112,787 in 2019/20 – increases of 41.4% and 24% respectively. Of these, the proportion of leavers citing ‘work-life balance’ as the reason for leaving has increased to its highest ever level, at 18.7% of total voluntary resignations.

Worsening retention reflects the pressure that many staff experienced during the pandemic. The proportion of sick days for mental health reasons rose as a percentage of total sick days between February 2020 and August 2020, from 25.6% to 32.5%. One interviewee described the mental health crisis in hospitals as a “vicious cycle”, wherein staff resign due to stress and burn-out, which in turn applies more pressure to remaining staff. ²⁹⁹ Institute for Government interview. The NHS also continues to experience a high number of staff absences due to cold, cough, flu, chest and respiratory problems, and infectious diseases, showing the ongoing effect of Covid on the hospital workforce.

The NHS is filling staffing gaps with agency staff and overseas recruitment, but both solutions come with problems. Agency staff are likely to be more inefficient as they work in unfamiliar teams, areas and roles ³⁰⁰ Rocks S, ‘Why is the NHS really under ‘record pressure’?’, The Health Foundation, 12 March 2022, www.health.org.uk/news-and-comment/charts-and-infographics/do-we-really-understand-why-the-nhs-is-under-record-pressure and also cost more per shift than regular staff. ³⁰¹ Palmer B, Leone C and Appleby J, Return on investment of overseas nurse recruitment: lessons for the NHS, Nuffield Trust, October 2021, p. 3, www.nuffieldtrust.org.uk/files/2021-10/1633336126_recruitment-of-nurses-lessons-briefing-web.pdf The NHS is trying to reduce the amount spent on agency staff. ³⁰² Anderson H, ‘NHSE tries to put £2.3bn cap on agency staff’, HSJ.COM, 20 July 2022, www.hsj.co.uk/finance-and-efficiency/nhse-tries-to-put-23bn-cap-on-agency-staff-spend/7032855.article?mkt_tok=OTM2LUZSWi03MTkAAAGFvoxfDCp8GL_sicV0mfX…; hqvxU5OtCnonGRCK3Y3R3XmD_Lpebdd6pol3qbxSVSAxe-nQAzlWCcJwPZOUkpA Reliance on agency staff also risks cannibalising the workforce of other hospitals, shifting staffing problems to another part of the NHS. ³⁰³ Palmer B, Leone C and Appleby J, Return on investment of overseas nurse recruitment: lessons for the NHS, Nuffield Trust, October 2021, www.nuffieldtrust.org.uk/files/2021-10/1633336126_recruitment-of-nurses-lessons-briefing-web.pdf

Since April 2021, more British nurses have left the NHS than have joined. In their place, the NHS hired more nurses than ever from outside of the UK and the EU/EEA. Recruitment costs of foreign nurses are generally lower than those trained in the UK ³⁰⁴ Ibid. but the government has no control over the number of nurses trained abroad and is likely to face greater competition for those nurses in the future as more OECD countries’ nursing workforces are increasingly staffed by foreign nurses. ^{305 Ibid., p. 7.}

Uncompetitive pay in the NHS is also worsening retention. This has been exacerbated by two key factors. First, the UK’s tighter post-pandemic labour market has caused employers in competing sectors – such as retail and hospitality – to offer better pay deals, including welcome bonuses and higher hourly wages in an attempt to attract in-demand employees. ³⁰⁶ UNISON, ‘NHS facing stiff competition for staff from high street firms, says UNISON’, press release, 28 March 2022, www.unison.org.uk/news/press-release/2022/03/nhs-facing-stiff-competition-for-staff-from-high-street-firms-says-unison Second, high and rising inflation is eroding the real value of employees’ pay. The government has recognised this and in July 2022 – one month after the most recent vacancy data – accepted the NHS pay review bodies’ recommendations for a pay uplift in full, ³⁰⁷ Department of Health and Social Care, ‘NHS staff to receive pay rise’, press release, 18 July 2022, www.gov.uk/government/news/nhs-staff-to-receive-pay-rise#:~:text=drive%20up%20inflation-,The%20government%20has%20today%20accepted%20the%20recommenda… which will increase the NHS’s wage bill “by almost 5% in 2022/23”, with the highest uplifts going to the bottom of the wage distribution. ³⁰⁸ The Health Foundation, ‘Unfunded NHS staff pay increase could leave big hole in severely stretched NHS budget’, press release, 19 July 2022, www.health.org.uk/news-and-comment/news/unfunded-nhs-staff-pay-increase-could-leave-big-hole-in-severely-stretched-nhs-budget The pay increase, however, is unfunded by central government, meaning that the money will have to come out of the existing NHS settlement. The King’s Fund estimates that this could cost the NHS an extra £1.6bn–£2.4bn. ³⁰⁹ The King’s Fund, ‘The King’s Fund responds to NHS pay announcement’, press release, 21 July 2022, www.kingsfund.org.uk/press/press-releases/kings-fund-responds-nhs-pay-announcement

The elective backlog has grown, but is smaller than expected

By August 2022, the elective backlog had grown to 7 million people, its highest ever level. People are also waiting longer for procedures. The proportion of the waiting list seen within 18 weeks of referral from a GP fell to 60.8%, its lowest level outside of the first months of the pandemic and far below the NHS’s target of 92%. ³¹⁰ Department of Health, Referral to treatment consultant-led waiting times: rules suite, October 2015, https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/464956/RTT_Rules_Suite_October_2015.pdf And 2021/22 is the first time that patients have waited more than two years for treatment since at least 2010, with 2,646 people still in this category by the end of July. But while Covid worsened wait times for elective surgery, it is not the root cause for them increasing. The last time that the NHS met the 18-week target was in February 2016. This is due to a combination of rising demand for services and underinvestment in the beds and staff that would have been needed to meet that demand. ³¹¹ Comptroller and Auditor General, NHS backlogs and waiting times in England, Session 2021–22, HC 859, National Audit Office, 2021, p. 30, www.nao.org.uk/wp-content/uploads/2021/07/NHS-backlogs-and-waiting-times-in-England.pdf

Though the backlog is the longest it has ever been, there is also evidence that more people than are currently on waiting lists should have come forward for care. In December 2021, the Institute for Fiscal Studies (IFS) estimated that 7.6 million fewer people than expected joined a waiting list for hospital care during the pandemic. ³¹² Stoye G, Zaranko B and Warner M, ‘Could NHS waiting lists really reach 13 million?’, Institute for Fiscal Studies, 8 August 2021, https://ifs.org.uk/articles/could-nhs-waiting-lists-really-reach-13-million

There are several possible explanations for this. First, is a change in patient behaviour. ³¹³ House of Commons Health and Social Care Committee, Clearing the backlog caused by the pandemic: Ninth report of the session 2021–22, (HC 599), The Stationery Office, p. 10, https://committees.parliament.uk/publications/8352/documents/85020/default While the NHS might have wanted to encourage people to come forward for care after the initial Covid wave, ³¹⁴ NHS England, ‘Help us help you: NHS urges public to get care when they need it’, press release, 25 April 2020, www.england.nhs.uk/2020/04/help-us-help-you-nhs-urges-public-to-get-care-when-they-need-it government messaging – for example, “Stay at home, protect the NHS, save lives” – portrayed the NHS as under immense pressure. ³¹⁵ Department of Health and Social Care, ‘New TV advert urges public to stay at home to protect the NHS’, press release, 10 January 2021, www.gov.uk/government/news/new-tv-advert-urges-public-to-stay-at-home-to-protect-the-nhs-and-save-lives This might have led to fewer people coming forward for care.

Second, and most importantly, there are now higher barriers to care at each stage of the referral process than before the pandemic. Our GPs chapter outlines the unprecedented demand for primary care services, which means that it is now more difficult to book a GP appointment than it was before the pandemic. The rate at which GPs refer patients through to secondary care has also dropped, in line with guidance from NHS England. ³¹⁶ NHS England, ‘Advice and guidance’, (no date), retrieved 10 August 2022, www.england.nhs.uk/elective-care-transformation/best-practice-solutions/advice-and-guidance Interviewees told us that, once referred, hospitals are now more likely to reject referrals that they do not believe need treatment. ^{317 BMA, ‘NHS backlog data analysis’, (no date), retrieved 10 August 2022, www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/pressures/nhs-backlog-data-analysis   318 Institute for Government interviews.}

The results of limiting access to the elective waiting list are mixed. On one hand, keeping people who do not need care away from an already overstretched system helps hospitals, freeing up capacity to meet emergency and Covid demand. The conditions that would have previously led to admission on to the waiting list, however, do not go away. Instead, patients seek care elsewhere, mainly in primary or social care. ³¹⁹ BMA, ‘NHS backlog data analysis’, (no date), retrieved 10 August 2022, www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/pressures/nhs-backlog-data-analysis So while this protects hospitals it places a greater burden on services struggling with demand pressures and creates a ‘hidden backlog’ of care, while keeping the elective waiting list artificially low. This is despite a supposed increased focus on improving health outcomes through early intervention and prevention. ³²⁰ NHS England, NHS Long Term Plan, 7 January 2019, p. 33, www.longtermplan.nhs.uk/wp-content/uploads/2019/08/nhs-long-term-plan-version-1.2.pdf There is also the risk that the longer would-be patients stay away the worse their condition becomes – meaning that when they do present, treatment could be more complex and expensive.

The NHS was very close to meeting the first – but most achievable – of its backlog recovery targets

NHS England launched its Covid backlog recovery plan in February this year. ³²¹ NHS England, Deliver plan for tackling the COVID-19 backlog of elective care, February 2022, www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2022/02/C1466-delivery-plan-for-tackling-the-covid-19-backlog-of-elective-care.pdf This plan includes measures such as the separation of elective from urgent activity to prevent surges in demand reducing elective activity, investing in community diagnostic and surgical hubs, increasing bed capacity, moving patients between trusts, and use of the independent sector, among others.

The NHS has already implemented some of these. By April 2022, the NHS had opened 77 community diagnostic centres across England. ³²² Department of Health and Social Care, ‘New diagnostic centres deliver nearly three-quarters of a million tests’, press release, 3 April 2022, www.gov.uk/government/news/new-diagnostic-centres-deliver-nearly-three-quarters-of-a-million-tests According to the government these centres are able to conduct an extra 30,000 medical tests of various types per week (or 1.6 million tests per year), and had already carried out an additional 1 million CT, MRI, ultrasound and endoscopy tests by May 2022. ³²³ NHS England, ‘One million checks delivered by NHS “one stop shops”’, press release, 6 June 2022, www.england.nhs.uk/2022/06/one-million-checks-delivered-by-nhs-one-stop-shops Despite this, the NHS carried out 328,000 fewer diagnostic tests in 2021/22 than in 2019/20 (22.9 million down from 23.3 million).

    The elective backlog recovery plan also lays out the NHS’s timetable for reducing the waiting list:

• Eliminate waits of more than two years by July 2022
• Eliminate waits of more than 18 months by April 2023
• Eliminate waits of more than one year by March 2025.

According to NHS England, it nearly met the first of these targets. By the end of July, 2,885 people who had been on the elective waiting list for more than two years were still awaiting treatment, down from 23,778 in January of the same year. ³²⁴ NHS England, ‘Consultant-led referral to treatment waiting times data 2022-23’, (no date), www.england.nhs.uk/statistics/statistical-work-areas/rtt-waiting-times/rtt-data-2022-23 There are, however, some caveats that NHS England make to these outcomes: of those 2,885 remaining on the waiting list, 1,579 opted to defer treatment and 1,030 were “very complex cases”. ³²⁵ NHS England, ‘NHS marks milestone in recovery plan as longest waits virtually eliminated’, press release, 9 August 2022, www.england.nhs.uk/2022/08/nhs-marks-milestone-in-recovery-plan-as-longest-waits-virtually-eliminated

The other targets will prove even harder to meet. There are far more people waiting 18 months or a year – and the NHS will not know who the latter group are until April 2024. ³²⁶ NHS England, ‘Consultant-led referral to treatment waiting times data 2022-23’, (no date), www.england.nhs.uk/statistics/statistical-work-areas/rtt-waiting-times/rtt-data-2022-23/ This means it does not yet know the types of procedure that will be needed to meet the target, making it harder to plan resource use.

It is not clear the planned measures to clear the backlog will work, as they are highly contingent on the extent to which Covid continues to impact the NHS. ³²⁷ Institute for Government interview. The NHS estimates that it needs to operate at 130% of pre-pandemic activity levels by 2024/25 to clear the elective backlog, ³²⁸ Gardner T and Fraser C, ‘Elective care: how has COVID-19 affected the waiting list?’, The Health Foundation, 27 September 2021, www.health.org.uk/news-and-comment/charts-and-infographics/elective-care-how-has-covid-19-affected-the-waiting-list but in 2021/22 was not yet running at 100% of 2019/20 activity, with completed pathways (admitted and non-admitted) at only 92.7% of the amount carried out in that year.

Performance of emergency and acute services is the worst on record

After a slight improvement in A&E wait times during the pandemic (mostly because fewer people attended emergency departments), only 57% of people attending type 1 A&Es were seen within four hours in July 2022, against a target of 95% – the lowest proportion on record. The same decline in performance is evident in the ambulance service, with response times at their highest recorded level. In July 2022, the mean response time for C1 ambulance incidents – the most urgent ambulance response category – rose to 9 minutes 35 seconds, the worst on record. The decline in performance is even worse for category 2 ambulance call-outs – a category that includes conditions such as strokes ³²⁹ NHS North East Ambulance Service, ‘Understanding ambulance response categories’, (no date), retrieved 25 August 2022, www.neas.nhs.uk/our-services/accident-emergency/ambulance-response-categories.aspx – where the mean response time has risen from 22 minutes 33 seconds in July 2018, to 59 minutes 7 seconds in July 2022.

Worsening performance in urgent and emergency care cannot be attributed to a post- pandemic surge in demand for this service. Attendances are up, but not by much. There were 16.1 million attendances at type 1 A&Es in 2021/22 compared to 15.8 million in 2019/20, an increase of 1% per year over the two years. This compares to an annual increase of 1.3% between 2011/12 and 2019/20.

Rather than increased demand, the major problems with urgent and emergency care relate to capacity. As with elsewhere in the hospital service, A&E departments are still experiencing staffing issues, both related and unrelated to Covid. ³³⁰ The King’s Fund, ‘What’s going wrong with A&E waiting times?’, 26 May 2022, retrieved 25 August 2022, www.kingsfund.org.uk/projects/urgent-emergency-care/urgent-and-emergency-care-mythbusters More vacancies and staff absences mean that many shifts are understaffed, which in turn reduces the number of patients seen. ³³¹ Campbell D, ‘NHS hospital staff illness or absence up to three times usual level’, The Guardian, 30 December 2020, retrieved 12 July 2022, www.theguardian.com/uk-news/2020/dec/30/nhs-hospital-staff-illness-or-absence-up-to-three-times-usual-level This reduces the flow through A&E and increases wait times.

Most importantly, pressure elsewhere in hospitals has a knock-on effect on the performance of urgent and emergency care. ³³² The King’s Fund, ‘What’s going wrong with A&E waiting times?’, 26 May 2022, retrieved 25 August 2022, www.kingsfund.org.uk/projects/urgent-emergency-care/urgent-and-emergency-care-mythbusters When staff eventually see people, they find it difficult to admit patients due to the lack of unoccupied beds in hospitals noted above. This has resulted in 2021/22 having the lowest percentage of A&E attendances resulting in admissions since 2016/17 – 28.3%, compared to 29.9% in both 2018/19 and 2019/20. This difficulty in admitting patients pushes up the amount of time that people wait in A&Es.

This also explains much of the delay in ambulance response times; ambulances cannot hand over patients for admission into hospitals due to a lack of available beds. This has resulted in the highest proportion of ambulance arrivals resulting in delayed handovers (more than 30 minutes) on record. ³³³ Nuffield Trust, ‘Ambulance handover delays’, 4 May 2022, retrieved 12 July 2022, www.nuffieldtrust.org.uk/resource/ambulance-handover-delays#background This in turn prevents ambulances from responding to new calls, thereby increasing response times.

Declining performance in emergency care is extremely serious. Beyond the worsening experience for attendees, there is evidence that those who wait more than five hours are more likely to die within 30 days of attending A&E. ³³⁴ Jones S, Moulton C, Swift S and others, ‘Association between delays to patient admission from the emergency department and all-cause 30-day mortality’, Emergency Medicine Journal, 2022, vol. 39, no. 3, pp.168–73, https://emj.bmj.com/content/39/3/168

More people are waiting longer for cancer treatment

The proportion of patients on a cancer referral pathway seen within the targeted 62 days declined again in 2021/22 – from 74.3% in 2020/21 to 68.8%. As with other aspects of hospital performance, increasing cancer wait times predate the pandemic: the last month that the NHS exceeded the 85% target was in December 2015.

Despite worsening wait times following a cancer referral, the NHS has run a successful campaign to encourage people to come forward for cancer care. ³³⁵ NHS England, ‘NHS chief urges people to come forward for life saving cancer checks ahead of new campaign’, press release, 14 August 2021, www.england.nhs.uk/2021/08/nhs-chief-urges-people-to-come-forward-for-life-saving-cancer-checks-ahead-of-new-campaign After a drop in the number of cancer referrals in 2020/21 – down to 2.1 million from 2.4 million in 2019/20 – GPs made 2.7 million urgent referrals in 2021/22. ³³⁶ NHS England, ‘Cancer waiting times’, (no date), retrieved 1 September 2022, www.england.nhs.uk/statistics/statistical-work-areas/cancer-waiting-times This equates to an average of 2.4 million referrals per year across 2020/21 and 2021/22, approximately equal to the amount in 2019/20, implying that a good number of the people who did not come forward for care in the early months of the pandemic did so at a later date, and potentially due to the NHS’s awareness campaign.