NHS pressures in England: Waiting times, demand, and capacity

NHS waiting times reached record highs in 2019. Demand for health services is growing, particularly from older patients, but this isn’t necessarily the only cause of increasing waits. Funding for the NHS will increase in future, but commentators warn that this isn’t enough to deal with performance and capacity issues and transform services.

This article focuses on trends in England, although similar pressures have been experienced across the UK.

Waiting times are increasing

Waiting times for health services in England have risen in recent years. This trend continued in 2019, with many waiting times recording record highs:

• A&E: In 2010/11, one in every 25 people attending major A&E facilities in England spent over four hours in the department. By 2014/15 this had risen to one in 10 patients, and in 2018/19 it rose to almost one in five. Performance has continued to decline so far in 2019/20, with over one in five major A&E visits lasting over four hours.
• Waiting lists: 2.5 million people were waiting for hospital treatment in 2010. This rose to 4.6 million in September 2019, the highest number to date. The waiting time target, which states that 92% of those on the waiting list should have been waiting for under 18 weeks, hasn’t been met since early 2016. Currently, more than 15% of patients have been on the list for over 18 weeks.
• Cancer waiting times: NHS England reports nine different cancer waiting time measures, and all have dropped to their worst levels in 2019. One key standard is that patients should wait less than two months for their first cancer treatment after an urgent GP referral, but the 85% target hasn’t been met regularly since 2013. So far in 2019/20, only 78% of patients have been treated within two months.

NHS England is planning to replace some performance standards, including the four-hour A&E target, with new measures. Some new standards have also been proposed, e.g. for cancer diagnosis. A review is currently underway and a progress report (PDF 496 KB) has been published. Questions have been raised about the level of consultation involved, the pace of the review, and the potential relaxation of standards. The idea of abolishing the four-hour target for A&E has received a mixed reception.

Rising demand and system pressures

Many NHS services have experienced an increase in demand, driven by a growing and ageing population. However, it’s not clear that this can account for all changes in waiting times and performance. Between 2010 and 2018, the population of England rose by 6%, while the population aged 65+ rose by 19%.

Between 2010/11 and 2018/19:

• The number of hospital admissions rose 15%, from an average of 40,800 per day to 46,900. Older people accounted for most of the growth, with the proportion of patients aged 60+ rising from 45% to 49%
• The number of people going to major A&E departments has risen 13% from an average of 38,200 per day to 43,000. Meanwhile, the average number of four-hour waits in A&E each day rose from 1,500 to 7,900 – larger than the increase in demand
• The number of emergency admissions to hospital via A&E rose by 35% from 9,500 to 12,850 per day
• The number of people receiving a first treatment for cancer has risen by 27%, from an average of 657 to 859 per day. The number of urgent GP referrals for suspected cancer has more than doubled.

Rising demand for NHS acute services shouldn’t be seen in isolation. Pressure on social care and general practice can also lead to more demand for hospital services. It’s estimated that 1.4 million people have unmet need for social care, and waiting times for GP appointments have risen in recent years.

NHS capacity: beds, staffing and maintenance

Alongside pressures on demand and performance, there is a mixed picture on the capacity of the NHS.

Funding is rising. Local NHS funding is increasing by 9% between 2018/19 and 2023/24 (after accounting for inflation and population growth). The King’s Fund welcomed this settlement but cautions that “The new five-year funding deal for the NHS is not enough for performance to recover against [waiting time targets] while also developing new and better services.”

Staffing levels are rising in most categories, but the number of GPs continues to fall. For some staff groups, e.g. nurses and GPs, numbers haven’t kept pace with rises in the population.

The hospital maintenance backlog has risen. The estimated cost to eradicate NHS hospitals’ outstanding maintenance backlog was £6.5 billion in 2018/19. Of this, £1.1 billion was categorised as “high-risk”: repairs required to avoid catastrophic failure or disruption to services. The high-risk backlog cost has trebled since 2013/14.

There are fewer hospital beds available. The number of overnight beds has decreased from 141,477 in 2010/11 to 127,225 now. Average occupancy has risen over this period.

Further reading

• NHS Key Statistics: England October 2019, House of Commons Library
• NHS waiting times: Missed targets, missed pledges?, Nuffield Trust, 6 Dec 2019
• Five reasons why this NHS winter may be different, King’s Fund, 2 Dec 2019
• Clinically-led review of NHS Access Standards, NHS England

Image: Accident & Emergency Sign / Lydia / CC BY 2.0