1.The NHS is failing to meet key waiting times standards for cancer and elective care, and its performance continues to decline. The NHS is treating more people for suspected cancer and elective care than ever before. For example, the number of patients referred for elective care has increased by 17% since 2013–14 and the number of patients referred for suspected cancer has almost doubled since 2010–11. However, the NHS has not met the 18-week waiting times standard for elective care since February 2016. In November 2018, 44% of NHS trusts and NHS foundation trusts (trusts) met this standard. The waiting list for elective care has grown, from 2.7 million in March 2013 to 4.2 million in November 2018. The NHS has not met the 62-day standard from urgent referral for suspected cancer to treatment since 2013, and in November 2018 only 38% of trusts met this standard. In 2015, NHS England committed to us that it would improve performance against the 62-day cancer standard, but performance has further declined since. Between July and September 2018, only 78.6% of patients were treated within 62 days of an urgent referral, down from 83.8% between September and December 2014. Substantial improvement is clearly needed. NHS England and NHS Improvement assert that that they will be in a better position to determine how best to improve performance once local NHS organisations have published their forward plans in September 2019.
Recommendation: NHS England should set out, by December 2019, how, and by when, it will ensure that waiting times standards for elective and cancer care will be delivered again.
2.The Department of Health & Social Care has allowed NHS England to be selective about which standards it focuses on, reducing accountability. Under the NHS Constitution, patients in England have the right to be treated within maximum waiting times. It is important that Parliament and the public can rely on NHS waiting times standards to hold the NHS to account over patients’ rights to timely access to care. However, in response to rising demand while under increasing financial constraints, the Department has allowed NHS England to prioritise meeting standards for emergency services and cancer care over elective care. NHS England told us that, in recent years, it has removed sanctions and penalties against NHS trusts for failing to meet elective care waiting times standards, as many of the trusts were already in financial difficulties. We welcome the action taken by NHS England to focus on reducing the number of patients waiting 52 weeks and over for elective care, but we are concerned that the Department is no longer holding NHS England to account for the other service standards that are still in place.
Recommendation: The Department of Health & Social Care and NHS England should clarify to the Committee by December 2019:
3.We are concerned that NHS England’s review of waiting times will not be enough to ensure a clear understanding of, and strong accountability over, the performance of the NHS. We welcome NHS England’s current review of standards for accessing NHS services, which includes waiting times standards for cancer and elective treatment. Its interim report, published in March 2019, proposes several changes to cancer and elective waiting times standards. Some stakeholders are concerned that, given the ongoing failure by the NHS to meet the 18-week standard, the review could be used as an opportunity to make the target easier to meet or less appropriate. The review is an opportunity to put patient experience and outcomes at the centre of waiting time standards, but the health bodies involved must ensure that strong accountability for performance remains if standards are being altered. It is also important that the NHS engages with the public regarding any changes that may affect their access rights.
Recommendation: The Department of Health & Social Care should ensure that any changes to current waiting times standards:
4.The national health bodies lack curiosity about the impact for patients of longer waits and how often this leads to patient harm. When waiting times are longer, patients may experience additional pain, anxiety and inconvenience. There is also a risk that longer waiting times may lead to patient harm through, for example, the deterioration of a medical condition. Similarly, outcomes for those who wait for more than six months for treatment can be poorer. The NHS has a very limited understanding of this issue. Although trusts collect data on patient harm through an incident reporting system, which is overseen by NHS Improvement, the data cannot be used easily to help understand the relationship between waiting times and patient harm. Individual trusts may carry out harm reviews due to long waiting times, but these data are not collected at a national level. NHS England is aware that some patients have suffered harm due to long waits and that research on the relationship between patient harm and waiting times is not consistent. NHS England relies on the professional judgement of clinicians to ensure that patients do not come to harm because of longer waiting times but accepts that widespread unwarranted variations in clinical practices exist across the country.
Recommendation: The Department of Health & Social Care, together with NHS England and NHS Improvement, should write to us by December 2019 on how they are going to ensure that the data on patient harm due to long waiting times are going to be routinely collected, reported and acted upon.
5.Bottlenecks in hospital capacity are having a detrimental impact on how long patients wait for treatment. There are wide variations in performance against waiting times standards across local areas and hospitals. For example, the proportion of patients waiting less than 18 weeks for their elective care varied between 75% and 96% across CCGs in England in 2017–18. Poorer performance in waiting times is related to bottlenecks in hospital capacity, including diagnostics and bed occupancy. We have highlighted the persistent lack of capacity in diagnostics services, including shortages in diagnostics staff, in our previous reports. In terms of access to diagnostics, England compares poorly to other countries that have a similar level of income to England. Hospitals now routinely operate with a bed occupancy rate of more than 90%. This can affect elective patient care as patients may have their elective care treatment postponed because the beds are needed for emergency admissions, resulting in delays to treatment. We are concerned that the number of NHS beds has been reduced over recent years but the NHS does not know what the right level of beds is to meet the growing demand for its services. NHS Improvement told us that there is still room to make better use of existing beds through improving patient pathways which may help meet some of the demand for services.
Recommendation: NHS England and NHS Improvement should evaluate and report back to the Committee on how the NHS plans to ensure that it has the required diagnostic and bed capacity to meet patient demand in the medium to long term. They should also set out, in the short term, how they will support local bodies to improve their patient flow through the health system and reduce unwarranted variation.
6.The NHS still does not understand sufficiently what is driving demand for referrals for elective treatment. Between the 12 months to March 2014 and the 12 months to November 2018, the number of referrals for elective treatment increased by 17%. Our recent report on NHS financial sustainability, published in March 2019, concluded that the rising demand for NHS services is not sufficiently well understood. The Department asserts that there are three groups of factors which are driving the increase in demand for elective treatment: demography, technology, and patient expectations. NHS Improvement explained that up to 45% of inpatient admissions and 25% of outpatient referrals are due to a growing and ageing population. But the impact of technology and patient expectations on referrals for elective treatment are difficult to quantify and less researched. NHS England expects local commissioners and sustainability and transformation partnerships (STPs) to forecast and develop plans to meet the demand from their local populations. However, we are concerned that each local body carrying out its own analysis will lead to duplication of efforts.
Recommendation: As we recommended in March 2019, NHS England and NHS Improvement should, by September 2019, write to us to set out how they will help local bodies to better understand the demand for care, and to plan their services accordingly to better meet the needs of their local patients.
7.NHS England has not yet identified how it will manage the variety of factors that could affect the success of its plans to better manage elective care. The NHS Long Term Plan, published in January 2019, commits to reducing face-to-face outpatient visits by one-third as part of a wider attempt to manage demand, but NHS England has not set out how this will be achieved. NHS England expects local STPs and integrated care systems to publish plans this autumn, setting out how this will be achieved for their local populations. We are concerned that it will be difficult for these local partnerships to plan effectively when they already face considerable uncertainties, for example, in their local budgets for capital, education and training, and adult social care. NHS England expects the next spending review to provide clarity on these budgets, but the timing of this is also uncertain. The NHS has not yet published its people plan to support its Long Term Plan. It often takes many years to train key staff such as those working in diagnostics, meaning staff shortages in these areas will continue for at least the next few years. Reducing outpatient appointments through providing more care in the community will also require an increase in capacity for primary care. NHS England told us that it will develop primary care networks that will cover a population of between 30,000 to 50,000 people, but we are concerned that this may not work well for rural areas.
Recommendation: The Department, NHS Improvement and NHS England should, by December 2019, clarify to us:
Published: 12 June 2019