1.On the basis of a report by the Comptroller and Auditor General, we took evidence from the Department for Health & Social Care (the Department), NHS England and NHS Improvement.
2.The NHS Constitution sets out the principles and values of the NHS in England and the rights to which NHS patients are entitled. The Department and NHS bodies are required by law to take account of this Constitution in their decisions and actions. Since 2010, the Constitution has included maximum waiting times for elective (non-urgent) and cancer treatment as patients’ rights. Patients have the right to receive consultant-led elective treatment within 18 weeks of their referral (usually by a GP). For patients urgently referred for suspected cancer, they have the right to a first outpatient appointment within two weeks.
3.To ensure that patients’ rights on maximum waiting times are met, the Department and NHS England also set out operational standards for NHS organisations. They do not expect all patients to be treated within maximum waiting times, recognising that, in some cases, it may not be clinically appropriate, or patients may wish to wait longer. These standards currently include: 92% of patients should wait no more than 18 weeks for their elective treatment from referral if they are still on the waiting list; 93% of patients should be seen by a cancer specialist within two weeks of being urgently referred by a GP for suspected cancer; and 85% of patients diagnosed with cancer should be treated within 62 days following their GP referral.
4.The Department holds NHS England to account for national performance against waiting times standards. In turn NHS England holds clinical commissioning groups (CCGs) to account for meeting the standards for their local populations. CCGs are responsible for enforcing waiting times standards through contracts with service providers, mostly NHS trusts and foundation trusts. NHS Improvement, which merged with NHS England in April 2019, regulates and supports trusts to achieve waiting times standards for their patients.
5.The NHS is treating more people than ever before. Between March 2014 and 2018, the number of people treated for elective care per month increased from 1.2 million to 1.3 million. Between 2010–11 and 2017–18, the number of urgent referrals for suspected cancer increased by 94%. NHS England told us that the NHS aims to improve cancer survival by encouraging more people to come forward for early diagnosis and that the number of people referred for suspected cancer had increased by a quarter of a million to more than 2 million in 2018–19.
6.Performance against waiting times standards has steadily worsened in recent years. The NHS has not met the 18-week elective care waiting times standard since February 2016 or the 62-day standard from a referral with suspected cancer to treatment since 2013. The number of people still waiting for their elective treatment grew from 2.7 million in March 2013 to 4.2 million in November 2018 and the number of people waiting for more than 18 weeks increased from 153,000 to 528,000. The National Audit Office reported that poor performance against waiting times standards is now widespread with most local NHS bodies failing to meet these standards. In November 2018, only 44% of NHS trust and foundation trusts (trusts) met the 18-week standard for elective treatment and only 38% of trusts met the 62-day standard for cancer treatment.
7.We examined progress in improving cancer services and outcomes in 2015. We found that the NHS was failing to meet national cancer waiting time standards for patients, including the important 62-day cancer standard. In response, the Department and NHS England committed to improve performance, but instead there has been a further decline. 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 when we last reported on it. NHS England assured us that additional investment will be available to help improve its performance against cancer waiting times as part of the NHS Long Term Plan. However, NHS England could not give a commitment as to when the cancer waiting times standard will be achieved again. NHS England and NHS Improvement told us that that they would be in a better position to determine a trajectory for improving performance once local NHS organisations (sustainability and transformation partnerships and integrated care systems) have published their plans in September 2019.
8.The Government introduced waiting times to help improve patients’ satisfaction with the NHS as well as patient outcomes. It is important that Parliament and the public can rely on waiting times standards to hold the NHS to account, to track progress made and, more importantly, to gain assurance over patients’ rights to timely access to care. The Department told us that it was very important to have waiting times standards to set out expectations for the public and NHS organisations, to track progress and to send the right signals to the system. NHS England added that it also allows for benchmarking between different countries.
9.The National Audit Office reported that, facing rising demand while under increasing financial constraints, national bodies have focused more on emergency and cancer care than elective care. NHS England explained that this reflected the clinical priority of these conditions. The Department told us that it asks the NHS to simultaneously pursue a range of different targets, including heart disease, mental health and older people’s services and that the NHS must balance these different priorities when making choices about NHS care.
10.Since 2015, NHS England has gradually removed financial sanctions and penalties against NHS trusts for failing to meet elective care waiting times standards. NHS England’s and NHS Improvement’s planning guidance for 2018–19 no longer required trusts to meet to meet the 18-week target for elective care. We were concerned that this could imply to local health bodies that these targets are no longer important. NHS England told us that it had removed sanctions because many trusts were already in financial difficulties and additional sanctions would not add anything”
11.We asked whether the 18-week elective care target was a genuine target for the NHS and whether witnesses were concerned that the target was not being met. NHS England and the Department asserted that short waits for routine care do matter to the NHS, but the recent action it described has focussed on those waiting over 52 weeks. The Department told us that it took ‘significant management action’ when it saw an increasing number of patients waiting 52 weeks and over in order to reverse this trend. NHS England told us that, “to send a clear signal” to people who wait 52 weeks, it was reinstating financial penalties for both providers and commissioners where patients wait longer that 52 weeks for treatment, but not for those waiting more than 18 weeks. NHS England assured us that it will ask CCGs to increase the amount elective care undertaken in the next five years, and that it was taking action to treat more people within short waiting time targets.
12.NHS England is carrying out a review of NHS access standards which covers waiting times standards for cancer and elective treatment. It published its interim report in March 2019 which proposed several changes to cancer and elective waiting times standards. The main proposed change to waiting times standards for cancer is the introduction of a 28-day standard from a patient’s referral to their diagnosis to replace the current two-week waiting time standard from a patient’s referral to their first appointment with a specialist. For elective care, the report proposed to explore a number of options, including an average waiting time target to replace the current 92% 18-week standard. We heard from the Independent Healthcare Providers Network and Versus Arthritis that they were 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.
13.NHS England and stakeholders told us that the review was an opportunity to put patient experience and outcomes at the centre of waiting time standards. NHS England accepted that it will be important that it engages with the public regarding any changes to the current waiting times standards and how they will affect patients’ access to care and their rights under NHS Constitutions. NHS England explained that, in carrying out the review, it had consulted widely with stakeholders and patient representative bodies, for example, Healthwatch. The Department clarified that any proposed changes would have to be approved by the Government before being adopted. We asked the witnesses whether any changes to waiting times standards in the NHS Constitution would be subject to consultation. The Department was unable to provide us with details of what specific changes would be subject to consultation but committed to checking the law and clarify the situation with us. The Department subsequently wrote to us to confirm that the Secretary of State has a statutory duty to consult, including with patients, NHS staff and members of the public, on any changes to the NHS Constitution, but that there was no legal requirement to consult on changes to the Handbook to the NHS Constitution. It told us that the waiting times standards were included in the Handbook to the NHS Constitution rather than the NHS Constitution itself so, in practice, there was no legal requirement for it to consult about changes to the waiting times if the NHS Constitution remained the same. However, it confirmed that, regardless of the legal position, it was committed to holding a public consultation if any changes to waiting time standards were proposed as part of its ongoing review.
14.We received written evidence from Versus Arthritis, a charity, who told us that patient outcomes from joint replacement surgery are worse for those who wait for more than six months for treatment. It told us that delaying access to joint replacement surgery can lead to deterioration in an individual’s medical condition and “worse overall outcomes, ultimately costing the health and care system more”. Versus Arthritis similarly told us that patients who wait longer for treatment experience increased pain and disability compared to those with shorter waits. NHS England told us that for most patients on long waiting lists, such as those waiting for orthopaedic operations, a delay does not impact on survival, but recognised that it could mean that they are in pain for longer. It told us that a review at one trust of people waiting a long time on the elective waiting list found that two cancer patients, out of thousands of patients treated, suffered harm due to their long waits. It asserted that the cause of this had been that these cancer cases had come through an elective pathway rather than a cancer pathway.
15.NHS England told us that findings from studies of the impact of long waiting times on patient harm were not consistent and the relationship is difficult to assess. It also told us that, as the National Audit Office reported, although trusts collect data on patient harm through an incident reporting system, overseen by NHS Improvement, the data cannot be used easily to help understand the relationship between waiting times and patient harm because of the way that these data are currently collected.
16.Trusts are required to review whether patients have been harmed if they have waited more than 52 weeks for elective care. But these data are not collected at a national level. NHS England told us that it expects clinicians to use their professional judgement to manage and prioritise individual patients to ensure that patients do not come to harm because of longer waiting times. But it also recognised that widespread unwarranted variations in clinical practices exists across the country. We were concerned that patients might suffer harm while waiting for elective care even if they wait for less than 18 weeks for their treatment. As Pancreatic Cancer UK told us, it is possible that some patients suffer harm while waiting to see a consultant due to longer waiting times even when no waiting times standard is breached.
1 C&AG’s Report, , Session 2017–2019, HC 1989, 22 March 2019
2 C&AG’s Report, Figure 1, paras 1.2–1.5
3 Qq 12–13; C&AG’s Report, para 1.7 and Figure 5
4 C&AG’s Report, paras 3, 1.8–1.10
5 Qq 18, 19, 31, 32; C&AG’s Report, paras 9 and 12
6 Q6, C&AG’s Report, paras 8, 10
7 Qq 18–19; Committee of Public Accounts, , Forty-fifth Report of Session 2014–15, 2 March 2015; Treasury Minutes, , Cm 9091, July 2015; NHS England, – Provider based October 2009 to February 2019 Q4 2008–09 to Q3 2018–19
8 Qq 21–24, 31–35
9 Q 56; C&AG’s Report, para 1.2
10 Q 17
11 C&AG’s Report, paras 14,17
12 Q 13
13 Qq 10–11, 16–17, C&AG’s Report, Figure 7
14 Qq 9–11, 13; C&AG’s Report, para 17
15 Qq 3, 36, 37, 56, 57; Versus Arthritis (), para 45; , March 2019
16 Qq 36–46, 56, 57, 94, 95; Independent Healthcare Providers Network (); Versus Arthritis ()
17 Qq 20, 42, 56, 57; Breast Cancer Care and Breast Cancer Now ()
18 Qq 36–46
19 , 14 May 2019
20 Q 101; Versus Arthritis (), para 24; British Orthopaedic Association (); C&AG’s Report, para 18
21 Q 101; C&AG’s Report, para 18
22 C&AG’s Report, para 18
23 Qq 59, 91, 93–97, 101; C&AG’s Report, para 18; Written evidence submitted by Pancreatic Cancer UK
Published: 12 June 2019