17.There are wide variations in performance against waiting times standards across local areas and hospitals. In 2017–18, the proportion of patients waiting less than 18 weeks for their elective care varied between 75% and 96% across clinical commissioning groups (CCGs), and from 73% to 100% across NHS trusts and NHS foundation trusts. For cancer, the percentage of patients treated within 62 days following a GP referral varied from 59% to 93% across CCGs.
18.Variations in waiting times performance is closely associated with the diagnostic capacity in the NHS. The National Audit Office found that a higher proportion of patients completing their diagnostic tests within six weeks is associated with a higher proportion of patients waiting less than 18 weeks for treatment. However, it also found there are staff shortages in specific specialties including pathologists, radiologists and radiographers, all of which are involved in diagnostics tests. In our 2015 report on Progress in improving cancer services and outcome in England, we highlighted the lack of capacity in diagnostics services, including shortages in diagnostics staff, and asked NHS England to assess whether the NHS had sufficient diagnostic services. NHS Improvement confirmed that there was still a big capacity issue around diagnostics which required major investment, and pointed out that, for access to MRI and CT scanners, England compared poorly to other OECD (The Organisation for Economic Co-operation and Development) countries.
19.Hospitals with a higher level of bed occupancy are more likely to perform poorly against the 18-week waiting times standard. Hospitals in the NHS 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. The number of NHS beds has reduced by 7% (8,000) since 2010–11. We asked whether the NHS had the right level of beds required to manage patient efficiently. NHS Improvement told us that it believed there was still room to make better use of existing beds through improving patient pathways and cutting length of stay in hospitals.
20.Between the 12 months to March 2014 and the 12 months to November 2018, the number of referrals for elective treatment increased by 17%. A good understanding of what is driving rising NHS activity is needed in order to manage this demand and plan for services in the future. However, as we concluded in our recent report on NHS financial sustainability, published in April 2019, the rising demand for NHS services is not sufficiently well understood. Our report found that the ageing population accounts for approximately half of the rise in demand for NHS services across England, but other factors that contribute to rising demand are not fully understood, at a national or local level. We also found that wider socioeconomic factors such as housing, employment, and changes to benefits and universal credit, were also contributing factors.
21.The Department explained that there are three groups of factors which were driving the increase in demand for elective treatment: demography, patient expectations and technology, which allowed the NHS to treat conditions which could not previously been treated. NHS England similarly told us that the increase in demand was the result of it expanding the number of interventions, such as cataract operations, knee replacements and hip replacements, and because it was “constantly pushing the boundaries of medical science”. NHS Improvement explained that up to 45% of inpatient admissions and 25% of outpatient referrals are due to a growing and ageing population. Both the Department and NHS Improvement accepted that the impact of technology and patient expectations are difficult to quantify and less researched.
22.The Department asserted that the NHS must have a system in place that is able to respond to changes it did not know about yet and needed a workforce that would be able to adapt to new technologies. The Department acknowledged that such a system was not yet in place. We asked whether the NHS is able to model the demand for its services. NHS England explained that local commissioners and sustainability and transformation partnerships (STPs) were responsible for forecasting and developing plans to meet the demand from their local populations. To support the development of local plans by STPs, NHS England committed to setting clear expectations about demographics and other demand drivers.
23.In January 2019, NHS England published the NHS Long Term Plan. It committed the NHS to reducing face-to-face outpatient visits by one-third over the next five years as part of a wider attempt to manage demand. NHS Improvement told us that the NHS will achieve this through a “clinically-led discussion about a change in clinical practice”. NHS England explained that this would be achieved by: maximising the use of “one-stop” clinics, where tests, tests results and treatment plans are all carried out in a single visit instead of multiple ones; integrating primary and secondary care so that patients can be managed in the correct environment first time, for example, treatment by physiotherapists in the community rather than being referred to hospital; and adopting a range of technologies that are used in everyday life, such as video consultations, emails or texts, instead of face-to-face consultations when no physical examination is required.
24.NHS England told us that it expected local STPs and integrated care systems to publish plans this autumn which set out how the aspirations in the NHS Long Term Plan will be achieved for their local populations. It explained that the local plan will set out the STP’s “trajectory” for service changes and NHS England will bring them together “in the autumn as part of the national implementation plan for the NHS Long Term Plan”. Our report on NHS financial sustainability, published on 3 April 2019, found that there were a number of uncertainties in the budgets for capital, education and training, and adult social care which made it difficult for local partnerships to plan effectively. NHS England told us that it expected the next spending review to provide clarity on these budgets, but there is uncertainty over its timing. The Department stressed that it often takes many years to train clinical staff. NHS Improvement told us that it has yet to publish its people plan and that this would not be finalised until towards the end of the year after the spending review.
25.NHS England told us that it intends to reduce outpatient appointments by providing more care outside of hospitals. For this to happen, it will require an increase in capacity for primary and community care. NHS England told us that it will develop primary care networks for populations of 30,000 to 50,000 people where GPs are supported by multidisciplinary teams, including therapists, social prescribers, physiotherapist, and clinal pharmacists and. It told us that supporting the generalist skills of GPs with a wide range of multidisciplinary staff would allow GPs to “focus on what they do best, which is the complex conditions that they increasingly see with an ageing population”.
24 Qq 47, 64; C&AG’s Report, paras 13, 2.5,3.6 and Figure 2
25 C&AG’s Report, para 2.16
26 Qq 64–66; Committee of Public Accounts, , Forty-fifth Report of Session 2014–15, 2 March 2015
27 Qq 69–74; C&AG’s Report, paras 14, 2.17–2.19
28 C&AG’s Report, para 17;
29 Committee of Public Accounts, , Ninety-First Report of Session 2017–19, 3 April 2019
30 Qq 58–59
31 Q 63
32 Qq 60, 63, 68, 78
33 C&AG Report, para 22
34 Qq 75, 76
35 Qq 77–81
36 Committee of Public Accounts, , Ninety-First Report of Session 2017–19, 3 April 2019
37 Qq 90–91, 99–100, 102–108
38 Qq 53, 54
39 Q 86
Published: 12 June 2019