With demand for hospital treatment outstripping capacity even before COVID-19, it is no surprise that the demands of delivering care during a pandemic have led to significant backlogs and longer waits for patients.
A growing backlog of care in England
The backlog in secondary care consists of the care that the NHS would normally have delivered but which was disrupted as COVID-19 impacted service delivery.
This includes:
- patients on a waiting list for treatment who would ordinarily have been seen by now
- patients who have not yet presented to their GP to seek a referral for symptoms due to concerns of burdening the health service or fears around COVID-19 infection
- patients who have had procedures cancelled
- patients who have had referrals delayed or cancelled
- patients who have had referrals refused due to a lack of capacity.
It will take years to clear the backlog. The ongoing need for stringent infection prevention control measures and workforce shortages mean it will take even longer to work through as demand continues to rise.
More patients than ever are waiting for treatment
High waits for treatment are not new. Prior to the pandemic in February 2020 there were already 4.43 million people on a waiting list for care.At the beginning of the pandemic, the combination of suspension of non-urgent services and changes to individuals’ behaviour meant that the number of people joining the waiting list initially dropped. However, this has since been rising - and despite some improvements earlier in the year, waiting times remain far higher than pre-COVID:The latest figures for July 2022 show:
- a record of over 6.84 million people waiting for treatment
- 2.67 million patients waiting over 18 weeks for treatment, a further increase from last month
- 377,689 patients waiting over one year for treatment - over 365 times the 1,032 people waiting over a year pre-pandemic in July 2019
- a median waiting time for treatment of 13.3 weeks – significantly higher than the pre-COVID duration.
The hidden backlog is growing
The waiting list is a visible backlog, but what we refer to as the growing 'hidden backlog' remains an unknown for the health service.The hidden backlog consists of patients who require care but have either not yet presented, or who have had referrals cancelled due to the impact of Covid-19 on the NHS; patients who, in normal times, would have been referred for treatment, received elective care and attended outpatient appointments, but who for a number of reasons relating to the pandemic have not yet found their way into the health system.
Despite improvements in 2021 and 2022 compared to the first year of the pandemic, the number of electives and outpatient attendances currently being carried out is still well below pre-pandemic levels.This is storing up greater problems for the future. These backlogs are likely to result in worsened conditions down the line, leading to greater demand on health services.
Cancer targets continue to be missed
While the number of patient referrals has surpassed pre-pandemic levels, the proportion of patients seen by a specialist consultant within two weeks of an urgent GP referral for suspected cancer remains worryingly low.
The 93% target for patients to be seen within that time frame has not been met since May 2020.
The percentage of patients receiving their first treatment within two months of attending a screening service dropped dramatically during the initial few months of the pandemic, and despite some improvement remains well below the operational standard.
The decline in these key indicators shows the level of pressure the system is under, and is a clear sign that significant investment in capacity is needed.
Patients are waiting longer for emergency care.
Prior to the pandemic, the situation in A&E was increasingly difficult with demand soaring and the percentage of people being seen within the four-hour target reaching an all-time low over the 2019/20 winter.
Since the start of the pandemic, A&E attendance decreased significantly which led to performance improvements. However, since lockdown eased demand has steadily risen, reducing performance against targets.
There were a total of 1.98 million A&E attendances in August 2022 – a drop from the 2.16 million waiting in July 2022.
Waiting times have rocketed
The combination of ongoing pressure on services, the backlog of care and chronic workforce shortages means waiting times have increased to record highs.
The number of patients waiting over 12 hours from decision to admission decreased slightly in August 2022, after a huge increase in July 2022. However, at 28,756, this number remains much higher than usual: it is over 77 times as high as it was in August 2019. This figure also represents an underestimate of actual waiting times, as patients will have been waiting for additional time before a ‘decision to admit’ was made.
GPs are finding it harder to make referrals
We can track GP referrals into consultant-led outpatient services alongside the waves of COVID-19: as the waves have peaked, referrals into secondary care have dropped. These drops are likely a combination of to changes to patient behaviour alongside capacity issues in secondary care effectively forcing GPs to take a more cautious approach with timings of referrals to avoid having referrals rejected.
GPs can still refer patients, but the pressures in hospitals means there is little capacity in secondary care, and those referrals are often rejected.
The number of GP referrals to consultant-led outpatient services that have been unsuccessful because there are no slots available has jumped from 238,859 in February 2020 to a staggering 401,115 in November 2021 (an 87% increase).
When GPs are unable to refer into hospital services, the care for these patients does not disappear. Instead, these patients need to be cared for by GPs while they wait for hospital treatment to go ahead, adding to the pressure in primary care.
The role of the private sector
Enlisting the help of the private sector is one of the measures the Government has taken to reduce pressures on hospitals and help cut waiting lists.
Purchasing private capacity is not new, but the pandemic has demanded unprecedented block-booking arrangements.
A recent BMA survey found that under these arrangements, 60% of private practice doctors who responded were unable to provide care to their patients at the time.
The extent to which private hospitals will be able to take on NHS waiting list initiatives going forward is unclear given the increased demand in the self-pay market and the backlog of private sector patients.Given that the NHS and the private sector largely draw on the same pool of doctors, additional capacity may be less than it initially appears. This was made clear in the 2020 block-booking arrangements, which saw the NHS gain facilities rather than the workforce to run them.