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Table of contents

The House of Lords is scheduled to debate the following motion on 15 June 2023:

Lord Scriven (Liberal Democrat) to move that this House takes note of the current performance of the NHS and innovation in the health service.

1. NHS pledges and performance objectives

Under the ‘NHS constitution for England’, patients have the right to “access certain services commissioned by NHS bodies within maximum waiting times, or for the NHS to take all reasonable steps to offer […] a range of suitable alternative providers if this is not possible”. The document explains that these waiting times are described in the separate ‘Handbook to the NHS constitution for England’.

The handbook to the constitution, last updated in January 2022, elaborates on patient rights as well as separate NHS pledges. It notes that some of these, such as those relating to waiting times for treatment, are long-standing commitments. In other areas, it says pledges refer to relatively new commitments that the NHS is working towards achieving.

Specific waiting time rights for patients, subject to certain exceptions, include being able to:

  • start consultant-led treatment within a maximum of 18 weeks from referral for non-urgent conditions
  • be seen by a cancer specialist within a maximum of two weeks from GP referral for urgent referrals where cancer is suspected

The handbook adds that all patients “should receive high-quality care without any unnecessary delay” and lists various government pledges on waiting times. These include:

  • a maximum one month (31-day) wait from diagnosis to first definitive treatment for all cancers
  • a maximum two-month (62-day) wait from urgent referral for suspected cancer to first treatment for all cancers
  • a maximum two-week wait to see a specialist for all patients referred for investigation of breast symptoms, even if cancer is not initially suspected
  • a maximum four-hour wait in A&E from arrival to admission, transfer or discharge
  • patients waiting for a diagnostic test should have been waiting less than six weeks from referral

The pledges also include the following waiting times for ambulance trusts to:

  • respond to category 1 calls [for life-threatening illnesses or injuries, for example cardiac arrest] in 7 minutes on average, and respond to 90% of category 1 calls in 15 minutes
  • respond to category 2 calls [for emergency or potentially serious conditions, such as strokes or major burns] in 18 minutes on average, and respond to 90% of category 2 calls in 40 minutes
  • respond to 90% of category 3 calls [for cases judged urgent, for example late-stage labour or diabetes] in 120 minutes
  • respond to 90% of category 4 calls [for less urgent cases, including diarrhoea and vomiting] in 180 minutes

NHS England set out its national objectives for health care providers for the current reporting year in a document entitled ‘2023/24 priorities and operational planning guidance’, last updated in January 2023. It set three overarching tasks:

  • recover core services and productivity
  • make progress in delivering the key ambitions in the ‘NHS long term plan’
  • continue transforming the NHS for the future

The document argued that to improve patient safety, outcomes and experience in support of the first of these tasks, it was “imperative” that the NHS:

  • improve ambulance response and A&E waiting times
  • reduce elective long waits and cancer backlogs, and improve performance against the core diagnostic standard
  • make it easier for people to access primary care services, particularly general practice

Alongside a series of health-related performance indicator ambitions, the objectives included performance targets in certain key areas including waiting times for planned (elective) care, diagnostic tests, A&E and cancer treatment, as well as ambulance response times. For example:

  • eliminate waits of over 65 weeks for elective care by March 2024 (except where patients choose to wait longer or in specific specialties)
  • increase the percentage of patients that receive a diagnostic test within six weeks in line with the March 2025 ambition of 95%
  • improve A&E waiting times so that no less than 76% of patients are seen within four hours by March 2024 with further improvement in 2024/25
  • continue to reduce the number of patients waiting over 62 days [for treatment after a GP referral]
  • improve category 2 [covering suspected serious conditions, such as stroke or chest pain] ambulance response times to an average of 30 minutes across 2023/24, with further improvement towards pre-pandemic levels in 2024/25

These performance objectives have been preceded in some cases by recovery plans, for example for elective care. This plan set an ambition for the NHS to eliminate all waits over 78 weeks by April 2023.

2. Latest performance statistics

Until February 2020 the NHS in England published combined performance summaries which provided an overview of key NHS performance statistics in a single release. From March 2020, NHS England has instead published separate performance data for service areas including for measures across urgent and emergency care, planned care, cancer care and mental health care.

2.1 House of Commons Library summary of NHS performance

The House of Commons Library briefing ‘NHS key statistics: England, March 2023’ (13 March 2023) summarised NHS performance using data from a selection of these releases. It noted that before 2020 the NHS in England “experienced increased demand alongside declining performance on its main waiting time measures”, and that in many cases these pressures increased following the Covid-19 pandemic. The briefing summarised the NHS’s performance in key areas up to and including February 2023 as follows:

The number of people on a waiting list for hospital treatment rose to a record of 7.2mn in January 2023. The waiting list rose consistently between 2012 and 2019 and has risen more quickly since early 2021. The 18-week treatment target has not been met since 2016.

The number of people visiting A&E in February 2023 was similar to pre-pandemic levels. The percentage of patients waiting over four hours in hospital A&E rose consistently [between] 2015 and 2020. A new record high was reached in December 2022 but performance has subsequently improved slightly.

The 62-day waiting time standard for cancer (measured from urgent GP referral to treatment) has not been met in recent years. Performance declined between 2013 and 2018. Since the pandemic it has fallen further, with 54.4% of patients waiting under 62 days for treatment in January 2023 (target: 85%).

NHS staff numbers have increased, with 21% more doctors and 16% more nurses [on a full-time equivalent (FTE) basis] than five years ago. However, the NHS vacancy rate rose from 8.3% to 8.9% over the past year [also on an FTE basis].

Ambulance response times have risen, with the average response to a category 2 call [for a suspected serious condition, such as stroke or chest pain, which may require rapid assessment and/or urgent transport] at over 1 hour 30 minutes in December 2022, compared to a target of 18 minutes. Performance has subsequently improved but remains outside the target.

Separate House of Commons Library briefings consider the NHS workforce, NHS dentistry, mental health measures, cancer statistics and delayed hospital discharges in more detail.

2.2 NHS Providers monthly activity tracker

NHS Providers, a membership organisation for the NHS services that treat patients, is among sector bodies that track NHS performance on a monthly basis. In the most recent instalment of its NHS activity tracker, covering May 2023, the body noted trends in a number of clinical areas. After summarising performance statistics, NHS Providers concluded that the data showed a “complex picture with different demand and activity trends in different areas”. It noted that while activity in some areas was higher than before the Covid-19 pandemic, including for diagnostic activity and two-week referrals for suspected cancer, increasing demand meant longer waiting times. The statement continued:

Demand for care outstripping supply is common across systems. For example, the supply of mental health inpatient beds is under pressure with a jump in OAPs [out of area placements] being borne out in this month’s data, showing that capacity constraints span physical and mental health.

Meanwhile, demand for urgent and emergency care appears to have stabilised, with an ease in the demand for ambulances and A&E attendances. However, patients are still not moving through the system easily with the numbers residing in hospital despite being fit for discharge remaining high, putting pressure on both health and social care services.

The NHS is doing more than ever in many areas as it strives to recover and simultaneously transform services. However, this clearly isn’t enough to keep up with demand. The pressing need for a fully funded workforce plan that will address the scale of the demand challenge is overwhelmingly evident in today’s figures.

On specific performance measures, the activity tracker observed:

Ambulance: April saw response times for emergency incidents cut by more than an hour (compared to December 2022) to the lowest level in nearly two years.

  • Category 1 incidents have fallen by 6.4% to 72,005, 6% fewer incidents compared to a year ago but 32.1% higher than before the pandemic in April 2019. Category 2 incidents have also fallen by 4.6% from the month before to 361,133. Compared to 4 years ago, category 2 incidents are down by 5.8%.
  • The average response time for category 1 calls fell to 8 minutes 7 seconds, missing the 7-minute target. This is down from 8 minutes 49 seconds last month. The average response time for category 2 calls also fell to 28 minutes 35 seconds, meeting the 30 minutes target.

Emergency care activity: Fewer A&E attendances were registered in April and performance against the four-hour target is the highest since September 2021 and February 2022, respectively.

  • There were 2.03mn A&E attendances, a smaller number compared to the number of attendances observed the month before (6.3% fewer). There were about the same number of attendances compared to one year ago (0.1% more). There were 490,787 emergency admissions in April, a 7.8% decrease on the previous month. This is a slight increase of 2.3% compared to a year ago.
  • Performance against the 95% target for all A&E types increased to 74.6%, the highest it has been since September 2021 (75.2%). Performance against the type 1 target [for major emergency departments that provide a consultant-led 24-hour service with full facilities for resuscitating patients, which account for the majority of A&E attendances] also increased to 60.9%.
  • The number of patients waiting more than 12 hours from the decision to admit to admission has decreased by 32.2% to 26,899 since the month before. This figure is still nearly 6,000% higher than the same month four years ago before the pandemic, when this number was 442.

Elective care: Activity has increased across the board in March, but the waiting list also increased and is now at an all-time high. However, the number of those waiting more than 78 weeks has decreased this month.

  • The number of admitted inpatient pathways and non-admitted pathways have increased by 10.8% and 9.6%, respectively, on the previous month. The number of new RTT [referral to treatment] pathways in January also increased on the previous month from 1.6mn to 1.9mn.
  • The size of the waiting list increased by 1.6% to 7.33mn. The size of the waiting list remains considerably greater than three years ago just before the pandemic (+67.2%).
  • The number of those waiting more than 18 weeks has also slightly increased compared to the previous month (+1.3%). Those waiting more than 52 weeks remained somewhat stable at 359,978 (-0.7%) however, those waiting more than 104 weeks has decreased by 46.1% to 559. The number of patients waiting more than 78 weeks has decreased this month by 63.9% to 10,737.

Cancer: Over 260,000 patients were seen within two weeks of an urgent referral for a suspected cancer pathway, the second highest month on record. Performance against the waiting time standard has improved for the 62-day wait pathway.

  • Activity across the two-week pathway has increased by 13.3% since last month, the second highest month on record, above levels seen one year ago (+2.6%) and above pre-pandemic levels (+31.2%). Over 29,000 patients completed the 31-day pathway, which aims to begin treatment within one month from the decision to treat, also the second highest month on record. This is up by 14.2% since the last month and higher than it was one year ago (+3.5%) and above pre-pandemic levels (+16.5%).
  • Over 16,000 patients completed the 62-day pathway, up by 15% from the previous month and the second highest month on record for this pathway. This pathway aims to start a first cancer treatment within 62 days from an urgent GP referral. Activity for this pathway is higher than it was this time last year (+5.1%), and also above pre-pandemic levels (+22%).
  • All key national targets have still not been met this month: 84% of urgent GP referrals were seen within two weeks, missing the 93% standard; 92% of people started treatment within one month of the decision to treat, missing the 96% target; 64% of people who started treatment did so within two months of an urgent GP referral, missing the 85% target.

Diagnostics: Although the waiting list has increased from the month before, March was the highest month on record for diagnostic activity.

  • In March 2023, 2.3mn diagnostic tests were carried out, an increase of 12% from the month before and the highest month on record. Activity is 11% higher than one year ago and 16% higher than pre-pandemic levels.
  • The number of MRI, CT scans and colonoscopies have all increased compared to last month, all up by 11%. Activity remains higher than the same time last year and pre-pandemic levels for all MRI, CT and colonoscopy tests.
  • The diagnostic waiting list remains high at 1.6mn, a 2% increase from the month before and 4% higher than the same time last year. Compared to March 2019 before the pandemic, the waiting list has grown by 52%.
  • The number of patients waiting six weeks or more for a test is at 25%; this is the same as the month before and is still missing the 1% target.

The release also included data on discharge delays, waiting lists for community services, and mental health referrals and treatment performance.

2.3 Nuffield Trust and Health Foundation NHS performance tracker

In addition, the Nuffield Trust and the Health Foundation maintain a monthly NHS performance tracker called QualityWatch which includes summary analysis of the health service’s performance against “totemic access and waiting times targets”. The latest version of the tracker included information for March and April 2023 released on 11 May 2023. In a statement accompanying the tracker update, Tim Gardner, assistant director of policy at the Health Foundation, said the figures confirmed that “the NHS has fallen short of its target to eliminate waits of over 18 months for hospital treatment”. He added:

Although further progress has been made in cutting long waits, more than 10,000 patients were waiting for 18 months or more, with almost 360,000 waiting over a year by the end of March.

With services and staff under intense pressure, patients continue to pay the price. One in 10 patients with a serious condition, such as a heart attack, waited over an hour for an ambulance in April, with over one in 13 spending over 12 hours in A&E departments.

Resolving the current pay disputes should help avoid more short-term disruption, so the recent headway made by the government and trade unions is welcome. However, this will not address the underlying challenges facing the health service and those who work in it. The workforce plan, long promised by the government to address chronic staff shortages and improve retention, must be published.

The tracker provided detailed summary breakdowns for key activity areas as follows:

Planned hospital care and diagnostic test waiting times

  • The waiting list to start elective (planned) care saw an increase, from 7.22mn in February 2023 to 7.33mn in March 2023. This is the highest the waiting list has been since records began.
  • The median waiting time decreased slightly to 14.1 weeks in March 2023 from 14.5 weeks in February 2023. However, this waiting time fluctuates month-to-month and since June 2021 there has been a worsening trajectory. The median wait is nearly double what it was before the pandemic in February 2020, when it was 7.5 weeks.
  • The number of people waiting longer than 18 months to start elective treatment continues to decrease and nearly 11,000 were waiting over this length of time in March 2023. This compares to nearly 30,000 in February 2023. There is only one more month to reach the objective of eliminating these waits by April 2023 (except for patients who choose to wait longer).
  • The number of people waiting over 52 weeks to start elective care also decreased, but not to the same extent as the 18-month waiters. In March 2023 there were nearly 360,000 people waiting over 52 weeks compared to just over 362,000 in February 2023. In the seven years preceding the pandemic, there were never more than 3,500 of these long waiters in a given month.
  • 25% of people waited over six weeks for a diagnostic test in March 2023. This is very similar to the previous month and is still far beyond the 1% target, as well as the goal of 5% by March 2025.

Cancer waiting times

  • In March 2023, 36% of patients who had their first treatment for cancer following an urgent GP referral waited longer than two months. This is an improvement on February, which saw 42% waiting longer than two months.
  • The number of patients who waited longer than two months from an urgent GP referral to a first treatment for cancer was almost 6,000 in March 2023. When the 15% target was last met in December 2015, only 1,704 patients waited more than two months for their first cancer treatment.

A&E

  • In April 2023, 25% of people attending A&E spent more than four hours from arrival to admission, transfer or discharge. This is a slight improvement on April 2022 which saw 28% wait this long.
  • Performance against the 4-hour target needs to improve by a further 1.4 percentage points to meet the March 2024 objective of 24%, but the 5% standard is still far from reach.
  • Trolley waits (the time between a decision to admit a patient and them being admitted) of over 4 hours decreased to 113,437 in April 2023. This is 14% lower than the same month last year, but 69% higher than before the pandemic in April 2019.
  • Trolley waits of over 12 hours also decreased to 26,899 in April 2023—11% higher than in April last year and over 60 times greater than in April 2019.
  • Total attendances to A&E were almost the same in April 2023 compared to the previous April, with attendances around 4% lower than before the pandemic in April 2019.
  • The number of emergency admissions via A&E also remain below pre-pandemic levels, with 9% fewer in April 2023 than in April 2019.

Ambulances

  • Ambulance response times to category 1 incidents (life-threatening conditions, such as cardiac or respiratory arrest) saw a month-on-month improvement in April 2023, with an average response time of 8 minutes 7 seconds. 1 in 10 people waited over 14 minutes 27 seconds, meeting the 90th centile target (15 minutes) for the first time since June 2021.
  • Response times to category 2 incidents (emergency conditions such as stroke or heart attack) also saw a slight improvement in April, with an average response time of 28 minutes 35 seconds. But there is still some way to go to meet the mean target of 18 minutes.

2.4 Other trackers and commentary

The British Medical Association and the Telegraph newspaper are among others to maintain monthly performance trackers for the NHS in England.

The NHS Confederation describes itself as a membership organisation that “brings together, supports and speaks for the whole healthcare system in England, Wales and Northern Ireland”. In a statement released following the publication of NHS performance data in May 2023, the body noted:

  • The 78-week waiting list for elective care has been cut by 90% since September 2021 but the overall waiting list has risen to over 7.3mn entries in England.
  • Around half of NHS trusts in England have no patients on their elective care waiting lists apart from those who have chosen to wait longer.
  • Ambulance response rates have improved to their fastest in two years.
  • The 62-day cancer backlog has fallen for the first time since before the pandemic.

Rory Deighton, director of the NHS Confederation’s acute network, said the “phenomenal efforts of its staff” had been behind the NHS reducing the 78-week elective care waiting list. He added that this progress was “despite the NHS facing huge challenges including record emergency care pressures, a very difficult winter which saw high hospital bed occupancy rates, and five months of disruptive industrial action where nearly 60,000 procedures had to be postponed to protect patients”.

However, Mr Deighton cautioned that the NHS’s workforce deficit was the “single most disabling limitation for why [health leaders’] hardworking teams can’t deliver even more for their local communities”. The NHS Confederation called for the “urgent publication of the NHS workforce plan to provide a long-term solution to the access challenges facing the NHS”.

In a report focusing on the longer-term performance of the NHS in England published in April 2023, Professor Sir Chris Ham, a former chief executive of the King’s Fund, said that “multi-year funding increases and a series of reforms resulted in major improvements in NHS performance between 2000 and 2010”. However, he alleged that “performance has declined since 2010 as a result of much lower funding increases, limited funds for capital investment, and neglect of workforce planning”. Sir Chris made a series of recommendations for how to improve NHS performance. These included:

  • NHS revenue funding should increase in line with the long-term average. There should be realistic targets for efficiency savings, and spending on capital, education and training, and public health should be given priority.
  • Gaps in social care funding must be filled and there must be fundamental changes to social care funding and provision.
  • Priority must be given to investing in primary care and community services in order to anticipate people’s needs, promote independence and offer alternatives to hospitals.
  • There must be a credible and fully funded workforce plan for the NHS and, ideally, social care.
  • There should be a sustained commitment to prevention and early intervention, both in the NHS and in other public services, to tackle the wider determinants of health and reduce inequalities.
  • The public must be fully engaged in improving health and care, and patients and the public seen as active agents in their care, with responsibilities as well as rights.

2.5 Government policy

The government has acknowledged that NHS waiting list pledges in England are not being met and on 4 January 2023 Prime Minister Rishi Sunak pledged to cut waiting lists so “people will get the care they need more quickly”.

The backdrop to the pledge is a number of announcements aimed at improving NHS performance over time, including but not limited to:

The government confirmed in the spring budget published in March 2023 that a long-term workforce plan, due to “include independently-verified forecasts for the number of doctors, nurses and other professionals that will be needed in 5, 10 and 15 years’ time”, would be published “shortly”. On 6 June 2023, Secretary of State for Health and Social Care Steve Barclay reaffirmed the government’s commitment to publish a long-term workforce plan. He said it was a “complex piece of work that NHS England is working on” and that it was “important that we get the reforms in that plan right”.

Mr Barclay had earlier said that as well as increased funding and investment in new ways of working, “building the NHS back to where we want it to be […] requires the widespread adoption of innovation, building on best practice already applied in specific trusts”.

3. Innovation in the health service

NHS England maintains that innovation is “critical” to enabling it to achieve the ambitions set out in its mandate from government, “ramp up” the pace and scale of change and deliver better outcomes for patients. It lists the NHS Accelerated Access Collaborative along with heat maps and an earlier Healthy new towns programme as examples of recent innovation.

In a blog post published on 1 March 2023, Matt Whitty, chief executive of the Accelerated Access Collaborative and director of innovation, research and life sciences at NHS England, wrote on the occasion of the service’s 75th anniversary that the NHS had a long-standing history of innovation including pioneering procedures. He added that innovation was “now more important than ever” before continuing:

The NHS is still facing ongoing pressures, but innovation is playing a crucial role in every aspect of our work. From operational pressures, increased demand to tackling health inequalities and improving outcomes, innovation is rising to the challenge, providing ground-breaking diagnosis and treatments.

Mr Whitty said that “focusing on areas that contribute most to early mortality, disability, and lost productivity in the UK” would “make the biggest impact on people’s lives”.

NHS England’s ‘2023/24 priorities and operational planning guidance’, updated in January 2023, had suggested innovation was a key priority to help achieve its three tasks for the coming year. Under the heading ‘system working’, the document noted:

Improving NHS patient care, outcomes and experience can only be achieved by embedding innovation and research in everyday practice. Integrated care boards (ICBs) have a statutory duty to facilitate or otherwise promote research and the use of evidence obtained from research and to promote innovation, for example artificial intelligence and machine learning which is driving efficiency and enabling earlier diagnosis.

NHS England will continue to support integrated care systems (ICSs) to draw on national best practice and peer insight to inform future development.

The government had previously committed to helping ensure health and social care staff have the skills to apply innovative digital technologies successfully and NHS organisations have cultures that foster innovation as part of its plan for digital health and social care, published in June 2022.

However, an expert panel convened by the House of Commons Health and Social Care Committee concluded in a report published in February 2023 that the overall progress for the digitisation of the NHS was “inadequate”. In a response published in April 2023, the government said it did not recognise this assessment but thanked the panel for its “very helpful insights and learning for improvement on the specific areas focused on that we look forward to building into our programmes”.

In December 2021 the National Audit Office (NAO) published a report on NHS backlogs and waiting times in England. It observed that the government’s September 2021 increased funding settlement for the NHS, aimed in part to help clear elective care backlogs, had come with an expectation that NHS England would demonstrate flexibility and embrace innovation to help maximise elective activity delivered with the available funding.

In a follow-up report published in November 2022, the NAO said that “well-judged innovation is to be encouraged”. However, it added: “Not everything that looks promising will go on to deliver increased value, so careful and timely evaluation is important also. Without it, there is a risk that future allocations of resources to new initiatives will not be informed by reality on the ground”. It suggested learning from previous experience could also be a useful means of improving performance.

In February 2023, members of the Health Foundation’s improvement team warned that “without good implementation, innovation amounts to very little”. The authors urged the government “to fund ‘the change’, and not just ‘the tech’”, helping NHS teams to implement and optimise innovative changes.

The government has also allocated funding to incentivise innovation in other areas of the health sector. For example, during the 2023 spring budget Chancellor of the Exchequer Jeremy Hunt announced that the Medicines and Healthcare products Regulatory Agency would receive an extra £10mn to help accelerate patient access to treatments. The chancellor also outlined proposed reforms to the regulation of medicines and medical technologies.

4. Read more

Cover image by ar130405 on Pixabay.