The secondary care acute sector comprises of acute, specialist acute and combined trusts delivering urgent and emergency care, planned care and specialised care for different conditions such as rare cancers, genetic disorders or complex medical or surgical conditions.
It isn't possible to cover the data associated with all acute pathways here. For this summary, we explore trends across A&E services, diagnostics, the elective care waiting list and cancer services. We also look at data relating to current levels of NHS capacity such as general and acute beds and metrics of patient flow.
Demand and activity
All ten months of data reported so far this year have seen record A&E attendances for that month; 2024 is on track to be the busiest year ever for A&E departments. There were 2.36 million A&E attendances in October, 6.4% more than the previous month and 6.2% higher than October last year. The difference is greatest when comparing to five years ago in October 2019, before the pandemic – we are now seeing nearly 9% more demand for services.
Figure 1
A&E attendences
Alongside the increase at the front door, there has also been an increase in the number of people being admitted to hospital through emergency departments. There were 567,450 emergency admissions in October, 36,620 more than in September. This figure is slightly higher than five years ago in October 2019, with 4,370 more patients being admitted to hospital via A&E.
For planned care, activity levels increased across consultant led treatments, diagnostics, and cancer care in September. Across elective care treatments, both admitted and non-admitted activity increased in September. This boost in activity helped reduced the overall size of the waiting list this month. There was a total of 310,500 completed inpatient pathways in September, which is 3.6% more than in August. Non-admitted pathways increased by 9% compared to the previous month, reaching 1.21 million non-admitted pathways in September. There were 1.7 million new RTT pathways in September, a slight increase on August showing that demand levels remain steady. Elevated levels of activity are really what’s needed to make inroads in reducing the backlog. The Secretary of State recently announced a new plan would be published setting out how the NHS will meet the 18-week constitutional standard by the end its first term.
Activity across tests and screening remained high this month, with the NHS regularly delivering more tests than ever before. This is in part due to the successful roll out of community diagnostic centres. In September 2024, 2.37 million diagnostic tests were carried out. This is 1.3% higher than the month before, 7.8% higher than a year ago and over a fifth higher than pre-pandemic levels. Activity is greater than the same time last year for MRI, CT and colonoscopy scans by 10.2%, 5.9% and 3% respectively. Compared to September 2019, activity is also higher for MRI, CT and colonoscopy scans compared to before the pandemic (up by 27.3%, 36.6% and 21.2%, respectively).
Figure 2
Number of patients starting admitted treatment
Cancer screening and cancer treatments increased in September. The number of patients completing the 28-day faster diagnosis pathway increased by over 2,800, reaching 262,260. A further, 53,860 patients completed the 31-day pathway, a 1.2% increase from last month. However, the 62-day pathway had 200 fewer patients start treatment this month, falling to 26,320.
Waiting times
In our recent survey of trust leaders, nearly three quarters of trust leaders (71%) who responded to our recent survey thought it was unlikely that the NHS could meet constitutional standards, such as the 18-week standard for planned hospital treatment and the four-hour A&E standard, over the next five years.
In the face of sustained record levels of demand, waiting times in emergency departments have worsened slightly this month. In October 2024, performance against the four-hour wait target was 73%, down by 1.2 percentage points from last month and missing the target of 76%. The performance across type 1 A&E only deteriorated by 1.7 percentage points, to 58.1% in October. Of the 122 trusts with a type 1 A&E department, 16 met the 78% recovery target in October. Of the 122 reporting trusts with a type 1 A&E department, 5 met the 78% recovery target in October.
The target in the 2024/25 planning guidance is to see 78% of patients in four hours by March 2025. This is an ambitious and challenging target for trusts and their systems to meet. Made even harder considering the cyclical trend of worsening performance in A&Es over the winter months, the performance gap could be even bigger.
There was a significant jump in the number of patients that waited more than 12 hours from the decision to admit to admission, an increase of over 10,000 from the previous month reaching 49,600. This is a key indicator relating to patient flow between A&E and hospital wards. This figure is 11% greater than October last year. Five years ago, before the pandemic, only 726 people waited more than 12 hours to admission.
Figure 3
Number of patients spending >12 hours from decision to admit to admission
In addition, to the above metric, NHS England is now publishing provisional statistics on time in A&E which indicates flow within the emergency department. There were 1,470,344 attendances at type 1 & 2 emergency departments in October and of these 162,931 waited more than 12 hours from arrival at A&E (11.1%). There were over 25,000 more patients waiting more than 12 hours from arrival in A&E compared to last month, and over 16,000 more than the same time last year.
The diagnostic waiting list increased this month by 1.8% to 1.59 million. Compared to last year, the waiting list is up 0.3% and up by 55.1% compared to September 2019, before the pandemic.
22.7% of patients waited six weeks or more for a test, a decrease from 23.9% last month, but missing the 5% target by some way. 159 trusts reported diagnostic waiting lists this month. 35 met or exceeded the target of 95% of patients seen within six weeks or less. There is significant variation across diagnostic waiting lists and specific tests.
The waiting list reduced slightly to 7.57 million in September with 70,000 fewer treatments than last month. The size of the waiting list is smaller than it was a year ago but 66% greater than five years ago in September 2019, before the pandemic. In September, 83.8% of patients on the waiting list were unique patients. This is an estimated 6.34 million people, slightly lower than previous four months.
The NHS reduced waits across all reported time periods >52 weeks, >65 weeks, >78 weeks and >104 week waits; however, trusts missed the national target to eliminate waits >65 weeks by the end of September 2024. The number of treatments waiting >65 weeks halved in September reaching a new low of 23,000. The number of treatments waiting >52 weeks reduced by over 33,000, falling to 249,000. There are now 113 people waiting > 104 weeks. At the end of September, 58.5% of treatments had been on the waiting list less than 18 weeks and, overall, 3.14 million treatments have waited more than 18 weeks.
There is, of course, trust variation and speciality variation across the waiting list. Size of trust also plays a role. Looking at waits over 65 weeks, 29 trusts have zero waits and therefore met the trust target. However, 126 trusts still have people waiting, missing the September deadline. However, 71 of the 126 trusts have fewer than 100 patients waiting.
The cancer standards were streamlined recently into three new targets: Faster Diagnosis Standard (FDS) 28-day referral, 75%; 31-day treatment standard, 96%; 62-day treatment standard, 70%. Performance for all targets did not meet the standard for the 28-day referral, 31-day and 62-day pathways.
Performance against the 28-day FDS target has fallen from 75.5% last month, to 74.8% people being told if they had cancer, or if cancer was definitively excluded within four weeks (28-days) of an urgent referral. This slightly misses the existing standard of 75% and falls short of the new 24/25 target of 77%. The NHS has announced that this standard will increase to 80% by March 2026.
90.6% of people treated began first or subsequent treatment of cancer within 31 days of receiving a decision to treat/earliest clinically appropriate date, down from 91.7% last month and missing the 96% standard.
67.3% of people treated began first definitive treatment of cancer within 62 days of an urgent suspected cancer referral, breast symptomatic referral, urgent screening referral or a consultant upgrade. This is down from 69.2% last month and falls short of the 62-day standard to reach 70% by March 2025.
Capacity
In our recent survey of trust leaders, we asked what presented the greatest risk to the provision of high-quality care this winter. Over half of trust leaders (57%) said delayed discharges, 49% said social care provision and 43% said acute bed capacity. In relation to acute hospitals, trust leaders are increasingly telling us that delivering against financial targets and keeping additional capacity open are challenging.
Trusts also tell us that to maximise the use of hospital capacity, delayed discharge is a daily focus and challenge. On 31 October (a Thursday), there were around 23,720 patients who no longer met the criteria to reside in hospital. Of these, 51.4% remained in hospital that day. On average in October, there were 22,660 patients who no longer met the criteria to reside and of these, 54.5% remained in hospital each day. This is down from 55.7% in the previous month. Reducing delayed discharge by working closely with community providers and social care partners will be a crucial factor over winter to improve patient flow across the health and care system.