May 2021

Our analysis

Introduction

As of Wednesday 12 May there were 907 people in hospital in England with COVID-19. As a direct result of the lockdown measures and the successful roll out of the vaccine programme, this number has come down from over 34,000 at the peak in January. We can safely say that we are now out of the latest wave. Please see our daily dashboard where we track the latest trends for further detail. 

This month, our NHS activity tracker shows COVID-19 pressure easing across acute hospitals alongside mounting urgency to restore services and treat those waiting for physical and mental health care.

 

As a direct result of the lockdown measures and the successful roll out of the vaccine programme, this number has come down from over 34,000 at the peak in January. We can safely say that we are now out of the latest wave.

   

This month’s performance figures

Each month NHS England and NHS Improvement  publish statistics looking at activity and performance across a range of services including urgent and emergency care, routine care, cancer, and mental health. Below we set out the latest trend for each clinical area:

NHS 111 and ambulance

Activity has increased since last month but ambulances managed to meet the Category 1 average response for the third month running.

• The number of calls received by NHS 111 in April increased by 2.1% since the previous month (36,005 more calls). Compared to April 2020, the number of calls received have increased by 3.6%.
• Ambulance category 1 incidents increased by 2.6% to 58,254 since last month (1,471 more incidents).
• In April 2021, the ambulance service delivered an average mean response time of seven minutes for Category 1 calls for the third month running. The average response time for Category 2 was 20 minutes and 16 seconds, missing the 18 minute target.

 

A&E and emergency care

Emergency care activity is increasing and is nearly back at activity levels seen in 2019 before the pandemic.

• In April 2021, there were 1.87 million A&E attendances, an increase of 10.6% since the previous month. In comparison to the same time last year, at the peak of the first wave, A&E attendances have doubled. A fairer comparison would be to activity levels in April 2019. There are currently only 11% fewer A&E attendances than two years ago.  
• Emergency admissions in April 2021 also increased by 1.2% from the previous month reaching 510,150. Compared to April 2019, emergency admissions are only down by 5% showing that activity is returning to pre-pandemic levels.
• The number of patients waiting longer than four and 12 hours from the decision to admit to admission have both fallen again this month. The number of patients waiting longer than four hours has fallen by 4.4% and those waiting over 12 hours has dropped by 24% to 523.
• Performance against 95% standard is currently 85.4% - a decline of 0.8 percentage points on the previous month. However, the level of performance is similar to that observed in April 2019.

 

Emergency care activity is increasing and is nearly back at activity levels seen in 2019 before the pandemic.

   

Elective care

There are long waits for planned care but elective activity is exceeding targets set out by NHS England and NHS Improvement in the 2021/22 planning guidance.

• The elective care waiting list is now 4.95million - up from 4.7million last month).
• The number of people waiting 52 weeks and over increased by 12% since last month and has reached 436,000.
• In March the NHS already exceeded the April targets set out in the planning guidance to deliver 70% of 2019/20 baseline activity. In addition the NHS England and NHS Improvement press release supporting today’s figures confirmed that in April (data will be published next month) elective activity is already at four fifths of pre-pandemic levels, so well ahead of the 70% target set out in official guidance.
• Performance against the 18 weeks standard has fallen by 0.01%, with 64.4% of people waiting less than 18 weeks, missing the 92% standard.

 

Diagnostics

Diagnostic activity has significantly increased but it remains a pressure point, potentially impacting on cancer and elective care pathways.

• The number of tests carried out in March 2021 has increased by 19.3% to 1.93 million (312,962 more tests than last month). In comparison to the year before, tests have increased by 27.1% (412,813 more tests). Numbers are similar to levels carried out in March 2019.
• MRI, CT and colonoscopy tests have all increased since last month (16.0%, 16.1%, 24.2% respectively).
• The diagnostic waiting list has increased by 9.1% since last month and 24.3% of people on the waiting list have been waiting six weeks or more for a test, falling short of the 1% target.

 

There are long waits for planned care but elective activity is exceeding targets set out by NHS England and NHS Improvement in the 2021/22 planning guidance.

   

Cancer

Cancer activity has soared this month with levels exceeding pre-pandemic levels. In terms of activity and performance across the three key cancer pathways:

• 232,084 people were seen within 2 weeks of an urgent referral for a suspected cancer - the highest on record. This is an increase of a third (33%) from the previous month and equates to an additional 57,460 consultations. 91% of urgent GP referrals were seen within two weeks, missing the 93% standard. For the 31 day pathway which aims for one month between starting treatment following a decision to treat, activity also increased by a fifth. The number of people who started treatment in March increased by 21% reaching 27,729. This equates to an additional 4,794 starting treatments compared to the previous month, also returning to pre-pandemic levels.  95% of people started treatment within one month of the decision to treat, just falling short of the 96% standard.
• Those on the 62 day wait from urgent GP referral to starting a first cancer treatment pathway also increased. The NHS started treatment for an additional 20% in total, reaching 14,686. Again, this matches the highest of pre-pandemic levels. There was also a marked jump in performance against this target with 74% of the people who started treatment, doing so within 62 days of their urgent GP referral.  This is an increase of over four percentage points since the previous month, but still falls short of the 85% standard.

 

Mental health

Trusts leaders continue to tell us that their services are increasingly under pressure with many members flagging an increase in the number and complexity of mental health presentations to emergency departments across England.

• In February 2021, similar to the previous month, there were 1.38 million people in contact with mental health services. This is 2.1% fewer people in contact with mental health services since the previous year.
• The number of people being referred for mental health services increased by 2.5% to 325,862 since the previous month. Compared to February 2020, referrals have fallen by 4.5%.
• In February 2021, the number of out of area placements increased again to 790 (30 more OAPs). This is the highest level witnessed in 17 months. Compared to April 2020, there are now 335 more OAPs.
• Trust leaders continue to flag the significant increase in demand for mental health services, in particular children and young people’s services. 

 

Cancer activity has soared this month with levels exceeding pre-pandemic levels.

   

Our view 

Longer waits in some areas but an encouraging increase in NHS activity

The impact of COVID-19 on the NHS means that the backlog of care is large and continuing to grow. Trust leaders are telling us they are now starting to see referrals  that had been delayed by the pandemic. Unfortunately, these bounce back referrals mean longer waits and growing caseloads spanning hospital, community and mental health services. Although much of the national focus is placed on tackling the elective care waiting list, trust leaders tell us the problem is more widespread, including an increasingly difficult situation in children and young people’s mental health services where both the demand and complexity of need has been impacted by the pandemic.

Today’s data shows that, sadly, lots more people are having to wait longer for planned care. Behind each person on a waiting list is an often difficult story of pain and risk of more serious harm. That’s why every trust leader, doctor and nurse are doing all they can to get through the waiting list as fast as possible.

But today’s figures also show how significantly the NHS has stepped up activity across emergency, elective, diagnostic and cancer care. Trusts are going as fast as they can, concentrating on the most urgent cases, and making good progress against the targets they were set in the planning guidance. This is on top of successfully rolling out the vaccination programme where 46 million doses in total have been administered by NHS staff.

Tackling the elective care waiting list

Today NHS England and NHS Improvement also announced £160m for accelerator sites to trial different initiatives to tackle the elective care waiting list. The additional funding will help to identify innovative approaches to getting through the backlog at pace. We know that trust leaders are committed to finding different ways of building capacity, embedding greater collaboration, and becoming more efficient and using technology.

Trusts were allocated £1bn at the start of the year to help tackle the waiting list. Beyond that, trusts need top up funding for the second half of the year to continue with the progress they are making. Over the longer-term trust leaders believe it will take between three and five years to recover and tackle longer waits. Trusts will likely need at least three years’ extra dedicated funding as the scale of the ‘bounce back’ demand is still unknown.

 

NHS activity tracker

A&E

   

Cancer

   

RTT

   

Diagnostic tests

   

Ambulance

   

Mental health

   

 

This month's case study comes from Helen Hendley, deputy chief operating officer (elective care) at Sherwood Forest Hospitals NHS Foundation trust, reflects on the challenges of delivering elective care through the pandemic.

 

Case study: Sherwood Forest Hospitals NHS Foundation Trust

Doing our best

I have worked in the NHS for 25 years including 18 years in operational management and regulation. Before the last 12 months, would I have believed anyone who told me they were doing their best while missing constitutional standards? Probably not, however I am a deputy chief operating officer who has lead elective care throughout the pandemic and I would defend my colleagues like a gladiator from anyone who questioned if we were doing our best.

I am so proud of what colleagues do every day to deliver safe care to our patients. We know there is always more we would like to do and we know patients who require non-urgent surgery are waiting longer than we would ever want them to. The impact this has on patients is something we have had to reluctantly come to terms with and we collectively share the burden of doing what we can, when we can. We are prioritising our patients so the sickest are treated first – a core principle of good elective care which we have maintained.

I know this because we set up a clinically-led, daily surgical prioritisation meeting. Surgeons, anaesthetists and business team colleagues collectively work together to ensure cancer and P2 patients are prioritised while reviewing P3 and P4 patients who have become overdue for their procedure. I recognise this is not perfect but where there is a patient who needs to be prioritised, we have a consistent place to discuss and a shared objective to resolve. As we enter the next recovery phase we will adopt the learning from this forum to support a revised and more robust weekly theatre scheduling process. We have built a superb clinical prioritisation dashboard with full credit and a massive thank you to our small and ever accommodating information team for developing.  

 

I am so proud of what colleagues do every day to deliver safe care to our patients. We know there is always more we would like to do and we know patients who require non-urgent surgery are waiting longer than we would ever want them to

   

Like everyone else we reacted swiftly and decisively to the first wave of COVID-19 by significantly reducing our elective programme. In the absence of knowing any better, I believe this was the right thing to do. When the first glimmer of hope started to emerge around late April/ early May 2020, a huge amount of effort went into restoring our services. We wrote to patients, we changed clinics and we ensured social distancing and other infection prevention and control guidance were followed. This was our teams at their best. The drive and passion to restore services was incredible. 

The impact of the second wave has reset my expectations about the delivery of standards. I want our patients to know they are safe and we have not forgotten about them. I want them to know who to contact if they are worried and in return I want them to be as flexible as they can in terms of where they will be treated but also to aim or maintain a healthy lifestyle before and after treatment. This is an area we will focus on more in the coming months.

The planning guidance has been helpful in setting out the six priorities for the year ahead and it was good to read that the plan to recover towards previous levels of activity and beyond would be over the "next few years". We must ensure that our colleagues have time to rest and decompress. They have the the full support of the executive team and I in terms of what they are able to deliver at the pace at which they can deliver it.  

 

Like everyone else we reacted swiftly and decisively to the first wave of COVID-19 by significantly reducing our elective programme. In the absence of knowing any better, I believe this was the right thing to do.

   

The guidance supports my personal view about continuing to focus on delivering cancer standards and the aim to have reduced long waits (in priority order) by this time next year. What we did in the first restoration and recovery phase was to empower our specialties to develop their own recovery plans and we have done the same again. I am proud we have a clear (specialty led) view of the activity levels that can be delivered while COVID-19 related constraints remain in place. We will work through these over the coming months and fully utilise the opportunity to be part of an accelerator system. This gives us access to important National resource to support our teams to unlock some of the capacity constraints or changes to ways of working they have wanted to do for some time. 

I want to be positive, consistent, honest and realistic with colleagues about what we can do and where we may need help, as well as supporting our teams to be as productive as they can be.  Let’s be honest, there were significant capacity problems pre-COVID that are still here. It will take years of commitment to right size elective capacity whilst remaining agile to urgent care or other demands. 

So how do I know we are doing our best for our elective patients? We have maintained or strengthened most of the usual elective rigour that was in place pre-COVID, we are prioritising our patients on the waiting list and we are striving for patients to know that ”we have not forgotten about you”. 

 

I want to be positive, consistent, honest and realistic with colleagues about what we can do and where we may need help, as well as supporting our teams to be as productive as they can be.

   

We continue to receive, diagnose and treat our patients – for cancer it is not always within 62 days, but we have welfare calls in place and a helpline for patients to contact if they are worried.  We have periodically communicated with different cohorts of patients, there are monthly public briefings and our chief executive shares a weekly community update - "You know who to contact if you need to".

We have redesigned clinics to offer more telephone and virtual appointments to our patients and expanded our surgical offer at our own and alternative sites – "we can be flexible and we need you to be too".

We will continue to do our best.

 

Press statement

Trust leaders deeply aware of the impact of delays for patients

Responding to the latest monthly combined performance data from NHS England and NHS Improvement, the chief executive of NHS Providers, Chris Hopson said:

"It is a real concern to see the waiting list for planned care heading towards 5 million people, with 436,000 people waiting longer than a year. Trust leaders are deeply aware of the impact of these delays for patients.

"Trusts are recovering from the pandemic as quickly as possible, prioritising the most urgent cases. Thanks to the dedication of frontline NHS staff, they are already ahead of their elective activity targets, and have seen a record number of people who were referred for urgent cancer checks in March. This is on top of successfully rolling out the vaccination programme.

"But there is still so much to do to get the NHS back on track, which is particularly hard to plan for when the true long term impact of the pandemic is still emerging.

"A trust leader told us that, at the moment, for every case they clear, another two referrals come through. While this remains the case the waiting list will continue to grow.

"And this is not just about pressure on hospitals. We are also seeing growing demand for mental health and community services.

"This is leading to a worrying increase in delays for patients and service users, but we should not overlook the step up in NHS activity, and the hard work that staff are doing – as they have throughout the pandemic."