Referral to Treatment Times - Backlog +Analysis
+Andy Wilson - NHS Transformation Unit
+26 January 2024
+ +Summary
+The Elective Waiting List across England has seen unprecedented +growth since the start of the COVID-19 pandemic. Patients are waiting +longer than ever for their treatment to start. The NHS has focussed on +eradicating the longest waiting times with only limited success. +Currently 355,412 pathways have been waiting more than a year for +treatment. This analysis explores how the waiting list has changed since +the pandemic. The key findings of the analysis are:
+-
+
- The waiting list has increased significantly since the stat of the +pandemic. This is also reflected in the increase in waiting times. +
- The deterioration in waiting times is prevalent across all NHS +England regions. +
- National ambitions to eradicate long waiters has seen only a limited +success. +
- Gynaecology, ENT and Oral Surgery have seen the greatest +deterioration in waiting times. +
Introduction
+Background to Referral to Treatment Waiting Times
+The Referral to Treatment (RTT) standard forms a key component of the +NHS +Constitution. This states that 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 maximum waiting times for elective care are 18 weeks from +referral to their treatment.
+NHS England publishes monthly +data on the numbers of patients commencing treatment and how long +they waited. Additionally, figures on the number of patients who are +still waiting for their treatment to start and how long they have been +waiting are published. These pathways are referred to as +Incomplete Pathways. The total number of these are also +referred to as the “size of the waiting list” or “the RTT +backlog”. This is a helpful indicator of the capacity to deliver +Elective care across England. The national target is that 92% of these +Incomplete Pathways should be waiting less than 18 weeks since their +referral.
+Impact of COVID-19 on Delivery of Elective Care
+To help free as much acute bed capacity across NHS hospitals at the +start of the COVID-19 +pandemic there was a pause in non-urgent Elective activity. This +resulted in a significant increase in the size of the RTT waiting list. +As the immediate pressures of coping with the pandemic eased, NHS +England has prioritised reducing the number of long waiters. They +published their Delivery +plan for tackling the COVID-19 backlog of elective care in +February 2022. These include the ambitions:
+-
+
- No patients waiting longer than two years (104 weeks) by July +2022 +
- No patients waiting longer than 18 months (78 weeks) by April +2023 +
- No patients waiting longer than one year (52 weeks) by March +2025 +
Aims of this analysis?
+The analysis will explore:
+-
+
- How the size of the waiting list has changed since the +pandemic. +
- How waiting times have changed since the pandemic. +
- Understand if these changes are similar across the country. +
- Identify which Treatment Functions are most challenged. +
- Understand if the ambitions set out for elective recovery are being +met. +
What’s happened to the size of the Waiting List?
+Figure 1 below shows the size of the Incomplete Waiting list +across all providers in England from April 2011 to November 2023.
+Figure 1
+
There was a steady increase in the waiting list across England up to +the start of the pandemic. The waiting list rose from 2.5 million +pathways in April 2011 to 4.4 million by February 2020. There was an +initial drop in the size of the waiting list at the start of the +pandemic. This was due to fewer referrals from Primary Care as a result +of pandemic restrictions. After the first lockdown the waiting list grew +rapidly. The waiting list currently sits at 7.6 million by November +2023. This growth has taken place across all regions of the country as +shown below in Figure 2:
+Figure 2
+
+Looking at Treatment Functions demonstrates that almost all
+services have seen an increase in the backlog since the pandemic.
+However, there is considerable difference in the scale of this increase.
+Figure 3 shows the number of Incomplete Pathways for seven key
+services since April 2011:
Figure 3
+
We can see these significant increases across many Treatment +Functions. Gynaecology Service has increased by 108.1% since February +2020 and Plastic Surgery Service saw a 99.2% increase. Figure 4 +shows the percentage increase for all Treatment Functions.
+Figure 4
+
Targeting Longest Waiters
+Since February 2022 there has been an emphasis on the eradication of +waiting times over 52 weeks. Despite a reduction for those over 104 +weeks and over 78 weeks, these haven’t been eradicated. Figure +5 below shows the number of people waiting more than 52+, 65+, 78+ +and 104+ weeks since June 2021.
+Figure 5
+
+There has been a major reduction in the number of 104+ week waiters from
+a peak off 24,424 to 227. Whilst the 104+ week waiters were not
+eradicated in line with ambition of July 2022 the current position of
+227 is suggestive of only a small number of complex pathways remaining.
+Similarly, for 78+ week waiters there has been a reduction from a peak
+of 123,969 to 11,168. Although this reduction has plateaued since April
+2023. The ambition of eradicating these long waits by April 2023 has not
+been achieved. The number of 52+ week waiters continued to grow to a
+peak of 401,895 in September 2022. Although there has been a reduction
+with the latest position at 355,412. Despite this, the eradication of
+52+ week waiting times by March 2025 does not appear to be
+achievable.
Deteriorating Waiting Times - Shape of the Waiting List
+Eliminating the longest waiting times are important for both patient +experience and clinical outcomes. Studies have identified delays in +treatment are associated with reduced +health gain from hip and knee replacement and increased dependence +on opiates and depression.
+However, this can’t be the sole focus in attempting to recover and +stabilise elective waiting lists across England. Focussing on thresholds +can also mask important changes in how long patients are having to wait +for treatment. Looking at the changes to the shape of the waiting list +provides a greater insight.
+Figure 6 below shows the median time for each incomplete +pathway at the end of each month going back to April 2011. The +interquartile range and the range of the 10th to 90th percentiles are +overlaid.
+Figure 6
+
+For most of the 2010s the waiting times across England remained stable.
+There was a median waiting time of 5-6 weeks although this had began to
+rise before the start of the pandemic. The distribution of waiting times
+was also reasonably stable. Although both the upper quartile and 90th
+percentile waiting times had increased in the three years before the
+pandemic.
At the start of the pandemic there was a sudden and sharp rise in +waiting times. This was driven by a significant drop in referrals into +secondary care during lockdown. Since mid-2020 waiting times continued +deteriorate. The median waiting time has now risen to 14 weeks. The +upper quartile waiting time currently stands at 27 weeks and the 90th +percentile is at 41.
+Figure 7 shows the changes in the shape of the +waiting list. The distribution of current waiting times has a longer +tail than pre-pandemic:
+
This national pattern also occurs across each of the NHS England +regions as shown in Figure 8 below:
+Figure 8
+
Increasing waiting times are seen across all Treatment Functions. +This is particularly evident for surgical services such as the ones +shown in Figure 9 below:
+Figure 9
+
Figure 10 below shows each Treatment Function comparing +their increase in median waiting times with the percentage increase in +their waiting list size. This size of each Treatment Function represents +the size of the current waiting list. This helps to identify the +services with the greatest challenges to Elective recovery. Gynaecology, +ENT and Oral Surgery have all seen larger increases to both waiting +times and waiting list size.
+Figure 10
+
Conclusions
+The deterioration of elective waiting times are a concern for the NHS +as:
+-
+
- Longer waiting times are associated with reduced clinical outcomes +and worse patient experience. +
- The ambition to eradicate the longest waiting times has not been +achieved. The focus on long waiters risks masking concerning changes to +the shape of the waiting list. +
- The Waiting List is in a much more precarious position than before +the pandemic. Future challenges to the delivery of Elective care will +likely result in greater increase to waiting times. +
- Services such as Gynaecology, ENT and Oral Surgery have a +substantial challenge to recover the waiting list to pre-pandemic +levels. +
Datasets and Methods
+Dataset
+This analysis has been undertaken on publicly available data released +by NHS England. The data is published on a monthly basis and is +available here. +The dataset contains the number of Incomplete Pathways for both NHS and +Independent providers split by Treatment Function and the number of +weeks waited. No adjustments to the data have been made to account for +months where there is missing data due to missing or erroneous provider +submissions. Whilst NHS England publish national +estimates to account for missing data, the methodology for this is +not available for inclusion here.
+Methods
+At the NHS Transformation Unit, we are committed to open and +transparent analysis. Therefore, this work has been undertaken using the +open source programming R. All the code to +create this analysis is available from our GitHub +Repository.
+Guidance and Further Reading
+The links below contain helpful guidance and further reading relating +to RTT standards and performance:
+-
+
- RTT Guidance: Guidance published by NHS England +relating to the standards and interpretation of RTT rules is available +here. +
- RTT Published Data: Data relating to performance +against RTT waiting standards is available here. +
- The NHS waiting list: when will it peak?: Analysis +by the Health Foundation on exploring when the RTT Waiting List may peak +can be read here. +