No quick fixes for growing hospital waiting times, the Nuffield Trust warns

Fundamental problems affecting the NHS will make it harder for all hospitals in England to meet key hospital waiting times targets in future, new analysis reveals today.

Whereas past dips in national performance have been attributed to a handful of ‘poorly performing’ hospital trusts, the study by the Nuffield Trust shows that marked deterioration on some measures over the past year has affected both the best and worst performing hospitals. This casts doubt on the idea that problems overall are caused by a series of local or managerial failings, and suggests instead that they are likely to be more systemic.

We’ve known that hospitals have been struggling to meet the four-hour A&E target for a while. But the fact that we are starting to see problems in other areas, like access to planned treatment, is a real concern. As this study makes clear, warning lights are now starting to flash across the wider hospital system.

Holly Dorning, Research Analyst and report author

Contained in a new policy briefing aimed at political leaders, the Nuffield Trust’s analysis looks at how all 156 hospital trusts in England have performed against six national targets over the course of this Parliament. It highlights the variation between the top and bottom ten percent of hospital trusts. As the briefing looks at the national picture affecting hospital care, individual trusts are not named.

The targets examined are: the four-hour A&E target; the 18-week target for a hospital bed (inpatient treatment); the 18-week target for an outpatient appointment; the six-week target for scans and other diagnostic tests; the two-week target for urgent cancer referral; and the 31-day target for cancer treatment.

Key findings include:

• National performance against the target for 90 per cent of inpatients and 95 per cent of outpatients to start treatment within 18 weeks held up between 2010/11 and 2013/14, but has deteriorated over the past year. Performance against diagnostic tests has followed a similar pattern.
• Although the top hospitals are still meeting the 90 per cent inpatient target, they too have seen a decline in their performance recently, whilst the bottom ten per cent have seen a marked deterioration.
• Performance against the four-hour A&E target has deteriorated considerably at national level since 2010 and this deterioration has occurred across the board: even hospitals in the top ten per cent breached the target in the most recent quarter.
• Targets for urgent cancer referral and cancer treatment have fared better in recent years, with these targets still being met at a national level and the top-performing hospitals retaining their past performance, although there has been a decline at the bottom end.
• The majority of hospitals breached a target on one or two measures – usually the A&E four-hour target and inpatient treatment or diagnostic tests. In 2013/14, no hospitals breached five or more targets, and only six trusts breached four targets. 

Co-author Holly Dorning, Research Analyst at the Nuffield Trust said:

“The vast majority of patients are still receiving care within the target times, but our analysis shows that deteriorating access to services is starting to affect patients attending even the best-performing hospitals.

“We’ve known that hospitals have been struggling to meet the four-hour A&E target for a while. But the fact that we are starting to see problems in other areas, like access to planned treatment, is a real concern. As this study makes clear, warning lights are now starting to flash across the wider hospital system."

The Nuffield Trust’s analysis also questions the assumption that access to care deteriorates as hospitals are asked to treat more patients. While extra activity in A&E, outpatient treatments and cancer care is matched with poorer performance against access targets, the NHS has absorbed an additional 240,000 diagnostic tests and an additional 45,000 urgent cancer referrals in the past year with little impact on performance against the associated targets. 

Co-author Ian Blunt, Senior Research Analyst at the Nuffield Trust said: 

“While looking at a narrow set of targets can only tell us so much about the quality of care, this analysis does suggest that some of the recent reductions in performance are systemic. The response to declining performance must be dictated by a deeper understanding of its causes, and political leaders should be aware of their system-wide nature.

“There are no quick fixes for growing waiting times and we need to be prepared to see further breaches of targets in the future.”