Elective care

In our latest update we look at trends in the quality of elective care.

Indicator update

Published: 29/04/2021

Elective care (care that is planned in advance) was under considerable pressure even before the coronavirus (Covid-19) pandemic. Over 4.5 million patients were waiting to start consultant-led elective treatment in February 2020, and the headline target that 92% of patients should wait no longer than 18 weeks to start elective treatment has not been met since 2016.

The pandemic caused widespread disruption to elective care. Referrals fell, waiting times for treatment worsened, and planned procedures were cancelled. Waiting times for diagnostic tests increased sharply as the number of tests carried out fell. Measures required to support safe working during the pandemic, for example separating Covid and non-Covid patients, reduced the number of available hospital beds. There was also a rapid shift towards more outpatient appointments taking place via telephone or video calls.

NHS England’s 2021/22 priorities and operational planning guidance outlines plans for elective recovery. It sets out national target thresholds for activity to increase from 70% of the value of 2019/20 activity in April 2021 to 85% in July 2021. Local systems which achieve activity levels above these thresholds are eligible for additional funding from the Elective Recovery Fund.

A review of NHS access standards is currently being undertaken, and in March 2019 the Interim Report was published suggesting changes to national targets for elective care and cancer. Field testing of the proposed standards began in late 2019, however publication of the report’s recommendations for elective care and cancer has been delayed due to the Covid-19 pandemic.

In this indicator update, we looked at trends in the quality of elective care, including the impact of the Covid-19 pandemic. A summary of our indicators is shown below. Click on the links for more detailed content. For regular analysis of the latest referral-to-treatment performance and activity data, see our NHS Performance Summary reports.

GP referrals

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  • Between 6 January and 15 March 2020, the number of GP referrals to consultant-led outpatient services fluctuated around 360,000 referrals per week. From the week starting 16 March 2020, the number of referrals began to fall dramatically, reaching a low of 53,268 in the week starting 13 April.
  • Over the summer and autumn of 2020, referrals began to increase but fell again in January 2021. By the week starting 22 March 2021, the number of referrals had increased to 332,564.

Diagnostic test waiting times

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  • The proportion of patients waiting six weeks or more for a diagnostic test increased from 0.7% in February 2010 to 2.8% in February 2020. In March 2020, it began to increase dramatically, reaching 58% in May 2020. Since then, performance has improved but remains worse than before the pandemic. In February 2021, 28% of patients had been waiting six weeks or more for a diagnostic test.
  • Since 2008, the waiting list for a diagnostic test has been steadily increasing. However, in March 2020, the waiting list fell to 838,569 (22% lower than in March 2019). It has since increased to over 1.1 million in February 2021 (6% higher than in February 2020).
  • The number of diagnostic tests carried out has been increasing over time, but fell sharply from 1.9 million in February 2020 to 612,232 in April 2020. The number of tests carried out increased to 1.6 million in February 2021.

Treatment waiting times

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  • In February 2020, 83% of patients had been waiting less than 18 weeks to start elective care. Performance fell sharply during the Covid-19 pandemic, reaching a low of 47% in July 2020. In February 2021, only 65% of patients had been waiting less than 18 weeks.
  • The total number of people waiting for elective treatment exceeded 4.7 million in February 2021, the highest number since records began. This follows a previous fall to 3.8 million in May 2020, corresponding to a drop in referrals.
  • Since March 2020, the number of patients waiting over 52 weeks to start elective treatment has increased dramatically. In February 2021, 387,885 patients had been waiting over 52 weeks, compared to only 1,613 in February 2020.
  • Between February 2011 and February 2020, the median waiting time for patients still waiting increased from 5.5 to 7.5 weeks. During the Covid-19 pandemic, the median waiting time increased sharply to a high of 20 weeks in July 2020. By February 2021, it had fallen slightly to 13 weeks.

Cancer waiting times

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  • Between 2009 and 2014, the percentage of people with suspected cancer having their first consultant appointment within two weeks of an urgent GP referral fluctuated around 95%. Since then, performance has declined. In Q3 2020/21, 87% of patients had their first consultant appointment within two weeks of an urgent GP referral.
  • The proportion of patients waiting less than 31 days for a first treatment for cancer following a decision to treat decreased from 98% in Q3 2009/10 to 96% in Q3 2020/21. The 96% threshold has not been met since Q3 2019/20.
  • The proportion of patients waiting less than two months to start cancer treatment following an urgent GP referral for suspected cancer has decreased considerably over time, from 87% in Q3 2009/10 to 75% in Q3 2020/21.

Hospital bed occupancy

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  • Between Q1 2010/11 and Q4 2019/20, the total number of NHS hospital beds (general & acute, learning disabilities, maternity, and mental illness) decreased by 11%, from 144,455 to 128,935. In Q1 2020/21, following the onset of the Covid-19 pandemic, the total number of available beds fell to 118,510. In Q3 2020/21, the total number of beds increased to 121,524 (5% lower than in Q3 2019/20).
  • The number of available general and acute hospital beds fell from 110,568 in Q1 2010/11 to 102,194 in Q4 2019/10. In Q1 2020/21, the number of available beds fell to 92,559, increasing to 95,649 in Q3 2020/21 (6% lower than in Q3 2019/20).
  • In Q1 2020/21, the number of occupied general and acute beds decreased sharply to 58,005, 37% lower than in Q1 2019/20. The number of occupied beds increased to 79,520 in Q3 2020/21.

Cancelled operations

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  • Between February and April 2020, the percentage of operations that were cancelled either by the provider or by, or on behalf of, the patient increased sharply from 3% to 14%. The percentage of operations that were cancelled fell to 4% in June 2020 where it remained constant until it increased slightly to 6% in January 2021.
  • The number of operation appointments fell to 869,580 in April 2020, 61% lower than in April 2019. In January 2021, there were 1,570,119 operation appointments, 36% lower than in January 2020.

Deprivation and access to planned surgery

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  • In 2019/20, the most deprived decile had the lowest surgery rate, with 163 hip replacements per 100,000 population. The highest surgery rate was found in decile nine, with 217 hip replacements per 100,000 population.
  • Between 2008/09 and 2019/20, the rate of hip replacement decreased by 9 per 100,000 population in the most deprived decile, but increased by 12 per 100,000 population in the least deprived decile.

For more information and analysis on elective care, see these Nuffield Trust blogs:

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