NHS system capacity

This month we review some of the NHS’s key system capacity indicators.

Indicator update

Published: 22/07/2020

Understanding the capacity of a health system is essential to ensure that demand for services does not outweigh supply. As our population is ageing and more people are living with multiple long-term conditions, demand for NHS services has been increasing. Treatment and investigation options for many conditions have also expanded, contributing further to growth in activity. Demand varies throughout the day, week and year, so demand and capacity planning is vital to improve patient experience and outcomes.

The coronavirus (Covid-19) outbreak has had a profound impact on the NHS, with elective activity postponed to free up inpatient and critical care capacity, and considerable changes in service use during the pandemic and lockdown measures. As routine activities are resumed, many of the measures required to support safe working mean that hospitals will have to operate at lower levels of activity.

This month we’ve updated some of our key NHS system capacity indicators. We’ve also updated our indicators looking at the provision of timely, high-quality care for stroke, heart attack and COPD patients, which may be impacted by constrained capacity. The latest data presented here for A&E waiting times, hospital bed occupancy, out of area placements, and access to antenatal services covers the Covid-19 outbreak period. Data on care home and nursing bed availability, ambulance handover delays, stroke care, and care for heart attack and COPD patients are for before the pandemic. Please find a summary below and click on the links for more content and analysis.

A&E waiting times

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  • The total number of A&E attendances has been increasing over time, reaching over 6.5 million attendances in Q2 2019/20 (July to September 2019). In Q1 2020/21 (April to June 2020), the total number of attendances fell dramatically to 3.6 million during the Covid-19 outbreak. This may be due to the introduction of lockdown measures, increased use of other services (such as NHS 111), and reluctance to attend A&E for fear of contracting Covid-19.
  • The percentage of patients attending A&E that were admitted, transferred or discharged within four hours fell substantially between 2010 and 2019, dropping to an all-time low of 69% in December 2019. By June 2020, performance had increased to 90% alongside the substantial fall in A&E attendances.
  • The median A&E waiting time increased from 129 minutes in May 2011 to 174 minutes in December 2019, before falling to 135 minutes in May 2020.
  • Trolley waits – the time patients wait between a decision to admit and the patient arriving on a ward – have increased considerably since 2010. By January 2020, 18% of admitted patients waited over four hours between the decision to admit and admission. In June 2020, following the fall in A&E attendances, 4.1% of patients waited over four hours from a decision to admit to admission.

Ambulance handover delays

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  • Since 2010-11, there has generally been an upward trend in the number of ambulances experiencing a handover delay of over 30 minutes during the winter period.
  • Comparing the two most recent winters, between Week 49 and Week 9 there were 164,275 ambulance handover delays of over 30 minutes in 2019-20, compared to 135,949 in 2018-19.

Hospital bed occupancy

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  • Between Q1 2010/11 and Q4 2019/20, the total number of NHS hospital beds decreased by 11%, from 144,455 to 128,935.
  • Bed occupancy tends to peak in Q4 (January to March) of each year, however in 2019/20 the bed occupancy rate peaked at 89% for Q3 (October to December) before falling to 86% in Q4.
  • General and acute hospital bed occupancy reached a peak of 92% in Q3 2019/20.

Care home bed availability

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  • Between 2012 and 2019, the number of beds in care homes – both residential and nursing (where there is always a registered nurse on duty) – per 100 people aged 75 and over declined from 11.3 to 9.8 – a 13% decrease. Likewise, the number of nursing home beds per 100 people aged 75 and over fell from 5.2 to 4.8 – a 9% decrease.

Out of area placements

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  • At the end of April 2020, there were 455 active out of area placements in England, of which 435 (96%) were deemed ‘inappropriate’.
  • Between September 2017 and February 2020, the number of inappropriate out of area placements started each month increased overall from 586 to 665. In March 2020, the number fell to 440 and decreased further to 210 in April. This may reflect changes in mental health inpatient care use due to the Covid-19 outbreak.
  • It is estimated that inappropriate out of area placements make up around 3% of occupied mental health beds.
  • In April 2020, there were 25 inappropriate out of area placements that required patients to travel a distance of 300km or greater. There were 65 inappropriate out of area placements that required patients to travel more than 200km but less than 300km.

Access to antenatal services

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  • The percentage of women who attend an antenatal booking appointment at 10 weeks gestation or less has increased over time, from 48% in April 2015 to 57% in March 2020.
  • The CQC Maternity Survey asks women if they saw the same midwife at every antenatal check-up. In 2019, 37% of respondents said that they saw the same midwife at every appointment.

Care for heart attack patients

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  • Between 2004/05 and 2013/14, there was a significant increase in the proportion of patients with ST-elevation myocardial infarction (STEMI) receiving primary percutaneous coronary intervention (PCI) within 90 minutes of arrival at a heart attack centre, from 52% to 92%. Since then, there has been a slight decrease to 88% in 2017/18.
  • Delays from admission to angiography for patients with non-ST elevation myocardial infarction (nSTEMI) have not improved over time. In 2010/11, 55% of patients with nSTEMI underwent angiography within 72 hours, and this increased only slightly to 57% in 2017/18.
  • The percentage of eligible patients accessing cardiac rehabilitation in England increased from 44% in 2006-07 to 50% in 2017-18. In 2017-18, uptake was highest in Wales (61%) and lowest in Northern Ireland (49%).

Care for COPD patients

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  • There was an increase in the proportion of COPD admissions reviewed by a member of the respiratory team within 24 hours, from 49% in 2014 to 66% in 2018-19.
  • The percentage of admissions for whom a spirometry result was available stayed constant between 2014 and 2018-19, at 46%.
  • In 2018-19, only 47% of admitted patients who were current smokers were referred to a behavioural change intervention and/or prescribed smoking cessation pharmacotherapy during their admission.
  • Only 10% of patients received non-invasive ventilation (NIV) treatment in 2018-19 compared to 12% in 2014. Of those who received it, 24% received NIV within two hours of arrival.

Stroke care

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  • Between 2013/14 and 2018/19, the percentage of patients presenting with acute stroke who had a brain scan within 1 hour of arrival at hospital increased from 42% to 55%.
  • Over the last six years, the percentage of patients admitted to a stroke unit within 4 hours fluctuated between 57% and 58%.
  • In 2018/19, compliance against the speech and language therapy target for patients having stroke rehabilitation in hospital or in the community was 52% compared with 82% for physiotherapy and 91% for occupational therapy.
  • The percentage of stroke patients receiving a joint health and social care plan on discharge has increased over time, from 70% in 2013/14 to 94% in 2018/19.