Waiting time disparities: a hidden problem in plain sight

For the purposes of this article, we have analysed NHS England RTT waiting times for patients admitted for treatment in November 2022 - the most recent month for which this data is available at the time of writing.

While NHS England waiting times are at record levels, with over 7 million people waiting for non-urgent treatment,¹ the general trend of long waiting lists masks significant regional variations. By analysing referral-to-treatment (RTT) waiting times published by the NHS, we have found that average waiting times can vary by more than a year for the same specialty. The massive pressures on NHS services are unevenly distributed, with some regions under greater strain than others. Notably, such disparities present an opportunity for patients to access NHS services quicker - patients have a right to choice in the NHS, meaning they have the right to choose where they are referred for non-urgent, consultant-led services.

National Variations

On a regional basis, the average (median) waiting time from being referred to receiving treatment is 12 weeks, ranging from 11 weeks in the North West of England to 13 weeks in the East of England. This range may be narrow, but it hides large variations. Even on the same regional basis, once waiting times are broken down into different specialties such as trauma and orthopaedics or paediatrics, there are stark differences. For paediatric services, there is an 18 week difference in the median waiting time, from 13 weeks in the South West of England, to almost 31 weeks in the North West of England.

The specialty where the most patients were treated in November (over 61’000) was ophthalmology, which encompasses eyecare treatments such as cataract surgery. Here, the two northern regions had the lowest waiting times, averaging at 9 weeks, compared to the South West of England, which averaged at 14 weeks.

Breaking down these regions into what the NHS calls sub-ICBs, one of the lowest divisions of ‘commissioning’ in the NHS, the differences are far greater. For cardiology services, which deal with heart-related problems, there is a tenfold difference between the longest sub-ICB waiting time (44 weeks in Southend) and the shortest (4.4 weeks in Tees Valley). This is one of the more extreme examples, but it is far from being an exception. Even for elective orthopaedic care (when treatment is necessary but not an emergency), there is a 27 week difference between the average wait in North Tyneside (13 weeks) versus Devon (40 weeks). This is a huge difference, both in absolute and relative terms. This means that patients in Devon being referred for hip or knee replacements, by choosing to be seen further away, could be treated up to three times sooner.

The largest waiting time differential at the sub-ICB level exists for paediatric care, with the difference in median waiting time between the best and worst sub-ICB being more than 52 weeks (Berkshire West and Heywood, Middleton and Rochdale respectively).

These findings are supported by analysis conducted by the Independent Healthcare Provider Network (IHPN) in partnership with the Patients Association, which found that “patients need to travel just 13.2 miles – around 30 minutes by car – to cut over three and a half months off their waiting time”.²

The right to choice

Such waiting time differentials have a number of important consequences. Firstly, it suggests that waiting times are something of a postcode lottery. Where you happen to live can have a massive effect on your ability to access treatment in a timely manner. The geographical inequalities in access to healthcare run contrary to the tenet of equality underpinning the basis for the NHS.

Despite most people being unaware, patients have a right to choice in the NHS for consultant-led services.³ This means that at the point of referral, patients have the right to choose what consultant-led team they are referred to. Included within this is that patients can choose where they are seen. Therefore, every month, the many thousands of patients being referred to treatment in the NHS can choose to be treated at a location which is further away but with shorter waiting times. This is not to say that everyone will choose to do so, after all there are many considerations beyond waiting times, but that they at the very least have the opportunity to. Therefore, the primary barriers preventing patients from empowering their treatment is knowledge of their rights, and the tools to easily find and compare NHS services - the two central missions of HealthSay.

Importantly, patients may not even have to travel far to access much quicker treatment. Based on data published under NHS My Planned Care at the start of February, where NHS trusts self-report mean waiting times to the first outpatient appointment and their first treatment for given specialties, huge differences in waiting times exist within London alone. Average referral-to-treatment waiting times for gastroenterology services varied from 8 weeks at Guy's and St Thomas' Trust to 19 weeks at Kingston Hospital Trust. Similarly, pain management waiting times varied from 8 weeks at King's College Hospital Trust to 26 weeks at the Royal Free Hospital Trust. The main hospitals of these two trusts are less than an hour apart by public transport.

With fear of stating the obvious, the very nature of needing pain management services is that you are in pain. Waiting 18 weeks for treatment can have a huge impact on a person’s quality of life while they wait, and also affect their ability to fully recover from treatment. Therefore, having the knowledge and ability to choose where you are referred has the potential to be life changing.

Wider implications

Beyond the impact on patients, and the subsequent implications of the benefits of patient choice, geographical inequalities in NHS waiting times have wider implications for the NHS. The existence of such waiting time differentials provides evidence of an unequal distribution of pressures in the NHS. Certain regions are shouldering a disproportionate burden of patient demand, relative to their ability to service that demand. While such variations are to some extent inevitable, the differences are so substantial that maintaining the status quo should not be considered an option. Given the financial and operational strains facing the NHS, improving geographical waiting time inequalities is important, helping to generate incremental improvements in waiting times as part of larger measures addressing NHS shortfalls.

What can be done?

Combatting health inequalities is one of the main aims outlined in the NHS’ Long Term Plan, released in 2019. This includes overcoming the evidenced geographic inequalities surrounding timely access to healthcare. One of the NHS’ main policy avenues for this is to divert funding towards regions with the worst health outcomes, with these funds “estimated to be worth over £1 billion by 2023/24”.⁴

Another, likely cheaper, option remains. Encouraging patient choice could drive changes in demand for services, helping to even out waiting times. By better enabling patient choice, patients may choose to be seen at locations with shorter waiting times, relieving demand from the most strained services and transferring it to where there is the greatest slack, thus creating an overall benefit for the NHS. This could be at little to no cost to the NHS, while also leading to a better service with improved patient outcomes.

Limitations

Perhaps inevitably, there are limitations to the conclusions which can be drawn from the publicly available data. Waiting times are released by specialty, yet these specialties are broad, with categories such as ‘Trauma and Orthopaedics’ aggregating data from a wide range of procedures, including hip replacements and ligament reconstructions. This limits the usefulness of the data for patients hoping to exercise their right to choice; without more detailed data, it is hard to make properly informed decisions. Even if such data was available, waiting time information would only provide a backward-looking estimate. Changes in demand and supply can vary significantly over time, with the order in which patients are treated primarily determined by a prioritisation system, rather than just being a case of first-in-first-out.⁵ Furthermore, if a patient has already been referred to a consultant-led team, this complicates the process of changing where they are referred - if they so choose - and would involve them moving to the back of the ‘queue’ at the new location.

Furthermore, there are other important patient considerations beyond the expected waiting time. Differences in care quality invariably exist throughout the country. Likewise, patients must weigh up shorter waiting times and better care quality against the practicality of travelling further.

Sources:

Where not cited, statistics come from HealthSay’s in-house analysis of publicly available data.

1. Baker, Carl. 2022. “NHS Key Statistics: England, November 2022 - House of Commons Library.” The House of Commons Library. https://commonslibrary.parliament.uk/research-briefings/cbp-7281/.
2. IHPN and The Patients Association. 2022. “Time to choose,” How patients exercising their right to choose can help clear the NHS elective backlog. Independent Healthcare Providers Network. https://www.ihpn.org.uk/wp-content/uploads/2022/07/IHPN-patient-choice-report-final.pdf.
3. Dixon, Anna, Ruth Robertson, John Appleby, Peter Burge, Nancy Devlin, and Helen Magee. 2010. “Patient Choice: how patient choose and how providers respond - final report - Picker Institue Europe, Office of Health Economics.” The King's Fund. https://www.kingsfund.org.uk/sites/default/files/Patient-choice-final-report-Kings-Fund-Anna_Dixon-Ruth-Robertson-John-Appleby-Peter-Purge-Nancy-Devlin-Helen-Magee-June-2010.pdf.
4. NHS England. 2019. “NHS Long Term Plan.” NHS Long Term Plan. https://www.longtermplan.nhs.uk/wp-content/uploads/2019/08/nhs-long-term-plan-version-1.2.pdf.
5. AOMRC. 2020. “National Clinical Prioritisation Programme (Including Evidence Based Interventions) Frequently Asked Questions Version 3 03/11/2.” AOMRC. https://www.aomrc.org.uk/ebi/wp-content/uploads/2021/05/National_Clinical_Validation_Programme_FAQ_1120.pdf.