NHS London leads the way, but waiting time inequalities persist

NHS waiting times in London are the joint-best in the country, with a mean, referral-to-treatment waiting time of less than 15 weeks. However, months-long waiting time inequalities, both within London and nationally, continue to persist.

At the national level, data released by NHS England for elective care waiting times shows a continued failure to meet standards, with more than 40% of those waiting for treatment already waiting more than 18 weeks - well short of the 8% NHS target.

As of the end of March 2023, 7.3 million patients were waiting for non-urgent treatment. Importantly, the backlog of patients waiting for treatment shows little sign of improvement. In March alone, 1.9m people joined NHS waiting lists, while just 1.6m people started treatment. This represents a capacity shortfall of 300’000 treatments in just March. This is despite more treatments being started in March versus any other month in the last 2 years.

HealthSay analysis suggests that for patients starting treatment in March, the mean waiting time was 17.2 weeks. Across specialties, this figure ranges from 9 weeks for elderly medicine, to 24 weeks for oral surgery or neurology. In the context of the NHS’ 18 week target, within which almost all patients should be seen,  these statistics make for sombre reading.

This is not to say that waiting times have been improving though. Reflective of ever increasing waiting lists, the time patients have been waiting before starting treatment has increased in all regions since September 2021. On average, patients are now having to wait a month longer for treatment than they were 18 months ago.

Waiting time inequalities

Notably, differences between regions are greater than differences over time. On a region-by-region basis, London and the North East and Yorkshire appear to be leading the way, with average waiting times under 15 weeks.

In the last few months, the North West has been the worst performing region. This has now reached the point where for patients starting treatment in March 2023, in the North West, they had to wait more than 6 weeks longer (on average) than in London or the North East and Yorkshire. Given that patients have the right to choice in the NHS, whereby you can choose where you are referred, even if it is further away, these results are particularly shocking. Such variations suggest that patients continue to be uninformed about the options available to them, representing a failure of the NHS to promote patient choice and combat regional health inequalities.

While waiting times are affected by a variety of factors, NHS London attributes much of its relative success to its small geographical area, high concentration of specialist facilities. Furthermore, by focusing on High Volume, Low Complexity (HVLC) patients, they have been able to “increase surgical capacity by allowing streamlined and focused delivery of surgical services, ensuring efficient use of resources and minimising delays”.

Notably, regional variations have increased over time, suggesting varying degrees of success in overcoming the Covid-19 backlog.

As well as regional variations, variations exist between providers. In the NHS, providers such as NHS trusts or independent sector organisations are tasked with providing services by local commissioning groups (called ICBs). Importantly though, this can lead to patients waiting for significantly different lengths of time depending on what provider they were referred to.

For cardiology services, patients starting treatment at Royal Berkshire NHS Foundation Trust had to wait just 6 weeks for treatment, versus 35 weeks at Cambridge University Hospitals NHS Foundation Trust (mean waiting times). Similarly, for neurosurgical services, patients referred to University Hospitals Sussex NHS Foundation Trust had to wait, on average, almost 5x longer for treatment (44 weeks) than those referred to King’s College Hospital NHS Foundation Trust (9 weeks).

As of mid-May 2023, NHS MyPlannedCare waiting time data shows the average wait for oral surgery as varying from 9 weeks at Imperial College Healthcare NHS Trust to 30 weeks at Royal Free London NHS Foundation Trust - a difference of 5 months. Importantly, this is not an isolated example. Across all specialties, the average difference in waiting time from the best and worst performing London trust was 10 weeks.

When asked for comment on waiting time inequalities, NHS London stated that they “have various mechanisms in place to direct patient referrals to hospitals with the lowest waiting times” including “Choose and Book [and] Referral Management Systems”, with NHS England continuing “to promote mutual aid across trusts”.

At a national policy level, patient choice is shaping up to be a central pillar of efforts to reduce waiting time inequalities. It has been reported that the government’s Elective Recovery Taskforce, set up in December 2022 and expected to publish its findings this summer, will lead with recommendations for improving patient choice. As part of this wider shift, NHS England is releasing tools to allow patients easier choice over where they will be referred.

This is a welcome move, and echoes much of what HealthSay has been advocating for. Placing patients at the centre of their care by facilitating informed decision making is a win-win.

Current NHS apps are commendable for their useability, and are symbolic of a wider digitisation of the NHS. Yet, it remains to be seen whether the new patient choice tools will have the required information to allow for properly informed decision making. An update released to NHS MyPlannedCare in the last few days allows patients to compare providers by distance, waiting times and CQC care quality. However, the current levels of information appear too limited to be truly effective. Waiting time data is by specialty, rather than specific condition, treatment or procedure. Similarly, it does not show the various locations of each provider; many providers have multiple hospitals, often far away from each other, which on their own may not offer all services.

Use of the independent sector

Through various partnership agreements with NHS trusts, integrated care boards (ICBs) and local authorities, the independent sector provides services on behalf of the NHS. This is done through various ways, such as through the block booking of capacity or payment by activity, where providers - be they independent sector or NHS trusts - are paid according to a tariff system (now called the NHS Payment Scheme). It is important to note that the independent sector includes all providers not NHS (foundation) trusts, such as GP federations.

Regardless, the independent sector is being increasingly utilised by the NHS to deal with capacity shortfalls, as staffing issues and ageing facilities limit the ability of NHS trusts to meet demand. This has meant that, on average, around 10% of patients starting treatment for elective care are doing so under the care of the independent sector. This has enabled the NHS to treat an extra 166’000 patients in March alone. While insufficient to fully satisfy demand, it has nevertheless been instrumental in holding back the tide, preventing waiting lists from truly spiralling out of control.

PHIN, an “independent, government-mandated organisation” which publishes metrics on independent healthcare providers, states that the “independent sector has worked alongside the NHS since its inception… with the public and private sectors working side-by-side to improve health in the UK”. The “independent sector is not looking to replace the NHS, but will work with it where appropriate to reduce waiting times and ensure patients get the care they need as soon as possible”.

Out of all regions, London has the lowest proportion of patients starting treatment with an independent sector provider. NHS London states that their shorter waiting lists allows them to place a lesser reliance on the independent sector than elsewhere.

In March, Circle Health was the largest independent provider of NHS services in England, starting treatment on more than 27’000 patients. Second to them was Ramsay, who started treatment on almost 20’000 patients. Across the 12 months to March 2023, the independent sector has helped 1.6 million patients come off the NHS waiting list.

Throughout this article, average waiting time refers to the mean waiting time as calculated by HealthSay. Median waiting times may vary significantly, for example, Cambridge University Hospitals NHS Foundation Trust cardiology waiting times for patients starting treatment in March 2023 can reasonably be stated as 35 weeks (mean) or 24 weeks (median). Mean waiting times have been used to reflect the fact that a small, but significant minority, of patients are having to wait for extra long periods of time.