NHS backlog data analysis (2024)

With demand for hospital treatment outstripping capacityevenbeforeCOVID-19, it is no surprise that the demands of delivering care during a pandemic have led to significant backlogs and longer waits for patients.

This page provides analysis on capacity in secondary care services and is updated monthly with new data.

Last updated in 15 March 2024

What is the backlog?

The backlog in secondary care consists of the care that the NHS would normally have delivered but which was disrupted as COVID-19 impacted service delivery. This includes:

• patients on a waiting list for treatment who would ordinarily have been seen by now
• patients who have not yet presented to their GP to seek a referral for symptoms due to concerns of burdening the health service or fears around COVID-19 infection
• patients who have had procedures cancelled
• patients who have had referrals delayed or cancelled
• patients who have had referrals refused due to a lack of capacity.

It will take years to clear the backlog. The ongoing need for stringent infection prevention control measures and workforce shortages mean it will take even longer to work through as demand continues to rise.

More patients than ever are waiting for treatment

High waits for treatment are not new. Prior to the pandemic in February 2020 there were already 4.43 million people on a waiting list for care.

At the beginning of the pandemic, the combination of suspension of non-urgent services and changes to individuals’ behaviour meant that the number of people joining the waiting list initially dropped. However, this has since been rising - and despite some improvements earlier in the year, waiting times remain far higher than pre-COVID:

The latest figures for January 2024 show:

• the waiting list decreased to 7.58 million cases, consisting of approximately 6.32 million individual patients waiting for treatment
• around 3.25 million of these patients have been waiting over 18 weeks;
• Over 321,000 of these patients have been waiting over a year for treatment, although this is a reduction of approximately 5% on the December 2023 figure of 337,000.
• a median waiting time for treatment of 15 weeks – almost double the pre-COVID median wait of 8.4 weeks in January 2020.

The target in the elective backlog recovery plan (February 2022) to eliminate waits longer than 65 weeks by March 2024 has been missed and the longer-running target that 92% of patients should receive treatment within 18 weeks of referral has not been met since September 2015.

NHS England recently announced in October 2023 that up to 400,000 patients waiting over 40 weeks will be offered the opportunity to travel to a different hospital to be seen sooner. However, many people may feel unable to travel, particularly without support networks.

The hidden backlog is growing

The waiting list is a visible backlog, but what we refer to as the growing 'hidden backlog' remains an unknown for the health service.

The hidden backlog consists of patients who require care but have either not yet presented, or who have had referrals cancelled due to the impact of Covid-19 on the NHS; patients who, in normal times, would have been referred for treatment, received elective care and attended outpatient appointments, but who for a number of reasons relating to the pandemic have not yet found their way into the health system.

Despite improvements in 2021 and 2022 compared to the first year of the pandemic, the number of electives and outpatient attendances currently being carried out is still well below pre-pandemic levels.

This is storing up greater problems for the future. These backlogs are likely to result in worsened conditions down the line, leading to greater demand on health services.

Changes to cancer waiting times standards came into effect from 1 October 2023 with the following three core measures replacing the previous standards:

• 28-days wait from an urgent referral to patient told they have cancer standard (75%)
• 31-days (one month) from a decision to treat to first or subsequent treatment standard (96%)
• 62-days (two months) wait from an urgent referral or consultant upgrade to a first definitive treatment standard (85%)

Despite the changes in the cancer care targets, services continue to operate well below operational standards.

While the number of patient referrals has surpassed pre-pandemic levels, the percentage of patients told they have cancer within four weeks (28-days) of an urgent referral remains low. In January 2024, this decreased to 70.9% from 74.2% in December 2023 and remains below the 75% operational standard.

The percentage of people receiving their first cancer treatment within one month from a decision to treat decreased from 91.1% in December 2023 to 87.5% in January 2024. This is well below the 96% operational standard.

The percentage of patients receiving their first cancer treatment within two months (62-days) of an urgent referral stood at 62.3% in January 2024, a decrease from the December 2023 figure of 65.9%. This is significantly below the operational standard of 85%.

The poor performance against these key operational standards illustrates the level of pressure the system is under, and is a clear sign that significant investment in capacity is needed.

Prior to the pandemic, the situation in A&E was increasingly difficult with demand soaring and the percentage of people being seen within the four-hour target reaching an all-time low over the 2019/20 winter.

At the start of the pandemic, A&E attendance decreased significantly which led to performance improvements. However, since lockdown eased demand has steadily risen, reducing performance against targets.

These pressures on emergency care persist into 2023, despite small improvements in certain areas. Demand for care across all A&E departments remained high in February 2024, with total A&E attendances standing at 2.15 million – a decrease from 2.23 million in January.

70.9% of people attending A&E were seen within 4 hours in February – a slight increase from the 70.3% in January 2024. This is below the target for 76% of patients to be seen within 4 hours by March 2024. In the past 12 months (from March 2023 to February 2024), approximately 1.59 million people have waited more than 4 hours in A&E.

NHSE introduced three new targets as part the Urgent and Emergency Care capital incentive scheme. The trusts that are on track to meet these targets based on their performance will be eligible to receive additional capital funding in 2024-25.

These include:

1. The 10 trusts delivering the highest level of 4-hour performance during March will each receive £2 million.
2. The 10 trusts who deliver the greatest percentage point improvement in March (compared to January 2024 performance) will each receive £2 million.
3. The next 10 trusts who deliver the greatest percentage point improvement in March (compared to January 2024 performance) would each receive £1 million.

The BMA has raised concerns regarding the introduction of the capital incentive scheme, on the basis that it risks creating perverse incentives for Trusts, diverting support away from where it is needed most, and widening existing health inequalities.

Waiting times have rocketed

The combination of ongoing pressure on services, the backlog of care and chronic workforce shortages means waiting times have increased to record highs.

The total number of patients waiting over 12 hours for an emergency admission decreased by around 18%, from about 54,000 in January 2024 to approximately 44,000 in February 2024. The number of patients waiting over 12 hours for an emergency admission in February was still about 27 times higher than in February 2020 – pre-pandemic. Note that this number represents an underestimate of actual waiting times, as patients will have been waiting for additional time before a ‘decision to admit’ was made.

These long waiting times are, in part, due to poor patient flow. General and acute bed occupancy has consistently been at over 90% since September 2021, and patients regularly remain in hospital despite being fit for discharge because there is no capacity for them in social care.

We can track GP referrals into consultant-led outpatient services alongside the waves of COVID-19: as the waves have peaked, referrals into secondary care have dropped. These drops are likely due to a combination of changes to patient behaviour alongside capacity issues in secondary care effectively forcing GPs to take a more cautious approach with timings of referrals to avoid having referrals rejected.

GPs can still refer patients, but the pressures in hospitals means there is little capacity in secondary care, and those referrals are often rejected.

The number of GP referrals to consultant-led outpatient services that have been unsuccessful because there are no slots available has jumped from 238,859 in February 2020 to a staggering 401,115 in November 2021 (an 87% increase).

When GPs are unable to refer into hospital services, the care for these patients does not disappear. Instead, these patients need to be cared for by GPs while they wait for hospital treatment to go ahead, adding to the pressure in primary care.

Enlisting the help of the private sector is one of the measures the Government has taken to reduce pressures on hospitals and help cut waiting lists.

Purchasing private capacity is not new, but the pandemic has demanded unprecedented block-booking arrangements.

A recent BMA survey found that under these arrangements, 60% of private practice doctors who responded were unable to provide care to their patients at the time.

The extent to which private hospitals will be able to take on NHS waiting list initiatives going forward is unclear given the increased demand in the self-pay market and the backlog of private sector patients.

Given that the NHS and the private sector largely draw on the same pool of doctors, additional capacity may be less than it initially appears. This was made clear in the 2020 block-booking arrangements, which saw the NHS gain facilities rather than the workforce to run them.