NHS England Status Update: Nov 2023

An overview of key NHS England hospital metrics for November 2023 covering emergency and elective care.

Introduction

This is the second in a series of posts that will take a deep-dive into some of the key performance metrics published each month by NHS England over the next few months. It is best viewed using your browser or the Substack app.

As we head into Winter, the main focus will be on emergency care covering the performance of the ambulance and Accident and Emergency (A&E) services.  However, hospitals are not only for emergencies so I will also cover performance metrics for planned elective care.

Summary

• Ambulance response times for November 2023 were better than in October although they continued to exceed targets, particularly for urgent incidents showing symptoms of strokes and chest pain.

• Ambulance response times for urgent incidents (60% of overall demand) improved in most regions but the South West and East of England continue to have the longest response times.

• In November, the excess time lost for each ambulance handover to A&E reduce to 23 minutes from 25 minutes in October.

• The percent of patients meeting the 4 hour target in A&E declined in November to 55% and is the third worst month ever.

• In November, 144,805 patients waited longer than 12 hours from arrival to hospital admission. These long waits are estimated to result in 407 additional deaths each week in the past three months.

• The good news is that the number of people waiting for planned elective treatment decreased in October for the first time this year.

• The number of people waiting for diagnostic tests remains at record levels and waiting times far exceed targets.

Ambulance Performance

The following table summarises the key demand metrics for ambulance services in England. To recap, C1 incidents are those that are life threatening, C2 require urgent attention (heart attacks and strokes), and C3 / C4 are less serious incidents.

In November, demand for ambulance services, as shown by the average number of calls received per day (27,534), was in line with the demand seen in October 2023 and November 2022. The good news is that compared to last year more of this demand is being met as there are more incidents being attended; for example, 12,761 urgent C2 incidents were attended this November which was 20% higher than November 2022.

November also saw most ambulance performance metrics improve when compared to October 2023 and were much better than November last year. However, they all continue to exceed the performance targets.

The following table shows the ambulance response times for the all categories of incidents for England.

Response times for all categories were lower than last month and much lower than November 2022. However, the life threatening (C1) and urgent (C2) incidents continue to far exceed the their target response times.

The following table shows the November 2023 response times for urgent (C2) incidents by region and gives a more varied picture.

The East of England and the South West showed the biggest month on month improvements but continue to have the highest response times. Most regions had better response times than November 2022 which had some of the worst response times on record leading up to the Winter 2022 crisis.

Accident and Emergency (A&E) performance

An important measure of A&E performance is the excess time it takes for ambulances to hand patients over to the A&E department. This is because it occurs as a result of a mismatch between A&E/hospital capacity and the number of emergency patients arriving.

National guidance states that patients arriving at an emergency department by ambulance must be handed over to the care of A&E staff within 15 minutes. The following chart shows the average ‘excess’ time, above the 15 minutes target, lost per ambulance handover.

There was a decrease in the time lost per ambulance handover in November 2023 compare to October. Worryingly, the early data published for December is showing that the time lost from ambulance handovers has started to increase. An early sign of trouble ahead. Hopefully, we will not see the significant rise we had last year.

The following chart shows that there remain wide variations in the time lost per handover across the Ambulance Trusts.

Whilst the Ambulance Trusts don’t map directly to the NHS regions its clear that the geographical areas with the highest time lost at handover tend to have the longest ambulance response times for urgent incidents.

Turning now to A&E performance. The following interactive chart shows the percentage of people admitted, transferred, or discharged within four hours from their arrival in A&E. This is for people waiting in acute hospital trusts who have the most serious need. The long-standing target is for this percentage to be above 95% but this was last achieved in August 2014! The NHS Winter Plan interim target is to get above 76% by March 2024.

In November, only 55% of people attending A&E in acute hospital trusts were seen before four hours from arrival to admission, transfer or discharge. This is the third worst performance ever and much lower than the interim target and pre-Covid standard.

The following interactive chart shows the number of so called ‘trolley waits’ where patients waited longer than 12 hours in A&E from when the admission decision was made to the time they were admitted to a hospital ward.

At 42,854 this was the third highest number of people waiting from when admission was decided to actual admission to a hospital bed.

Finally, the following chart shows the number of people that waiting longer than 12 hours from arrival in A&E to being admitted to hospital.

In November 2023, 144,805 patients waited 12 hours or more from their time of arrival until being admitted to a hospital ward. This accounts for nearly 11% of all A&E attendances and was the fourth highest number ever. To put this in context, in 2010 fewer than 2% of A&E attendances waited more than 4 hours to leave.

This is a serious problem as taking longer than 12 hours from arrival to admission has been linked to higher death rates. A recent report from by the actuarial group LCP estimated that between September and November 2023 there were 407 additional deaths each week as a result of these long waiting times in A&E.

In our earlier analysis, we estimated the number of additional deaths associated with long waiting times in A&E. Using our central approach, based on trolley waits, we estimated 415 additional deaths each week arising from delays between September and November 2022. For the same period in 2023 this is very similar at 407 additional deaths a week.

Planned elective care performance

After the worrying report on A&E performance there is some good news on planned elective care performance.

The waiting list to start elective treatments decreased from 7.77 million in September 2023 to 7.71 million in October . This is the first decrease in 13 months and a welcome sign.

There were 6.44 million people waiting to start elective care in October 2023 which was 60,000 less than September. Note that this is lower than the overall ‘waiting list’ of 7.71 million because some people are waiting for multiple treatments.

Unfortunately, the time waiting for elective treatment to start remains a problem and there was little sign of improvement in October. The objective is to have no people waiting over 65 weeks to start consultant-led elective treatment by March 2024, except where patients choose to wait longer. However, the following chart shows over 107,000 people waiting this long in October 2023 (red line), very similar to the previous month, with no improvement seen since March 2023. 

The number of people waiting over 52 weeks to start elective care (blue line) stood at just over 377,000 in October 2023. This is much higher than the 1,553 waits of over 52 weeks in October 2019! The aim is to have nobody waiting this long by March 2025.

Finally, lets look at the waiting list for diagnostic tests which remain at record high levels and have not improved since March 2022. In October 2023, there was a very slight increase in the number of people waiting tests.

The following chart shows the percentage waiting longer than six weeks for a diagnostic test fell slightly in October.

In October 2023, 25% of people waited over six weeks for a diagnostic test. This is far above the long-standing 1% target, as well as the Winter Plan objective of 5% by March 2025. Again there has been no improvement since March 2022.

In Conclusion

As we head in to the winter season, hospitals in England are showing signs of increased pressure particularly in A&E Departments At the moment, performance measures are bad but not as quite as bad as in 2022. We can only hope that we don’t have the ‘double hit’ of Covid and a bad Flu season that we saw last winter. Unfortunately, the latest data shows that hospital admissions for Covid and Flu are just starting to rise albeit from relatively low levels.