DHSC has “overseen years of decline in the NHS’s cancer and elective care”, say MPs in report

• Waits dependent on a postcode lottery there is “no national plan to address”

In a report today the Public Accounts Committee says the Department for Health and Social Care “has overseen years of decline in the NHS’s cancer and elective care waiting time performance and, even before the pandemic, did not increase capacity sufficiently to meet growing demand.”

The NHS has not met the 18-week maximum waiting time standard for elective care since February 2016 nor the eight key standards for cancer care in totality since 2014. The Committee says now that “on top of these previous failures and despite the heroic efforts of the NHS workforce, the COVID-19 pandemic has inevitably caused a further huge deterioration in the NHS’s provision of elective and cancer care.” 

At the end of December 2021, 6.07 million patients were waiting for ‘elective’ care - such as hip or knee replacements or cataract surgery - the biggest waiting list since records began.

The legal standard for elective care states that 92% of people on the waiting list should be seen within 18 weeks, but only 64% (3.87 million) of these patients have been waiting less than that, and 311,000 have now been waiting for more than a year. Even before the pandemic only 83% were being seen within 18 weeks.

Only 67% of patients with an urgent referral for suspected cancer were treated within 62 days, compared to the requirement for 85% to be treated within that time.  

The Committee also notes “a striking feature of the pandemic was that very large numbers of patients did not present at, or were unable to access, routine NHS services”. As of September 2021, there were between 7.6 million and 9.1 million missing referrals of patients for elective care and between 240,000 and 740,000 missing urgent referrals for suspected cancer. People will face serious health consequences as a result of delays in treatment, with some dying earlier and many living with pain or discomfort for longer.   

The Committee says “any transparent and realistic assessment of what the Department and NHSE&I expect elective and cancer care services to achieve by 2024-25” must include an “assessment of the number of staff that will be available and how staff who have been working under intense and consistent pressure will be supported”.

Dame Meg Hillier MP, Chair of the Public Accounts Committee, said: “DHSC has overseen a long-term decline in elective and critical cancer care that is dragging our National Health Service and the heroic staff down. We on PAC are now extremely concerned that there is no real plan to turn a large cash injection, for elective care and capital costs of dangerously crumbling facilities, into better outcomes for people waiting for life-saving or quality-of-life improving treatment. Nor is it obvious that the Department finally understands that it’s biggest problem, and the only solution to all its problems, is the way it manages its greatest resource: our heroic NHS staff. Exhausted and demoralised, they’ve emerged from two hellish years only to face longer and longer lists of sicker people. And this is compounded by staffing shortages in a number of professional areas.

“The cycle of glib headlines and fiddling with management structures must be broken, with an overhauled “people plan” that gets to the core of the desperate under-staffing and under-resourcing that have undermined our health system.”

PAC report conclusions and recommendations

8. The Department has overseen years of decline in the NHS’s cancer and elective care waiting time performance and, even before the pandemic, did not increase capacity sufficiently to meet growing demand. The NHS has not met the 18-week maximum waiting time standard for elective care since February 2016 nor, in totality, the eight key standards for cancer care since 2014. As demand for services rose faster than supply in the years before the pandemic, performance against waiting times standards declined but the Department neither adjusted these standards to realistic levels nor sought to hold NHSE&I to account adequately. This Committee’s June 2019 report NHS waiting times for elective and cancer treatment concluded that the Department allowed NHS England to be selective about which standards it focused on, reducing accountability.  

Recommendation: The Department must strengthen its arrangements for holding NHSE&I to account for its performance against waiting times standards for elective and cancer care. This should include specific expectations for improving waiting time performance in 2022-23. The Department should write to us alongside its Treasury Minute response to set out the specific and measurable performance indicators for elective and cancer care it has put in its 2022-23 mandate to NHSE&I.   

9. At our evidence session the Department and NHSE&I appeared unwilling to make measurable commitments about what new funding for elective recovery would achieve in terms of additional NHS capacity and reduced patient waiting times. NHSE&I will receive an additional £8 billion for elective care recovery and £5.9 billion for capital between 2022-23 and 2024-25. Government expects that this additional funding will enable elective care activity to be 30% higher than pre-pandemic levels. However, the Department and NHSE&I have not set out in meaningful detail what the money will be spent on. NHSE&I is planning for 566 more elective care beds, but this appears to be a small number compared with the scale of the problem. 

Recommendation: In implementing its elective recovery plan, NHSE&I should set out clearly:  

• timeframes, costs and outputs of the components of the recovery plan covering elective care and cancer care to 2024-25; 
• the longer-term investments and plans that are being made now to improve the resilience of elective care and cancer care beyond 2024-25; and, 
• the national performance levels expected in each year between now and 2024-25.

10. The NHS will be less able to deal with backlogs if it does not address longstanding workforce issues and ensure the existing workforce, including in urgent and emergency care and general practice, is well supported. NHSE&I believes it will be 2 or 3 years before there is a material increase in NHS capacity as a result of the changes it plans to elective care. Large numbers of people waiting for so long presents a huge risk to primary care and emergency services (such as general practice and A&E) because unmet health demand can result in more GP appointments and more medical emergencies. Evidence from the University of Manchester’s Voices of COVID-19 project highlights the concerns of frontline NHS staff regarding the public dissatisfaction they face and the NHS’s lack of capacity to deal with backlogs of care. The Department and NHSE&I need to ensure the NHS workforce is adequately supported and that its service recovery planning is integrated with its planning for staffing and other types of resources.

Recommendation: In implementing its recovery plan NHSE&I’s should publish its assessment of how the size of the NHS workforce (GPs, hospital doctors and nurses) will change over the next three years, so that there is transparency about the human resources that the NHS has available to deal with backlogs.  

11. It will be very challenging for the NHS to focus sufficiently on the needs of patients when it comes to dealing with backlogs, both patients already on waiting lists and those who have avoided seeking or been unable to obtain healthcare in the pandemic. NHSE&I is concerned about those people who have avoided or been unable to obtain healthcare during the pandemic. This includes the estimated 240,000 to 740,000 missing urgent cancer referrals since February 2020. There is also the huge challenge of communicating effectively with the 6 million people already waiting for elective care and providing them with support that they may require. NHSE&I expects trusts to focus on treating patients who have been waiting the longest.

Recommendation: The Department and NHSE&I must ensure there is a strong focus on patient needs in all their recovery planning, including:  

• measuring the success of all initiatives to encourage patients to return to the NHS for diagnosis and treatment; 
• creating guidance and tools, and setting aside resources, for meaningful communication with patients who are waiting; and, 
• supporting NHS trusts through planning guidance and other means to prioritise patients fairly, so they are able to strike an appropriate balance between clinical urgency and absolute waiting time.

12. Waiting times for elective and cancer treatment are too dependent on where people live and there is no national plan to address this postcode lottery.   In September 2021, patients in the worst-performing geographic areas were more than twice as likely as patients in the best-performing areas to have been waiting over 18 weeks for elective care or more than 62 days for cancer treatment following an urgent referral. The difference between the worst and best areas in the proportion of patients waiting over 52 weeks for elective care was around 12 times. NHSE&I is expecting the same levels of improvement across NHS areas but, if this were the end result, it would mean continuing large disparities between these areas. 

Recommendation: NHSE&I should investigate the causes of variations between its 42 geographic areas and provide additional support for recovery in those that face the biggest challenges. NHSE&I should write to us in December 2022 on the actions it has taken to address geographical disparities in waiting times for cancer and elective care and include a summary of any analysis it has done on differences in health outcomes for elective and cancer care in different parts of the country since the start of the pandemic.   

13. For the next few years it is likely that waiting time performance for cancer and elective care will remain poor and the waiting list for elective care will continue to grow.  The UK has low numbers of healthcare resources per person compared with similar countries and actions taken now to increase its resources will likely take years to be realised. We are concerned that officials are too optimistic about the resilience of NHS services in the short- and medium-term, particularly as NHS staff have been working under continuously high pressure during the pandemic and the system is yet to feel the full effect of missing cancer and elective patients returning for care. The National Audit Office estimates that the elective care waiting list might grow to around 7 million people by March 2025, compared with 6.075 million in December 2021, even if the NHS manages to increase elective activity to its stated aim of 30% above pre-pandemic levels.  

Recommendation: The Department and NHSE&I must be realistic and transparent about what the NHS can achieve with the resources it has and the trade-offs that are needed to reduce waiting lists. In implementing its elective recovery plan, NHSE&I should set out clearly what patients can realistically expect in terms of waiting times for elective and cancer treatment. By the time of the next Spending Review at the latest, the Department and NHSE&I should have a fully costed plan to enable legally binding elective and cancer care performance standards to be met once more.