The secondary care acute sector comprises of acute, specialist acute and combined trusts delivering urgent and emergency care, planned care and specialised care for different conditions such as rare cancers, genetic disorders or complex medical or surgical conditions.
It isn't possible to cover the data associated with all acute pathways here. For this summary, we explore trends across A&E services, diagnostics, the elective care waiting list and cancer services. We also look at data relating to current levels of NHS capacity such as general and acute beds and metrics of patient flow.
Demand and activity
Demand for urgent and emergency care continues to soar – on top of record June and July data, the highest August figures for A&E attendances ever mean that it has been the busiest summer on record. In August, there were 2.16 million A&E attendances, 2.6% higher than August last year and 1.7% greater than five years ago in August 2019, before the pandemic.
A&E attendances
Despite this increase in attendances, there has been a slight decline in the number of emergency admissions compared to five years ago: there were 525,600 emergency admissions in August 2024, 3,600 fewer than August 2019. A lower conversion into admissions means these people may have accessed the care they needed in A&E, received treatment through a SDEC service or been referred elsewhere.
For planned care, record levels of activity were seen this month. In July 2024, a record high of 2.48 million diagnostic tests were carried out. This is 6.8% higher than the month before, 12.3% higher than a year ago and 20% higher than pre-pandemic levels (July 2019). The number of MRI, CT and colonoscopy scans all increased compared to last month (up by 5.4%, 4.6%, and 6.8% respectively). Compared to July 2019, MRI activity was 27.6% higher, there were 36.8% more CT scans and 21.2% more colonoscopy scans. Once again demonstrating how the NHS is doing more across many services. The diagnostic waiting list decreased slightly this month by 0.9% to 1.62 million. There is still a difficult task ahead to reduce this further: compared to last year, the waiting list is up 2.1% and up by 53.6% compared to July 2019, before the pandemic.
Diagnostic waiting list
Record levels of activity were also delivered across all cancer pathways in July. The number of patients completing the 28-day faster diagnosis pathway increased by 11.3% compared to June reaching 290,600. A further 58,800 patients completed the 31-day pathway, which is a 14% increase from last month and 29,100 patients completed the 62-day pathway, up by 13.1% from June.
Finally, demand and activity within elective care both rose compared to last month. There were 1.86 million new RTT pathways in July, 160,000 more than June, and the highest month so far this year. Admitted and non-admitted activity also increased compared to June: there were 1.27 million non-admitted pathways, an increase of over 100,000 since June, and 330,500 inpatient pathways which is over 30,000 more than in June.
Waiting times
A government-commissioned independent investigation of the NHS in England by Lord Darzi highlighted that performance on access to care has been declining and constitutional standards, such as 95% of people who attend A&E being seen within four hours, are not being met.
This month the four-hour A&E performance moved closer to current targets but remains some way from constitutional standards. In August 2024, performance against the four-hour wait target was 76.3%, up by 0.9 percentage points on last month. Performance met the target of 76% that was set for trusts at the end of the 23/24 financial year, which had been missed previously. The new target in the 2024/25 planning guidance is to see 78% of patients in four hours by March 2025.
Performance for trusts with major emergency departments (categorised as type 1 A&E) also improved slightly to 62.5% in August. Of the 122 trusts with a type 1 A&E department, seven met the 78% recovery target in August – one more than last month. To get a sense of the variation across trusts; the performance of 26 trusts sat at 70% or above; 46 trusts between 60% and 69.99%; and 37 between 50% and 59.99%.
Data on the number of patients waiting more than 12 hours in A&E from arrival builds understanding of performance within the department, which has improved this month but has declined since last year. Of the 1.45 million attendances at type 1 & 2 emergency departments in August, 111,100 waited more than 12 hours from arrival at A&E (8.6%). There were 8,000 fewer patients waiting more than 12 hours from arrival in A&E than last month but close to 11,000 more than the same time last year.
The wait from decision to admit to admission provides further insight into A&E pressures as well as patient flow across trusts and systems. While in August the number of patients waiting more than 12 hours from the decision to admit to admission decreased by over 8,000 from the previous month, the numbers are still very high at 28,500. This is nearly half of the record high figure of 54,000 in January 2024, however it is broadly unchanged from August 2023 and is extremely high compared to five years ago before the pandemic, when only 372 people waited more than 12 hours.
Number of patients spending >12 hours from decision to admit to admission
The diagnostic waiting list decreased slightly this month (by 1%), reaching 1.62 million. Compared to last year, the waiting list is 2.1% bigger and over half as big compared to July 2019. Over a fifth (22%), of patients waited six weeks or more for a test, well away from the 5% target.
156 trusts reported diagnostic waiting lists this month. 36 met or exceeded the target of 95% of patients seen within six weeks or less. There is significant variation across diagnostic waiting lists. By trust, the percentage of patients waiting more than six weeks for a test ranged from 0% to 97.1%. Nine trusts had over half of patients waiting more than six weeks for a test.
The waiting list held steady at 7.62 million in July, with 1,650 more treatments than last month. The size of the waiting list is nearly 1% smaller than it was a year ago but 69% greater than five years ago in July 2019, before the pandemic. In July, 83.8% of patients on the waiting list were unique patients. This is an estimated 6.39 million people, similar to the previous two months.
The numbers of treatments waiting over 52 weeks dropped to the lowest since December 2020. With 50,860 treatments waiting over 65 weeks in July, there is still a way to go to meet the 2024/25 operational planning guidance for no patients to be waiting longer than 65 weeks by September 2024.
There is, however, movement in the right direction, with 65 week waits reducing by over 7,000 since last month and over 45,000 since July 2023. The number of treatments waiting within 18 weeks fell by 3,200 this month. At the end of July, nearly 59% of treatments had been on the waiting list less than 18 weeks. Overall, 3.1 million treatments waited more than 18 weeks in July.
There is, of course, trust variation and speciality variation across the waiting list. Size of trust also plays a role. Looking at waits over 65 weeks there are 26 trusts with zero waits. However, 13 trusts have more than 1,000 treatments waiting 65 weeks or more. The trust with the most waits has over 5,000, this is 3,380 more than the second trust. This trust also has the highest number of waits over 78 and 52 weeks.
The cancer standards were streamlined recently into three new targets: Faster Diagnosis Standard (FDS) 28-day referral, 75%; 31-day treatment standard, 96%; 62-day treatment standard, 70%.
Performance against the 28-day faster diagnosis standard remained stable and was met again this month. Performance for both other targets did not meet the standard for the 31-day and 62-day pathways.
Performance against the 28-day FDS target remained stable, with 76.2% people being told if they had cancer, or if cancer was definitively excluded within four weeks (28-days) of an urgent referral. This exceeds the existing standard of 75% for the fifth time in six months and is a positive move towards the target of 77% by the end of 24/25. The NHS has announced this standard will increase to 80% by March 2026. 76 out of 134 acute trusts reporting this month would meet the 28-FDS target of 77%.
In relation to cancer treatments, nearly 92% of people treated in July began their first or subsequent treatment of cancer within 31 days of receiving a decision to treat/earliest clinically appropriate date, improving by one percentage point on last month's performance but missing the 96% standard. For the 62-day pathway, 67.7% of people treated began first definitive treatment of cancer within 62 days of an urgent suspected cancer referral, breast symptomatic referral, urgent screening referral or a consultant upgrade. This is a slight improvement from the previous month. It is also a positive step towards the new target, introduced in April 2024, for performance against the 62-day standard to reach 70% by March 2025.
Capacity
In the second year of the delivery plan for recovering urgent and emergency care services, the NHS has a limited amount of additional capacity to help with the increase in demand. But patient flow around the health and care system remains a systemic issue across the country with average time in A&E (including waits over 12 hours from time of arrival), handover delays and delayed discharges important metrics for all systems to monitor.
For hospitals, delayed discharge is a daily focus and challenge. On Saturday 31 August, there were 20,600 patients who no longer met the criteria to reside in hospital. Of these, 60% remained in hospital that day. On average in August, there were 21,875 patients who no longer met the criteria to reside and of these, 55.3% remained in hospital each day. This remains at a similar level to the two previous months.