Organisation objective

• Statutory Item

Executive summary

This annex provides a more comprehensive summary of operational performance based on published data and work to restore services.

Urgent and emergency care (including discharge)

1. The UEC Recovery Plan was published in January 2023.

2. Nine days of industrial action by junior doctors placed another period of challenging pressures on urgent and emergency care in December and January. A significant amount of work and resource has been invested to prepare for and manage this industrial action period, particularly since it coincided with the usual winter pressures seen by the NHS in early January, and two Bank Holiday periods.

3. Ambulance services answered 889,389 calls to 999 (or 28,690 per day in December 2023), which was 4.2% more than November. Ambulance services also handled 760,589 incidents. 380,793 incidents were conveyed to A&E, which equates to 12,284 per day during December.

4. The average response time for a category 2 call in December 2023 was 45 minutes and 57 seconds. This is half the average time in the same month last year. The average response time for a category 2 call in December 2022 was 1 hour 32 minutes and 55 seconds.

5. In December 2023, there were 2,179,232 attendances in A&Es across England, an average of 70,298 per day. Between April and December 2023 there were 5.5% more emergency admissions than the same period last year.

6. Despite this, the proportion of patients attending A&E who were admitted, transferred, or discharged within four hours remained above last year, at 69.4% compared to 65% in December 2022.

7. Same Day Emergency Care (SDEC) has been beneficial including decreasing A&E visits and reducing ambulance conveyances to A&E, as well as avoiding overnight stays. This has enhanced patient experience and streamlined patient flow getting them to the right place the first time.

8. Urgent Community Response services have helped avoid hospital admissions by providing urgent care to people in their homes. All ICBs now have full coverage and the latest provisional data shows that nationally 84% of patients were seen within the 2-hour standard in November with every region exceeding or meeting the 70% target.

Elective care

9. Despite ongoing pressures and the impact of industrial action, focusing on treating patients and reviewing the ongoing care needs of patients through validation is having an impact, with reductions in overall waiting list size. We are supporting the work to ensure waiting lists are accurate and consistent application of waiting list rules across providers through the development of a national model access policy.

10. NHS staff are continuing to bring down the longest waits for elective care, with a focus on those patients whose waiting time will exceed 65 weeks if not treated by the end of March 2024 (the ‘65w cohort’). We have also seen two consecutive months of reduction in the total waiting list – it now stands at 7.61 million (for November 2023).

11. The latest figures show the median wait for admitted treatment in November 2023 was 12.5 weeks, against a median wait of 12.3 weeks in November 2022.

12. Validation of waiting lists continues to be a key priority to ensure that waiting lists are accurate and well maintained. Two successful small-scale pilots have been carried out in a GP practice, with different cohorts of patients. Both pilots found 10% of patients who did not need to be on the waiting list and were subsequently removed.

13. The enhanced choice offer to patients who are waiting for elective care has continued. A cohort of patients have been enabled to move providers through this new process, PIDMAS (the Patient Initiated Digital Mutual Aid System). PIDMAS allows us to proactively offer patients the ability to ‘opt in’ to move provider where they have been waiting over 40 weeks for care and meet certain criteria. In addition to the digital offer, a telephone line is available for patients who wish to activate this choice offer.

14. The Further Faster GIRFT programme is continuing at pace with a second cohort of providers beginning to be onboarded. It continues to focus on the high-volume low complexity specialties and supporting outpatient transformation within those specialties. The learning from cohort one is being shared with cohort two trusts through speciality level meetings, written work, and handbooks to help share best practice. In addition, specific focussed sessions on clinic templates and digital solutions have also been held.

Diagnostics

15. 2.32 million of the 15 key diagnostic tests were performed in November 2023 (6% more than in November 2022), with the highest monthly activity on record, demonstrating the impact of the new capacity investments. The percentage of patients waiting less than six weeks for a diagnostic test improved from 24.7% in October 2023 to 23.3% in November – the third monthly improvement in succession.

16. Overall, 146 operational permanent and 4 temporary Community Diagnostic Centres (CDCs) have delivered 6.6m tests since the first CDC was launched and 2.9m tests in the current financial year up to Christmas – 7% ahead of activity plan.

Cancer

17. As at w/e 3 December 2023 there were 21,762 patients waiting longer than 62 days following an urgent suspected cancer referral, for either exclusion of cancer or first treatment for cancer. This is approximately 4,000 lower than the peak in Summer 2023 and around 5,700 lower than the same point in December 2022.

18. Performance against the 75% Faster Diagnosis Standard increased to 71.9% in November 2023, up from 71.1% in October 2023, and 69.7% in September 2023, with the recovery in performance in line with seasonal trends. Performance against the standard in 2023 has been consistently higher than that seen in 2022, with performance in November 2023 2.3% points higher than it was twelve months previously.

19. In November 2023, performance against the 62-day from referral or upgrade to first treatment standard increased to 65.2%, up from 63.1% in October 2023. This improvement is in line with expected seasonal patterns and is attributable in part to the absence of industrial action.

20. The level of demand for cancer services remained high in November 2023 with the number of urgent suspected cancer referrals at around 128% of pre-pandemic levels. The NHS has increased the levels of first treatments provided in response which are 12% above pre-pandemic levels.

21. Progress continues to be made against our transformation initiatives. All Cancer Alliances now have Targeted Lung Health Check services in operation, and since its inception in April 2019, the programme has diagnosed 3,031 lung cancers, 76% of these at stage one or two, with over 1.2m people invited for a lung check.

22. Liver cancer mortality rates are almost four times higher in the most deprived areas compared to the least deprived areas. The NHS Cancer Programme is working to detect more hepatocellular carcinomas early as part of the NHS Long Term Plan ambition to diagnose 75% cancers at an early stage by 2028. Eighteen Community Liver Health Check pilots, targeted at the most underserved in the community, have been funded across the country to diagnose more patients with cirrhosis or advanced fibrosis. Since June 2022 over 33,500 people have received a FibroScan, and 8% of these patients have been referred into 6-monthly ultrasound surveillance, which is key to identifying liver cancers earlier.

Primary care and community health services

23. The Primary Care Access Recovery Plan (PCARP) was launched in May 2023. The plan responds to feedback from patients and outlines measures that will make a difference to patients and staff now, supporting primary care teams to improve and recover access in general practice. A programme of work is in place focusing on the following four areas:

1. Empowering patients to manage their own health including using the NHS App, using self-referral pathways and through accessing more services offered from community pharmacy.
2. Implementing Modern General Practice Access to tackle the 8am rush, provide rapid assessment and response and avoid asking patients to ring back another day to book an appointment.
3. Building capacity to deliver more appointments from more staff than ever before and adding flexibility to the types of staff recruited and how they are deployed.
4. Reducing the workload across the interface between primary and secondary care, and the burden of medical evidence requests, so practices have more time to meet the clinical needs of their patients.

24. Pharmacy First was officially launched on 31 January. Community Pharmacy Contraception Service and Community Pharmacy Blood Pressure Check services were successfully expanded on 1 December 2023. An additional £75 million per year of funding has been made available to support the expansion of both these services. The Pharmacy Contraception service now permits initiation of oral contraception.

25. The number of appointments taking place in General Practice continues to increase. In the 12 months to November 2023, 364.2 million appointments took place, including 7.4 million for COVID-19 vaccinations delivered by general practice and 7.2 million Primary Care Network appointments. The last 12 months has shown a higher proportion of in-person appointments than last year at 72.0% for November 2023, compared to the pre-pandemic percentage of 81.9% (October 2019).

26. The target of recruiting 26,000 additional direct patient care staff into General Practice has been achieved early, with 34,380 additional direct patient care FTE in post as of 30 September 2023. As of 30 November 2023, there were 37,308 FTE doctors working in General Practice in England. This is an additional 8.1% compared to the baseline of 31 March 2019 and reflects the continued increase in GP training places, although the number of fully qualified GPs has reduced by 3.5% over the same period. The NHS Long Term Workforce Plan sets out plans to further increase GP training and we are developing a streamlined retention offer for qualified GPs.

27. Monthly contracted dental activity has fluctuated across the year. From 1 July 2022 we reverted to usual contractual performance requirements, expecting to get close to 100% of contracted units delivered. In November 2023, the total percentage of contracted units of dental activity (UDAs) submitted across all contracts was 97% compared to 83% in October 2023.

28. The Department of Health and Social Care (DHSC) and NHS England have undertaken a period of consultation with the BMA General Practitioners Committee (GPC England) on changes to the GP Contract in 2024/25. The consultation closed on 10 January 2024 and DHSC and NHS England are considering the feedback received from GPC England.

Mental health

29. Although challenges and pressures remain across the sector, the NHS continues to make progress on public mental health commitments including:

• Talking Therapies referral to treatment times are being met with 90.6% seen within the 75% 6-weeks target and 98.4% within the18-weeks 95% target (as of November 2023).
• The proportion of Early Intervention in Psychosis (EIP) referrals entering treatment within 2 weeks were 71.2% in November 2023, an increase from 70% in October 2023, against a standard of 60%.
• Access to Community Mental Health Services continues to increase with 573,065 people receiving 2+ contacts in the 12 months to November 2023, an increase of 14.5% on November 2022 position.
• There has been significant improvement for access to Individual Placement and Support (IPS) services with 31,365 people reported to have accessed an IPS service in the 12 months to November 2023, an increase from 22,626 in October 2023.

30. Mental Health Support Teams (MHSTs) in schools have become established, from having no operational teams in 2019, to 398 teams covering 35% of the pupil population as of Spring 2023. MHSTs are on track to cover 44% of pupils and learners by Spring 2024.

31. There are currently 12 gambling clinics in operation. A further 3 gambling clinics will be opening during Q4 2023/24, bringing the total to the LTP ambition of 15 by the end of 2023/24.

32. There continues to be high demand for services. As a result, a number of areas remain challenged with work continuing with regions and systems to prioritise recovery. Bed occupancy remains high in the Urgent and Emergency Care pathway, with average lengths of stays at 49 days nationally as of October 2023. There continue to be challenges with flow through the system, meaning that Out of Area Placements (OAPs) remain high. In October 2023, 520 new inappropriate OAPs were started, an increase of 17% from September 2023, and 39% higher than October 2022.

33. NHS England have prepared and circulated a Winter Resource Pack to assist with planning this winter. This includes good practice across the mental health pathway and as well as dedicated sections on Children and Young People and Learning Disability and Autism. Regions continue to support systems this winter and joint UEC and MH escalation processes are in place for individuals experiencing long attendances in ED. Further work by NHS England and DHSC is planned to identify good practice to ensure people access to appropriate care as quickly as possible.

34. Although the two recent periods of industrial action by BMA Junior Doctors impacted mental health services with cancelled appointments across many providers, the needs of mental health patients were closely managed by the hard work of colleagues across the system. Work is being undertaken to deliver sustainable reductions in long waits in emergency departments, including for mental health attendances.

35. November 2023 data shows an increase in Children and Young People (CYP) access to 739,751, up from 703,168 in August 2023. Whilst positive, attention is required to ensure this upward trend is sustained. CYP Eating Disorders pathways continue to be pressured; for the rolling 3 months to November 2023 66% of CYP started urgent treatment within 1 week (an increase from 63.7% in October 2023) and 77.5% CYP started routine treatment within 4 weeks (an increase from 76.9% in October 2023), both against a 95% standard.

36. The number of patients accessing NHS Talking Therapies services for the first time in November 2023 is 112,898, an increase on the October 2023 position (110,160). Over 54,200 women accessed a specialist community perinatal mental health service or a maternal mental health service in the 12 months to November 2023, continuing the increase in access seen since July 2023.

37. Each ICB is in the process of co-producing a 3-year plan to localise and realign inpatient care in line with the best modern evidence. A culture of care improvement programme, available to all inpatient mental health service providers, was launched in January 2024. This programme includes offers such as ward development programmes, executive mentoring and support, and cross-organisational approaches to quality improvement. A renewed and coordinated approach to supporting systems facing immediate challenge has been developed, with Priority Early Warning Signs being defined to support upstream intervention where quality and safety risks first emerge.

38. Workforce remains the biggest risk to service delivery, expansion, and transformation, and there remains high vacancy rates, particularly in mental health nursing at around 18%. NHS England has set up a dedicated mental health workforce task and finish group, currently focusing on identifying and implementing initiatives to improve the workforce situation in mental health nursing.

Learning disabilities and autism

39. We remain on track to meet our LTP commitment that by March 2024 at least 75% of people aged 14 and over on the GP learning disability register will receive an annual health check. As at the end of October 2023, the percentage of completed health checks for eligible people (34.5%) was higher than at the same point in the previous year, and we have seen a reduction in the number of people declining a health check.

40. We continue work to support the quality of health action plans, and to further increase the size and accuracy of GP learning disability registers, including reviewing adults who may benefit from being added to registers despite not having a confirmed learning disability diagnosis. A specific health check for autistic people is currently being piloted in 4 NHS regions, with formal evaluation due to take place in 2024/25.

41. The annual LeDeR (learning disability and autism mortality review) report published in November 2023 showed that the median age at death, for people with a learning disability who had had their death reviewed, has increased to 62.9 years, although this is still 20 years earlier than for the general population. This was the first year that the deaths of autistic people without a learning disability have been reported to LeDeR. We have published a LeDeR Action from learning report which provides examples of actions to reduce health inequalities for people with a learning disability and autistic people.

42. The Reasonable Adjustment Digital Flag Information Standard Notice mandates that by March 2024 all health and social care providers should identify, and record disabilities and reasonable adjustment needs for disabled patients and clients on their systems. From April 2024, this information will begin to be shared in the digital flag across the NHS Spine between digital systems.

43. At the end of November 2023, there were 1,820 adults and 210 under 18s in a mental health inpatient setting, representing a reduction of 30% since March 2015. Work continues to support local systems to deliver alternatives to inpatient care including optimal use of Care (Education) and Treatment Reviews and Dynamic Support Registers and we continue to work to build sufficient community infrastructure to support people to live well in their community.

44. In September 2023, there were 157,809 patients with an open referral for suspected autism, an increase of 50% since the same point in 2022. Of the current open referrals, 134,315 (85%) patients had a referral that had been open at least 13 weeks compared to 82% in June 2023. In September 2023 the number of new referrals (9,239) and closed referrals (7,003) increased by 27% and 46% respectively compared with numbers seen in September 2022. In December 2023, we published guidance for ICBs, health organisations and wider system partners on Meeting the needs of autistic adults in mental health services.

45. The ‘train the trainer’ autism training for mental health care providers has now been rolled out in residential special schools and youth justice settings, and we continue to support delivery of the Oliver McGowan mandatory training on learning disability and autism for the health and social care workforce, with over 1 million people now having completed the e-learning component.

Prevention and long term conditions

46. Thrombectomy and thrombolysis activity continues to track towards trajectory, with increased adherence to the National Optimal Stroke Imaging Pathway (with 96% of units using AI decision support as of January 2024), video triage for rapid diagnosis, publication of a GMC thrombectomy credential, funding for additional equipment and QI initiatives to increase thrombolysis rates. Implementation of the National Integrated Community Stroke Service (ICSS) model is being directed by the Stroke Quality Improvement in Rehabilitation (Squire) programme with 62.3% of patients transferred from hospital to home-based stroke rehabilitation to drive recovery in Q2 2023/24.

47. Latest published data from the National Respiratory Audit Programme shows 61% of the patients who had an initial assessment in September 2023 and enrolled for pulmonary rehabilitation (PR), completed a discharge assessment in line with the audit KPI. This figure has remained relatively stable over the past four years. Key pieces of contextual information are the actual number of people completing PR together with details of the ethnicity and deprivation of those who complete, and we are working with the audit provider to report on these figures in 2024. We have also just published commissioning standards to support both providers of services and commissioners make improvements in these domains.

48. Over 1.3 million referrals have been made into the NHS Diabetes Prevention Programme to date. A recent independent evaluation looking at programme completers found that they reduce their risk of developing type-2 diabetes by 37%, and the programme in general resulted in a 7% reduction in population-level incidence in areas where the programme was delivered between 2016 – 2018. When looking at people referred to the programme, independent research published in February 2023 demonstrated a 20% reduction in incidence in those at risk of type 2 diabetes that are referred into the programme compared to those not referred.

49. The NHS Type 2 Diabetes Path to Remission Programme is currently available in 70% of the country (30 ICSs) and will expand to full national coverage by the end of 2023/24. To date over 15,700 referrals have been made. Early data indicates participants each lose 7.2kg (over one stone) on average after one month, and 13.4kg (over two stone) after three months. This is in line with the outcomes seen in the trials where participants were able to improve their diabetes control, reduce diabetes-related medication and, in around 50% of cases put their type 2 diabetes into remission.

50. The 2023/24 operational planning guidance highlights hypertension and lipid management as key targets for improvement. Two new QOF indicators for cholesterol have been introduced in 2023/24. In June 2023, 60.3% of people with a high-risk score were being treated with lipid lowering therapy meaning the 2023/24 Operational Priorities and Planning Guidance target has been met. QOF data published in September 2023 indicates that in 2022/23 6.2 million patients with hypertension were managed to NICE targets. This is 175,000 more than pre-pandemic in 2019/20, an increase of 8.2 percentage points compared with 2021/22 and is close to the pre-pandemic baseline of 70%. Up to June 2023, 66.7% of hypertension patients in England are managed appropriately. This is over 7 percentage points improvement compared to June 2022, although there is variation across the ICBs. The 2023/24 Planning Guidance goal is 77%.

51. Revised standards of performance have been agreed to improve the emergency management and clinical outcomes of the most serious type of heart attacks, to be monitored through the national heart attack audit. Communications to providers have asked for increased frequency of audit data submission aiming to achieve monthly submissions and removing the requirement to also submit data through the Specialised Services Quality dashboard.

52. Heart failure is a frequent cause for emergency admission and is associated with long lengths of stay in hospital. Targeted funding for systems has been allocated to support improved community diagnosis and support. Patients are also supported through managing heart failure @Home pilots and heart failure virtual wards. In December 2023 guidance for Enhancing GP direct access to diagnostic tests for patients with suspected chronic obstructive pulmonary disease, asthma, or heart failure was published  to further support primary care diagnosis of heart failure and respiratory disease.

Screening and vaccinations

53. All NHS screening programmes have removed backlogs caused by the pandemic including breast screening. Funding has been provided to increase the number of advanced breast screening practitioners being trained.

54. The NHS bowel cancer screening programme continues to exceed the 65% uptake target with age extension to 58-year-olds and 56-year-olds rolled out as planned since 2021/22 and the roll out to 54-year-olds is on track for completion by the end of 2023/24. A marketing campaign to promote the return of bowel screening FIT kit (home testing) samples was run in February and March 2023 and successfully increased uptake. There was an additional campaign in London at the end of 2023, with the results to be analysed.

55. Uptake for the NHS diabetic eye screening programme continues to meet the efficiency standard. Uptake of initial ultrasound screens in the Abdominal Aortic Aneurysm screening programme is exceeding the achievable standard.

56. In October 2023, the Diabetic Eye Screening programme commenced moving participants assessed as low risk to biannual screening, with any remaining services on track to implement extended intervals in January 2024. This complies with a recommendation of the United Kingdom National Screening Committee and reduces the need for participants to attend unnecessary appointments. Financial savings will be re-invested into a more sensitive test called Optical Computerised Tomography which should reduce the number of referrals to hospital eye services. This will avoid inconvenience for patients and help clinical services.

57. The three NHS antenatal and three NHS new-born screening programmes continue to achieve continuous coverage levels close to 100%.

58. The Sickle Cell and Thalassaemia programme is participating in a national initiative to improve lifetime care for people suffering from sickle cell and thalassaemia disease.

59. A change in HPV schedule for adolescent boys and girls primarily administered in schools is underway across all regions with delivery from September 2023 which means eligible adolescents will only require one dose of the vaccine to be fully protected. Regions continue to implement their catch-up campaign across all cohorts.

60. There is an improvement plan in place which all regions are signed up to focus on increasing MMR uptake. A number of initiatives are being implemented as part of the plan including a GP led campaign from November 2023 and a national call/recall campaign beginning February 2024 as part of a major new NHS drive to protect children from becoming seriously unwell, as measles cases continue to rise across the country.

61. Following JCVI guidance and DHSC policy decision, NHSE are planning the implementation of an RSV infant and adult programme for September 2024 roll out.

62. The 2023/24 delivery for the seasonal flu and COVID-19 vaccinations programmes were accelerated to September in line with Government guidance. The 2023/24 flu immunisation programme made its fastest ever start with improvements in uptake across cohorts and for those most at risk. Improvements in uptake have been seen in cohorts, notably including care homes, 2-3 year olds and over 65s. This will build on the NHS achieving its second highest total of people vaccinated for flu in the 2022/23 season, where 21.2 million people took up the offer of a vaccination as of 31 March 2023.

Genomics

63. The NHS continues to provide the NHS Genomic Medicine Service (NHS GMS) through a consolidated laboratory network made up of seven NHS Genomic Laboratory Hubs. There are seven NHS GMS Alliances working together to support clinical leadership and embedding of genomic medicine in end-to-end pathways; and clinical genomic services that diagnose and manage complex rare and inherited disease.

64. In line with the NHS Long Term Plan, we have continued to see growth in the number of patients accessing the whole genome sequencing service and an increase in the number of extensive genomic tests offered to patients diagnosed with cancer, during 2023/24. In total, over 80,000 Whole Genome Equivalents (WGE) have been sequenced, including more than 13,000 cancer genomes and more than 67,500 rare disease genomes.

65. In line with the commitment in the NHS Genomics strategy, Patient Level Contract Monitoring data from the NHS GMS was made publicly available for the first time in December 2023. Activity and turnaround times data will continue to be published on a quarterly basis.

66. NHS England is continuing to support the Generation Study, which is delivered by Genomics England and supported by the NHS GMS. Colleagues from Genomics England and NHS England have been working with clinicians to agree the genes or conditions to be included in the programme and map downstream care pathways. The initial list of genes and conditions was published in October 2023 to enable public consultation on inclusion into the research study.

67. January and February will see the launch of the last of the 8 approved NHS Genomic Networks of Excellence, which will start to deliver work packages as early as March 2024. The NHS Genomic Networks of Excellence, announced in the NHS Genomics strategy, will play a key role in bringing together the NHS GMS, National Institute for Health and Care Research, Biomedical Research Centres, Academic Health Science Networks and other partners across industry and academia to accelerate genomic research. This will support the generation of evidence and models of adoption for new technology and testing, and clinical and laboratory practice, for example rapid whole genome sequencing, in defined areas of strategic importance.

Recovery Support Programme

68. The Recovery Support Programme (RSP), provides national mandated intensive support to trusts and ICBs in NHS Oversight Framework segment 4 and have complex, deep-seated concerns around leadership, governance, finance, patient safety, quality, and/or performance.

69. Since the last update in December 2023, one trust, East of England Ambulance Service NHS Trust, has exited from the RSP. The Programme now has 19 trusts (five legacy special measures) and 4 ICBs.

70. 38 RSP Review Meetings have been held between March 2021 and December 2023 to stress test the trusts’ improvement plans, review progress against their exit criteria, acknowledge improvements made following exit and escalate where there has been national or regional concern about lack of progress. There are a further three meetings planned for the remainder of Q4 23/24 with meetings for Q1 24/25 currently being scheduled.