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. Five days of industrial action by junior doctors placed another period of challenging pressures on urgent and emergency care (UEC) in February. A significant amount of work and resource has been invested to prepare for and manage this incident, which has been particularly challenging in the context of demand increases seen in 2023/24.
2. Ambulance services answered 763,141 calls to 999 (or 26,315 per day in February 2024), which was 12% more than February 2023. Ambulance services also handled 704,111 incidents. 355,564 incidents were conveyed to A&E, which equates to 12,261 per day during February.
3. The average response time for a category 2 call in February 2024 was 36 minutes and 20 seconds. This is over 3 minutes faster than the previous month (40 minutes and 6 seconds).
4. The NHS reported a record number of attendances for a February with a total of 2,152,361 attendances in A&E across England, an average of 74,219 per day. This compares to an average of 68,367 per day in February 2023, an increase of 8.6%. Between April 2023 and February 2024, there were 6.3% more emergency admissions than the same period the previous year.
5. February 2024 saw 70.9% of patients admitted, transferred or discharged within 4 hours, an improvement on 70.3% reported the previous month.
6. The NHS achieved its target to deliver 99,500 core beds in January 2024. This has been sustained, with an average of 99,926 core beds open in February 2024.
7. The UEC recovery plan committed to delivering 76% 4-hour performance in March 2024. It also committed to achieving performance of 30 minutes for category 2 ambulance response times on average over 23/24. The 4-hour standard remains an important metric for measuring flow and the timeliness with which, across local health and social care systems, the NHS can support patients who arrive at our A&E departments needing care. NHS England continues to work with systems to implement winter plans that set out a path to achieving 76% performance in March 2024.

Elective care

8. Industrial action has continued to create challenges. However, we are still focussed on long waits and continue to work with the NHS to minimise the number of 78+ week waiters. We are also doing some targeted work with the ‘hard-to-clear’ specialties working with Getting It Right First Time (GIRFT) to understand the opportunities that are available for significant and impactful pathway change.
9. The total waiting list has fallen for the fourth consecutive month in a row for the first time since 2017/18, and now stands at 7.58 million. This is a reduction of 27,761 compared to December 2023.
10. 78+ week waiting list is the only long wait metric which increased month on month, since August 2023, with an increase of 849 (6.45%) seen in January 2024 compared to December 2023. It is, however, projected to decrease in February.
11. We have seen month on month decreases in the 65+ week waiting list since October 2023, with a reduction of 6,161 (-6.26%) in January 2024 compared to December.
12. The Referral to treatment (RTT) recording and reporting guidance document was updated on 2 February 2024, to reflect changes to the reporting requirements of community services pathways in RTT datasets. The change has been made as community paediatric activity is currently inconsistently reported across providers, and it is not possible to get a consolidated view of waiting times for this specialty due to fragmented recording across different datasets. Pathways will now be reported through the Community SITREP and the Community Services Data Set. This change will impact next month (February) published RTT statistics.
13. The planning guidance for 2024/25 continues to focus on virtually eliminating 65 week waits, but also introduces a new outpatient target for 2024/25. Outpatient activity is made up of four distinct types and our proposed new ratio-based metric will measure all of them. It measures the progress of providers in increasing the efficiency and productivity of pathways and allocates more resource to the most effective types of appointments. It also considers when overall patient need has gone up and when more people are being referred for outpatient treatment. In 2024/25, this target would mean over 3 million fewer outpatients follow-up attendance-only appointments. That is a 14% change for the better in the balance of outpatient appointments that provide the most effective support for patients.
14. To support with tackling long waits, GIRFT has rolled out its Further Faster initiative to all remaining NHS trusts in England to support them in rapidly reducing the number of patients waiting over a year. 49 trusts in 2 cohorts have taken part in the Further Faster pilots to date. Data from the initial pilot shows that from July 2023 to January 2024 the 52-week backlog reduced by 34.8% across cohort 1 and 12.4% across the later onboarded cohort 2 trusts. Non-participating trusts reduced their backlog by 7.1%.

Diagnostics

15. 2.34 million of the 15 DM01 tests were performed in January 24. This the highest monthly total on record, and a 14% increase on the December figure – a product of more working days and higher activity per working day. Despite this, the total waiting list increased 2% to 1.58 million in January 23 – expected due to the Christmas break. There was an improvement though in patients waiting >6 weeks, which dropped to 26.2% of the total, from the expected seasonal peak of 26.8% in December – this spike is less pronounced than in previous years.
16. Overall, as of 14th March there are 156 community diagnostic centres (CDCs) in operation. Three more are planned to go live in March, with another 11 due in following months. By the beginning of March 2024 CDCs had delivered 7.6 million tests since the first CDC was launched in July 2021, and 3.9 million tests in the current financial year. This is 2% ahead of the activity plan, and since the turn of the year, activity now routinely exceeds 100,000 tests per week.

Cancer

17. As at week ending 28 January 2024 there were 22,459 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 3,000 lower than the peak in Summer 2023 and around 6,000 lower than the same point in January 2023.
18. Performance against the 75% Faster Diagnosis Standard was 70.9% in January 2024 which is 4% points higher than in January 2023 and continues the trend of this year’s performance being significantly higher than in 2022/23.
19. In January 2024, performance against the 62-day from referral or upgrade to first treatment standard was at 62.3%. This is 3% points higher than performance in the same month last year.
20. The level of demand for cancer services remained high in January 2024 with the number of urgent suspected cancer referrals at over 128% of pre-pandemic levels. The NHS has increased the levels of first treatments provided in response which are 11% above pre-pandemic levels.
21. Cancer alliances continue to expand their targeted lung health check coverage. Since April 2019, the programme has diagnosed 3,332 lung cancers, 76.6% of these at stage 1 or 2 with over 1.3 million people invited for a lung check.
22. A second successful “Cancer Bus-ting” tour took place at the end of November 2023 with a focus on tackling health inequalities in areas of poorer early diagnosis rates, including those of high deprivation and high ethnic diversity. The bus covered 500 miles and held sessions in 5 new locations, including Coventry and Nottingham. 78% of those surveyed are now more likely to contact their GP practice if they think they have a symptom of cancer.
23. As well as public outreach, the bus tour provided a significant opportunity to generate coverage to reach an even higher audience with campaign messaging. This included key Black and South Asian national radio stations encouraging listeners to go and see their GP if they are worried about something in their body not feeling right. This achieved up to 60 mentions each day across 13 radio stations across the country.

Primary care and community health services

24. 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 continues focusing on the following 4 areas:

• 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.
• 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.
• 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.
• 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.

25. 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.  Uptake for these expanded services has been positive and a Pharmacy First Service public campaign commenced in February.
26. The GP contract consultation for 2024/25 has now concluded and the final arrangements were communicated to GP practices via letter on 28 February 2024. The changes for 2024/25 cover five broad areas including: reducing bureaucracy, providing increased financial flexibilities; giving primary care networks more staffing flexibility; improving outcomes by simplifying the Directed Enhanced Service requirements, and improving patient experience of access through using data from digital telephony systems to better understand demand on general practice in advance of next winter.
27. The number of appointments taking place in general practice continues to increase. In the 12 months to 31 January 2024, 367.7 million appointments took place in general practice, this includes 7.2 million for Covid-19 vaccinations and 8.0 million primary care network appointments. This now exceeds the target of 50 million additional GP appointments (excluding Covid-19 vaccinations) by March 2024.
28. The target of recruiting 26,000 additional direct patient care staff into general practice has been achieved early and exceeded, with 36,523 additional direct patient care FTE in post as of 31 December 2023. As of 31 January 2024, there were 7,208 FTE doctors working in general practice in England. This is an additional 7.8% compared to the baseline of 31 March 2019. 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.
29. The Dental Recovery Plan was published 7 February 2024, with the aims of delivering up to 2.5 million additional NHS dental appointments for patients over the next 12 months, including up to 1.5 million extra treatments being delivered. The plan sets out how the NHS and government will drive a major new focus on prevention and good oral health in young children and deliver an expanded dental workforce. From 1 July 2022 we reverted to usual contractual performance requirements, expecting to get close to 100% of contracted units delivered. In February 2024, the total percentage of contracted units of dental activity submitted across all contracts was 88% compared to 88% in January.

Mental health

30. 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 92.1% of patients seen within the 75% 6-weeks target, and 98.7% within the 95% 18-weeks target, as of January 2024. Talking therapies access for January 2024 was 118,699, an increase from January 2023 (109,806).
• The proportion of early intervention in psychosis referrals entering treatment within 2 weeks was 70.8% in January 2024, against the 60% standard.
• Access to community mental health services continues to increase with 583,731 people receiving 2 or more contacts in the 12 months to January 2024, up from 579,537 in the 12 months to December 2023.
• There has been significant improvement for access to individual placement and support (IPS) services, with 34,063 people reported to have accessed an IPS service in the 12 months to January 2024, an increase from 27,774 in the 12 months to December 2023.
• The dementia diagnosis rate is 64.4% as of January 2024 against the national ambition of 66.7%, demonstrating steady improvement since January 2023. If this trajectory is maintained, it is expected that the ambition could be achieved in 2024/25.
• In quarter 3 2023/24 292,719 full physical health checks were delivered to people living with severe mental illness (SMI) compared to 279,935 in the previous quarter. These checks are an important way of contributing to the reduction of health inequalities given the higher mortality rate among people with SMI
• There are now 37 established sites for specialist mental health provision for rough sleepers.
• 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 with almost 500 MHSTs by March 2024.
• There are now 14 gambling clinics in operation, achieving representation across every region of England, the 2 remaining clinics are due to open by the end of March 2024.

31. There continues to be extremely high demand for mental health services. As a result, a number of areas remain challenged, with work continuing with regions and systems to prioritise recovery. The mental health urgent and emergency care pathway bed occupancy remains high, with average length of stay at 46 days nationally as of December 2023. There continue to be challenges with flow through the system, meaning that out of area placements (OAPs) remain high. In December 2023, 425 new inappropriate OAPs were started, a decrease from November 2023 (475) but higher than in December 2022 (290).
32. In the 12 months to January 2024 the number of children and young people (CYP) accessing services increased to 758,485, from 749,833 in the 12 months to December 2023. Whilst positive, performance is still behind trajectory, and monitoring is required to ensure this upward trend is sustained. CYP eating disorder pathways continue to be pressured – for the rolling 3 months to January 2024, 60.8% of CYP started urgent treatment within 1 week, a decrease from 63.8% in the rolling 3 months to December 2023. 78.2% CYP started routine treatment within 4 weeks, a decrease from 79.4% in the rolling 3 months to December 2023, both against a 95% target.
33. Access to specialist community perinatal mental health and maternal mental health services has been increasing since July 2023. In the 12 months to January 2024 55,873 women accessed these services, an increase from 54,822 in the 12 months to December 2023.
34. Ensuring we have sufficient additional workforce available to meet increased demand remains the biggest risk to service delivery and transformation. However, progress is being made, with the mental health workforce growing by over 37% (40,900 FTE) between March 2016 and December 2023. Workforce expansion remains a priority, as does addressing significantly high vacancy rates, which in mental health nursing stand at around 18%.

Learning disabilities and autism

35. At the end of December 2023, there were 1,830 adults and 200 under 18s in a mental health inpatient setting, representing a reduction of 30% since March 2015. We have recently published a letter with the Local Government Association (LGA) and the Association of Directors of Adult Social Services around the 5 key elements to support people being discharged from an inpatient setting. We are also leading a programme of work jointly with LGA around those individuals who have the most complex care and support needs, to develop the system conditions to enable these people to leave hospital and to be supported with the lowest level of restriction in their community.
36. The latest autism data shows that in December 2023 there were 172,022 patients with an open referral for suspected autism. Of these, 147,042 (85%) patients had a referral that had been open at least 13 weeks, which is similar to the proportion in September 2023. There were 8,578 new referrals and 8,208 closed referrals in December 2023, an increase of 1.4% for new referrals and 67.2% for closed referrals compared to December 2022.
37. We continue to support and build on the delivery of Oliver McGowan mandatory training on learning disability and autism for the health and social care workforce, with over 4 million e-learning launches and 1 million people now having completed the e-learning component.
38. By the end of 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 (known as the ‘digital flag’). We are currently piloting e-learning training for health and care staff on this, which is due to be rolled out from April 2024.
39. Following a robust period of annual health check (AHC) delivery, a coding update error to the learning disability register in November 2023 has had a considerable impact within GP practices providing this learning disability directly enhanced service. The error has now been resolved, however this has had an impact on activity, with the latest data indicating approximately 5% fewer AHCs were completed in the financial year to date as at the end of December 2023, compared to the same period in 2022.
40. We are working with the Vaccinations and Immunisations team on the Autumn and Winter 2024/25 flu and Covid campaign to increase access to and improve uptake of these vaccinations, and ensure accessible information is readily available to people with a learning disability and their carers. We are also working with respiratory colleagues to collate the supporting evidence for introducing pneumococcal vaccinations, given the increasing numbers of avoidable deaths from respiratory conditions.
41. Building on the development of several highly successful modules on the MindEd learning platform, further modules are now being developed to support the understanding of medication for children. The development team have won the 2023 Health Service Journal Learning Disability Innovation of the Year Award for their work on creating a community of practice, and a podcast and supporting ‘how to’ guidance are being launched.

Children and Young People (CYP)

42. Following its publication in November 2023, the national paediatric early warning system (PEWS) continues to be rolled-out in all paediatric inpatient settings to track potential deterioration in children. Work is underway for phase 2 which will expand the use of PEWS into emergency departments (ED) and ambulances in addition to digitisation of the system. A new ED PEWS prototype is being developed which will be tested with a number of pilot sites over 2024/25 prior to national roll-out.
43. The CYP Transformation Programme continues to deliver its Long Term Plan commitments, including those to improve outcomes for CYP with long-term conditions. An independent evaluation of the national asthma bundle of care is being finalised and will be published in Spring/Summer 2024 and integrated care boards are implementing the national bundle of care for children and young people with epilepsy following its publication in October 2023.
44. The programme has been working with internal and external partners to ensure CYP have been a priority this winter, with the 2023/24 winter guidance setting out key areas of focus for paediatric services. Paediatric A&E attendance rates have been lower this winter compared to last, however, they continue to exceed pre-pandemic levels. Respiratory syncytial virus (RSV) infections appear to have peaked and are reducing, however, concerns remain around MMR vaccination rates and measles cases, particularly in Midlands and London. Work is continuing with the UK Health Security Agency on measles and our wider winter response.

Prevention and long-term conditions

45. Thrombectomy and thrombolysis activity continues to track towards trajectory, with greater adherence to the national optimal stroke imaging pathway and 96% of units using AI decision support as of February 2024, video triage for rapid diagnosis, publication of a General Medical Council (GMC) thrombectomy credential and the establishment of training academies, and quality improvement work to increase thrombolysis rates. Implementation of the Integrated Community Stroke Service model is driven by the Stroke Quality Improvement in Rehabilitation (Squire) Programme with 62.3% of patients transferred from hospital to home-based stroke rehabilitation in quarter 2 2023/24.
46. Over 1.5 million referrals have been made into the NHS Diabetes Prevention Programme to date. Independent evaluation, carried out by the University of Manchester, shows that people who complete the programme reduce their risk of developing type 2 diabetes by 37%, and that the programme resulted in a 7% reduction in population level incidence in areas where the programme was delivered between 2016 – 2018. In November 2023, the University of Birmingham published international research that showed that the programme also reduced the risk of complications from cardiovascular events.
47. The NHS Type 2 Diabetes Path to Remission Programme is currently available in 70% of the country (31 integrated care systems) and will expand to full national coverage by the end of 2023/24. To date over 17,700 referrals have been made. Early data indicates participants each lose 7.2kg (over one stone) on average after 1 month, and 13.4kg (over 2 stone) after 3 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.
48. October’s published data from the National Respiratory Audit Programme (NRAP) shows the proportion of people having an initial assessment and enrolling for pulmonary rehabilitation (PR) remaining relatively stable, in line with the trend over the past 4 years (58% compared to 61% in September). NRAP’s data is also showing a gradual reduction in waiting times for people from the point of referral to start of PR, particularly amongst those with stable COPD.  NHS England is working with the audit provider to provide data on the actual number of people starting and completing PR, together with details of the ethnicity and deprivation of those who complete. We expect to report on these figures from quarter 1 of 2024/25.
49. We continue to work with local systems to improve access to cardiac rehabilitation. The national cardiac rehabilitation audit report 2023, showed 75% of services meeting the standard, which was a 10% improvement in the number of cardiac rehabilitation services providing cardiac rehabilitation to both acute coronary syndrome patients and heart failure patients. The report also evidences good service coverage, with cardiac rehabilitation provision in each integrated care system.

Screening and vaccinations

50. The NHS bowel cancer screening programme continues to exceed the 65% national uptake target. Age extension is in progress to delivery testing to 50- to 74-year-olds by end March 2025.  Roll out to 54-year-olds on track for completion by the end of March 2024, with plans to extend to 52- and 50-year-olds by end March 2025.  From July 2023, people with Lynch syndrome have been introduced into the surveillance arm of the Bowel Cancer Screening Programme.
51. The NHS Breast Screening Programme commitment to improving uptake continues with national interventions and initiatives to support regional and local plans. Uptake and coverage remain below the 70% efficiency standards. Rates are improving month by month with the national uptake rate showing a 2.3% increase on the previous year to 64.6% for the year ending 2023. Coverage has also risen from 66.9% in June to 68.3% in July 2023.
52. The NHS Cervical Screening Programme coverage is at 72%, which is below the 80% programme standard. National and regional initiatives continue to be developed and implemented to support improvements in coverage. Work continues at pace to plan for the implementation of the new NHS Cervical Screening Management System.
53. Uptake of initial ultrasound screens in the Abdominal Aortic Aneurysm Screening Programme is exceeding the achievable standard but below the optimal standard.
54. The NHS Diabetic Eye Screening Programme has commenced moving participants who are assessed as lower risk (expected to be 70% of the cohort) to biannual screening. This will be phased in over a two-year period to ensure activity continues to be broadly balanced between years. Phase 1 of the project has now been successfully delivered. The programme has begun to plan for the implementation of optical coherence tomography within the digital surveillance pathway and R2 grading refinement from October 2024. Both initiatives will reduce the number of referrals to hospital eye services.
55. The NHS antenatal and newborn screening programmes continue to achieve continuous coverage levels close to 100%.
56. The seasonal flu and Covid-19 vaccinations programmes 2023/24 were accelerated to September in line with Government guidance, and achieved 11.8 million Covid-19, and 18.2 million flu vaccinations (February 2024). The Covid-19 vaccination programme concluded 31 January 2024; the flu vaccination programme will continue until 31 March 2024.
57. Following the UK Health Security Agency (UKHSA) announcement about increased risk of measles outbreaks in July 2023, NHS England developed an action plan to address a decline in MMR vaccination uptake including further call and recall, increased community engagement and scoping alternative models of delivery to improved access. This work has been further accelerated following the outbreaks of measles in the West Midlands and subsequently London and the Northwest. A nationally-led call and recall campaign began in February with children aged 6-11 who are unvaccinated or partially vaccinated being invited to come forward. This is being extended in London, the West Midlands and Greater Manchester to cover those up to 25 who are not fully vaccinated. This builds on existing NHS wide ranging and targeted communications activity, working with Department of Health and Social Care and UKHSA, as well as system partners at a local level, to support vaccination uptake.
58. Following Joint Committee on Vaccination and Immunisation guidance, NHS England continue to plan for implementation of both an RSV infant and RSV adult programme for eligible cohorts subject to approval by Ministers.
59. The risk of polio outbreak in NHS London has been reduced and WHO polio free status has been reinstated in England. The London region continue to focus efforts on improving uptake in high-risk areas to reduce risk of recurrence.

Recovery Support Programme

60. The Recovery Support Programme (RSP), provides national mandated intensive support to trusts and integrated care boards in NHS oversight framework segment 4 and have complex, deep-seated concerns around leadership, governance, finance, patient safety, quality, or performance.
61. The programme now has 20 trusts (5 legacy special measures) and 3 integrated care boards enrolled. Since the last update in February 2024, there has been one new entry and one exit from the RSP, as set out below:

• On Tuesday 13th February, it was agreed by the Quality Performance Committee (QPC) that Norfolk and Waveney Integrated Care Board successfully met its exit criteria and should transition into segment 3 of the NHS oversight framework and exit the RSP.
• Following a recommendation from the regional team it was also agreed by QPC in February that Nottinghamshire Healthcare NHS Foundation Trust should transition into segment 4 of the NHS oversight framework and enter the RSP.