Date published: 27 July, 2023
Date last updated: 27 July, 2023
Board meetings

Annex: Operational performance update

Agenda item: 4.1 (Public session)
Paper type: For discussion
27 July 2023

Organisation objective

  • NHS Long Term Plan

Executive summary

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

Elective Care

  1. The NHS has made significant progress to reduce the number of people waiting the longest for care, against a backdrop of significant industrial action and a number of bank holidays over the early-summer period. We wrote to providers in May 2023 to set out the next priorities for addressing long waits in elective and cancer services. This letter identified seven key priorities: excellence in basics, long waits, outpatient productivity, cancer pathway redesign, activity, choice and health inequalities.
  2. As at the end of May 2023, the overall wait list was 7.47 million. The median waiting time for elective treatment is now 14.1 weeks, down from a peak of 19.6 weeks in July 2020. 
  3. Four in five people who are waiting for treatment do not require an admission to hospital, requiring either a diagnostic test or outpatient care instead. The NHS is working to reduce the time people wait for an outpatient appointment by transforming the model of care and making greater use of technology. We have been working with local areas to improve outpatient care, including sharing data with the most challenged trusts and identifying opportunities for transformation in their outpatient activity.
  4. NHS England and government made an announcement on patient choice in May stating that, after speaking with their GP, patients will be able to view information for a minimum of 5 providers where possible, with information about waiting times, distance to travel and quality to help them make their choice. They will then be able to make a choice about where they go for treatment using the NHS App or website, based on their own circumstances.

Urgent and Emergency Care (UEC), (including discharge)

  1. The UEC Recovery Plan was published in January 2023, with two clear public ambitions:
    • To improve category 2 ambulance response time to 30 minutes on average over 2023/24, with further improvement in 2024/25 towards pre-pandemic levels
    • For patients to move through emergency departments more quickly with the ambition to improve to 76% of patients being admitted, transferred, or discharged within four hours by March 2024, with further improvement in 2024/25.
  2. Demand for UEC services is high and the system remains pressured as A&E departments experienced the busiest June on record. Despite this, performance has improved considerably compared with last year.
  3. In June 2023, the average response time for a category 2 ambulance call was 36 minutes and 49 seconds, which is 14 minutes and 36 seconds quicker than the same period last year; 787,675 calls were made to 999, 26,256 per day, which was 5% greater than in May 2023.
  4. There were 2.22m attendances in A&Es in June 2023, the highest for any June on record and 1.3% higher than June 2022. This was also just below the level we saw in December 2022 (which saw the highest number of attendances post-COVID). Despite this, 73.3% of patients attending A&E were admitted, transferred, or discharged within 4 hours in June 2023, compared to 74.0% in May 2023 and 72.1% in June 2022.
  5. The fourteen hospital trusts that have been piloting alternative measures as part of the clinical review of standards, have recommenced reporting against the four-hour A&E standard and this is reflected in the June data.
  6. A key priority is to free up hospital capacity by safely discharging patients who no longer need to be there. Since January 2023, there has been a steady decline of inpatients who do not meet the Criteria to Reside and remain in hospital falling by 13% from nearly 14,000 on average in January to just over 12,300 in June. (Criteria to Reside are national guidelines that determine when a patient no longer requires the level of care provided in an acute setting and is ready to be either transferred to a less intensive care facility or sent home.)
  7. There are a number of key recent actions we are taking to support the UEC Recovery Plan, including:
  8. Prioritising the level of national improvement support each system will receive. All 42 systems have been categorised based on performance data and qualitative information. 7 systems and 1 ambulance trust have been placed in Tier 1 (the highest level of support), 7 systems and 2 ambulance trusts in Tier 2 and the remainder in Tier 3.
  9. We have launched the universal improvement offer which will be open to all systems to help them improve ahead of winter. This includes 10 high-impact priority interventions drawn from the UEC Recovery Plan.
  10. Plans for increasing ambulance capacity have been agreed with all ambulance trusts. Demand and capacity planning exercises for General & Acute beds and intermediate care have been completed, to ensure increases in capacity can be achieved ahead of winter.
  11. Work is in progress on the development of the improvement support package for Transfer of Care Hubs, which are local health and social care system-level coordinating centres linking all relevant services across sectors to aid discharge, recovery and admission avoidance.
  12. Development of a new metric that better measures discharge delays, for publication by Winter 23/24.
  13. Sharing of learning and best practice from the Discharge Integration Frontrunners is underway following the announcement of ICS-led integrated programmes to test discharge innovations across systems in January 2023.
  14. Work continues with stakeholders to develop an intermediate care rehabilitation and reablement framework, including setting out the data collections required to implement a national standard for rapid discharge into intermediate care.

Diagnostics

  1. 19 million of the 15 key diagnostic tests were performed in May 2023, 8.5% more than in May 2022. The percentage of patients waiting less than six weeks for a diagnostic test increased slightly, from 72.4% in April 2023 to 74.1% in May 2023.
  2. The 106 operational CDC sites (plus three temporary sites) have delivered over 4.4m tests to date since the first CDC was launched (25/06/23) and 735,000 in-year – ahead of activity plan in 23/24 to date.

Cancer

  1. Following the progress seen in the second half of 2022/23, where the year ended with the 62-day cancer backlog being lower than the previous year for the first time since the start of the pandemic, at w/e 28 May 2023 there were 23,499 patients waiting longer than 62 days following an urgent suspected cancer referral, for either exclusion of cancer or for cancer treatment to start. This represents an expected seasonal increase in comparison to the April 2023 position but remains almost 3,450 lower than the same point last year.
  2. Performance against the 75% Faster Diagnosis standard has been maintained above 70%, at 71.3% in May 2023. This in line with normal seasonal trends and remains higher than in May last year. This demonstrates that progress continues to be made against the ambitions set for 2023/24, despite ongoing capacity reductions related to Industrial Action.
  3. The level of demand for cancer services remained high in May 2023, with the number of urgent suspected cancer referrals at 128% of pre-pandemic levels. The NHS has increased the levels of first treatments provided in response which are higher than the same point last year and 114% above pre-pandemic levels.
  4. The NHS is making notable achievements through cancer transformation initiatives. Over 900,000 invitations have been issued for scanning as a result of our Targeted Lung Health Checks Programme. Of the people who have come forward for treatment we were able to diagnose 2,204 lung cancers to date since 2019, 76% at the earliest stages which give the best chance of effective treatment. People in deprived areas are now more likely to be diagnosed with lung cancer at an earlier stage, thanks to the success of the programme. For the first time ever, new data shows more than a third of people diagnosed with lung cancer from the most deprived fifth of England were diagnosed at stage one or two in 2022 (34.5%) – up from 30% in 2019.

Primary care and community health services

  1. The Primary Care Access Recovery Plan (PCARP) was launched in May 2023. Supported by investment, the plan responds to feedback and outlines measures that will make a difference now to patients and staff, supporting primary care teams to improve and recover access in general practice. A programme of work is in place, with seven key workstreams to deliver the plan. The plan focuses on the following four areas:
    • Empower patients to manage their own health including using the NHS App, self-referral pathways and through more services offered from community pharmacy.
    • Implement 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.
    • Build capacity to deliver more appointments from more staff than ever before and add flexibility to the types of staff recruited and how they are deployed.
    • Reduce 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. 
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  2. The number of appointments taking place in General Practice continues to increase. In the 12 months to May 2023, 347.4 million appointments were carried out, including 10.2 million COVID-19 vaccinations. This is 14.9% higher than the number of appointments carried out in the 12 months to March 2019.
  3. Workforce data shows that as of 30 May 2023 there were 36,194 FTE doctors working in general practice in England. This is an additional 4.8% compared to the manifesto commitment baseline of 31 March 2019 and reflects the continued increase in GP training places, although the number of fully qualified GPs has reduced by 4.5% over the same period. The NHS Long Term Workforce Plan sets out a further 50% increase to GP training places.
  4. As of 30 March 2023, the primary care workforce continued to expand with 29,103 additional direct patient care staff recruited into general practice, achieving the March 2024 target of 26,000 additional direct patient care staff a year early (patient facing staff who are not GPs or nurses).  
  5. In June 2023, 80% of contracted dental activity was delivered across England compared to 77% in May and 56% in April. 
  6. Urgent community response (UCR) services provide assessment, treatment and support for adults who are experiencing a health or social care crisis which puts them at risk of hospital admission in the next 24 hours. UCR is available in every ICB, and is delivered 8am-8pm, 7 days a week at a minimum. Latest data from April 2023 shows that over 35,000 referrals were responded to by UCR services, which is more than double the activity recorded in March 2022. All UCR services aim to achieve a national threshold of 70% of activity being seen within two hours of referral. This target was achieved ahead of the December 2022 deadline, with data from April showing referrals within two hours of referral at 84%.
  7. In 2023/24, there is continued focus on the growth of virtual ward services, effectively increasing the NHS’s capacity to deliver urgent and emergency care, ensuring that services are enabled by technology, utilising remote monitoring and point of care testing to deliver high quality acute level care at home. All ICSs continue to deliver against trajectories agreed with the national programme towards an ambition of 40-50 Virtual Ward beds per 100,000 population, contributing to a reduction in system pressures. Local implementation is translating into increased capacity and improved data quality is being reflected in more robust sitrep submissions.
  8. Against an LTP commitment of 900,000 people being referred to a social prescribing service, there are currently 2,943 social prescribing link workers employed by a PCN/GP practice and since April 2019, they have seen over 2 million patients. Currently 84% of PCNs have access to a social prescribing link worker, which means more patients than ever now have access to this service. We are also on track to meet the LTP commitment of 200,000 people having received a personal health budget by 23/34, which includes some one-off personal health budgets that facilitate hospital discharge. Overall, 7.1 million individuals have now benefitted from a personalised care intervention.

Mental Health

  1. Systems are continuing to make progress against the transformation and expansions ambitions set out in the LTP and the 2023/24 priorities and operational planning guidance against a backdrop of rising demand and long waiting lists. As of June 2022, there were 1.23 million people waiting for their second contact from a mental health service. 
  2. Despite pressures, a number of mental health commitments continue to be met, including the 6 week and 18-week standards for referral to treatment, and the 50% recovery rate for NHS Talking Therapies. The Early Intervention in Psychosis (EIP) services waiting times standard continues to be met, and during 2022/23 67% of EIP services achieved Level 3 NICE concordance or higher, the highest ever achievement against the LTP target and a 50% improvement on last year.
  3. Physical health checks for people with Severe Mental Illness (SMI) support tackling health inequalities and premature mortality. In the 12 months to March 2023 the NHS provided a physical health check to 313,022 people with SMI; this is the highest number of checks delivered to date, with a 38% increase from the previous year. 
  4. Several critical areas remain extremely pressured. The Urgent and Emergency Care Adult Mental Health pathway continues to experience high bed occupancy at 96.3% as at 5th July 2023, and length of stay has continued to rise to an average of 45.6 days nationally as of April 2023, due to delayed discharges.
  5. As of June 2023, the proportion of people with a mental health need waiting over 12 hours in A&E is 18%, whilst mental health accounts for just 3% of A&E attendances. Mental health patients are more than twice as likely to wait over 12 hours or more compared to all other patients. NHS England continues to work with regions and systems on this as a priority, identifying solutions for issues identified through the discharge challenge implemented in December 2022.
  6. In the 12 months to March 2023, 721,506 Children and Young People (CYP) (0-17s) accessed support. CYP Eating Disorders data shows that in Q4 2022/23, 78.7% of urgent cases started treatment within one week (compared to 61.9% Q4 2021/22), and 82.5% of routine cases started treatment within four weeks (compared to 64.1% Q4 2021/22).
  7. For Q4 2022/23, Talking Therapies services delivered access for 320,254 people (71% of the target). Monitoring of the Talking Therapies rebrand campaign continues, as does work to improve referrals from GPs and wider healthcare professionals by launching resources and strengthening relationships via the Royal College of General Practitioners. In addition, NHS England will work to expand and strengthen the workforce through clearer entry routes, development opportunities and expanding the use of permanent contracts for trainees.
  8. The latest data shows that 52,545 women accessed specialist community perinatal mental health services and maternal mental health services in the 12 months to the end of March 2023. Work is underway to increase access by ensuring that systems fully understand the expanded cohort of women, improving links with maternity and primary care, and joint working with other adult mental health services. Further high impact actions are being taken nationally and locally to address areas facing challenge, including supporting regions with 2023/24 operational planning, issuing national guidance and expanding capacity across the NHS workforce. 
  9. Workforce remains the biggest risk to service delivery, expansion and transformation, with vacancy rates in mental health nursing continuing to be of particular concern. Within this context the NHS Long Term Workforce Plan sets out a need to grow the overall mental health and learning disability workforce the fastest, out of all care settings.

Learning Disabilities and Autism

  1. Between April 2022 and March 2023, 78.1% of people aged 14 and over on a GP learning disability register received an Annual Health Check, meeting the March 2024 commitment of 75% a year earlier than planned. This has been supported through work by GP practices and champions and additional roles within Primary Care Networks. A strong focus remains on increasing the number of people with a learning disability who are on a GP learning disability register, and on the completion and implementation of the health action plans that accompany an Annual Health Check.
  2. The Learning from the Lives and Deaths of People with a learning disability and autistic people (LeDeR) review programme aims to reduce health inequalities and prevent early deaths, with 95% of reviews completed within six months as at May 2023. Clinical statements have been published in partnership with the British Thoracic Society setting out best clinical practice for community-acquired pneumonia and aspiration pneumonia, and a LeDeR constipation campaign has recently begun. A LeDeR resource bank has also been launched for professionals supporting people with a learning disability of people who are autistic with their health or care.
  3. At the end of May 2023, there were 2,045 people (1,820 adults and 230 under 18s) with a learning disability and autistic people in a mental health inpatient setting; a 30% decrease from the March 2015 figure of 2,905. While there has been an over 50% reduction in inpatients with a learning disability who are not autistic, there has been an 88% increase in the number of autistic patients (with no learning disability) in a mental health inpatient setting since March 2015.
  4. Support to local areas to develop community alternatives to inpatient care includes national investment of £121 million in 2023/24, publication of the Dynamic Support Register and Care (Education) and Treatment policy, £13m housing capital for 2023/24 for community accommodation, and delivery of the keyworker programme for children and young people.
  5. In April 2023, NHS England published national guidance to help ICBs deliver improved outcomes in all-age autism assessment pathways. This includes a framework of principles for autism assessment services and operational guidance to aid strategic decision making about the range of services that should be provided in each area.
  6. NHS England is also developing further guidance for providers on adjustments to clinical practice for autistic people with mental health needs. A positive practice guide for Talking Therapies for autistic people is in development and guides for other services are to follow.
  7. Work continues to support the delivery of Oliver McGowan Mandatory Training on Learning Disability and Autism for the health and social care workforce. Since November 2022 there have been over 1 million launches of the e-learning components of training for people who require general awareness (Tier 1) or people who may need to provide care and support (Tier 2).

Prevention and Long Term Conditions

  1. The 2023/24 operational planning guidance highlights improvement in hypertension and lipid management as key targets for improvement. Two new QOF indicators for cholesterol have been introduced in 2023/24. In December 2022 58.6% of people with a high-risk score were being treated with lipid lowering therapy, this is a 3.1 percentage point increase since September 2021. The number of patients submitting their home BP readings as part of the BP@Home programme (1.6 million people in 12 months to Jan 2023) and having checks in community pharmacy (over 750,000 people in 12 months to Dec 2022) continue to increase month on month. 
  2. In December 2022, the England Heart Failure (HF) readmissions average was 20.3%, an improvement on the 2021/22 baseline of 21.2%. Reducing admissions is a focus of the cardiac programme in collaboration with projects including HF virtual wards and Managing HF@ home which have demonstrated reductions in readmissions and mortality. All 15 cardiac networks have submitted plans to reduce 30-day non elective readmissions, improve community diagnosis and management of people with heart failure and to improve access to cardiac rehabilitation. 
  3. Thrombectomy and thrombolysis activity continue to improve. Identifying patients to benefit from this treatment requires access to immediate brain scans, and the National Optimal Stroke Imaging Pathway incorporates the use of Artificial Intelligence (AI) to support rapid decision making – 88% of England’s stroke units now have access to AI (up from 5% in 2019). Stroke rehabilitation is a key part of the stroke care pathway. The national model for an Integrated Community Stroke Service with provision of both Early Supported Discharge and needs-led community stroke rehabilitation has been adopted by 49% of services, with patient access rising to 61% in 2023/24 and a target of 75% in 2027/28.
  4. Over 1.2 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 those referred to the programme, the latest independent research published in February 2023 demonstrated a 20% reduction in Type 2 diabetes incidence in those at risk that are referred into the programme compared to those not referred.
  5. The NHS Type 2 Diabetes Path to Remission Programme is currently available in 50% of the country (21 ICSs). The service will start in 9 additional ICSs in September 2023, expanding to full national coverage by the end of 23/24. To date over 10,500 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.

Screening and vaccinations

  1. All NHS screening programmes have removed backlogs caused by the pandemic, except for the last 3/75 breast screening providers.  Funding has been provided to increase the number of advanced breast screening practitioners being trained.
  2. 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 21/122 and the roll out to 54-year -olds having commenced as planned from April 2023. A marketing campaign to promote the return of bowel screening FIT kit samples was run in February and March.
  3. Uptake for the NHS diabetic eye screening programme continues to meet the efficiency standard. 
  4. Uptake of initial ultrasound screens in the Abdominal Aortic Aneurysm screening programme is exceeding the achievable standard.
  5. The three NHS antenatal and three NHS new-born screening programmes continue to achieve continuous coverage levels close to 100%.
  6. 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.
  7. The use of a new vaccine and an increase in eligible cohorts for the Shingles Immunisation Programme is well underway to be delivered from September 2023.
  8. A change in HPV schedule for adolescent boys and girls primarily administered in schools is also underway to be delivered from September 2023 which will mean that eligible adolescents will only require one dose of the vaccine to be fully protected.
  9. NHS London are offering Polio vaccinations to those children who missed the opportunity to be vaccinated previously in response to the detection of levels of polio in the sewage system in the city.
  10. Changes to the targeted neonatal BCG vaccination programme following the introduction of a new neonatal screening programme are being monitored closely in order to improve uptake amongst at risk babies.
  11. 2 million people were vaccinated against flu in 22/23. Uptake for those aged over 65 was 79.9%, exceeding the World Health Organisation target for the third consecutive year. Cohorts for the flu programme in 23/24 were confirmed in the Annual flu letter on 25 May.
  12. The spring COVID booster campaign commenced on the 3rd April in care homes, and 17th April for other cohorts. By the 25th April, we had vaccinated over 1 million people, and half of all eligible care home residents. At 28th June 2023, 4.4m people have been vaccinated.

Children and young people (CYP)

  1. The CYP Transformation Programme has exceeded its commitment to treat 1,000 children a year for severe complications related to their obesity by the end of 2022/23. Some 1,417 patients began treatment during 2022/23, with a further 404 patients starting treatment in Child Excess Weight clinics as at the end of May 2023. Work is now underway to further expand the number of clinics and their reach in 2023/24.
  2. Work continues to implement the recommendations set out in the national urgent and emergency care recovery plan including the development of virtual wards for children and young people, which will expand from July 2023 to cover children in every region of England building on existing models of paediatric wards; roll-out of the inpatient paediatric early warning score (PEWS) chart in July/August 2023; and continued expansion of the paediatric NHS111 clinical assessment service, including the onboarding of Advanced Clinical Practitioners.
  3. A national elective recovery campaign focused on children and young people is now underway, with a number of events being held examining and taking action on key clinical and operational challenges to address backlogs in paediatric elective care.

Maternity

  1. A combination of national, system and local efforts has resulted in good progress to grow the maternity workforce. The latest NHS data shows that 22,308 full-time equivalent (FTE) midwives were employed across NHS hospitals and organisations in England as at March 2023; an increase of 281 FTE (1.3%) compared to the same time last year.
  2. Following the publication of the 3-year Delivery Plan for Maternity and Neonatal Services, a range of operational resources have been made available to support ICBs, trusts and neonatal operational delivery networks to implement the plan and to deliver the highest quality services. These include a new Saving Babies Lives Care Bundle (version 3) to promote implementation of the most up-to-date best practice clinical guidance; and a revised Core Competency Framework which sets outs core training requirements for staff working in maternity and neonatal services and includes a nationally-standardised Training Needs Analysis tool to help plan training and calculate resources required.

Genomics

  1. 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.
  2. In July we have continued to see an increase in access to genomic services. In line with the NHS Long Term Plan, there has been a growth in the number of patients accessing the whole genome sequencing service, in addition to the rapid whole genome sequencing service launched in October 2022 for acutely unwell babies and children. There has also been an increase in the number of extensive genomic tests offered to patients diagnosed with cancers and May saw a record high of cancer whole genomes being sequenced.
  3. July also saw the first in a series of workshops looking to ratify pathways and turnaround times for solid cancers across the NHS Genomic Medicine Service, as well as the submission of business cases from NHS GMS Alliances for forming NHS Genomic Networks of Excellence. 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.

Recovery Support Programme

  1. The Recovery Support Programme (RSP) provides national mandated intensive support to trusts and ICBs in NHS Oversight Framework segment 4 which have complex, deep-seated concerns around leadership, governance, finance, patient safety, quality or performance. Since the previous update to Board in May 2023, there has been one new entry and one exit from the RSP. The programme has 23 trusts (seven legacy special measures) and five ICBs. The new entrant is the Hampshire and Isle of Wight system, so the ICB and all seven trusts (although South Central Ambulance Service was already part of the RSP). Northern Lincolnshire and Goole NHS Foundation Trust exited the RSP and transitioned to segment 3 of the NHS Oversight Framework on 17 May 2023.
  2. 26 RSP Review Meetings chaired by Sir Andrew Morris, with National Executives in attendance, have been held between March 2021 and May 2023 to stress test the trusts improvement plans, progress against their exit criteria, acknowledge improvements made following exit and where there has been national or regional concern about lack of progress. There is one further meeting planned for the remainder of Q2 23/24.

Publication reference: Public Board paper (BM/23/23b(Pu)

Date published: 27 July, 2023
Date last updated: 27 July, 2023