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NHS waiting times for elective care in England

The National Audit Office has highlighted the increasing challenge to the NHS of sustaining the 18-week waiting time standard for elective care and the importance for trusts of having reliable performance information and shared good practice. Today’s report to Parliament concludes that value for money is being undermined by the problems with the completeness, consistency and accuracy of patient waiting time data; and by inconsistencies in the way that patient referrals to hospitals are managed.

The introduction of the standards in 2008 was followed by more patients being treated within 18 weeks. The recent strengthening of the standards also appears to have had a rapid and significant effect on reducing the numbers of people waiting a long time for treatment. The number of people each month waiting longer than 18 weeks without treatment fell to 138,000 by the end of October 2012 (from 234,000 in October 2011) but by the end of October 2013 had increased to 169,000.

With few exceptions, the waiting time standards have been met nationally, although some trusts are breaching the standards. In 2012-13, for example, 58 trusts breached the standard, overall, in at least one month for patients admitted to hospital.

Today’s report does suggest that published waiting time figures need to be treated with a degree of caution. The NAO has identified inconsistencies in the way trusts measure waiting time and errors in the waiting time recorded. Although the rules for applying the waiting times standards  are set at a national level, the performances of individual trusts are not directly comparable owing to local variations in how and when each patient’s waiting time ‘clock’ is started, paused or stopped. The NAO’s review of a sample of cases also found that errors in trusts’ recording of patients’ time: in 167 cases, there was evidence of at least one error, leading to under- and over-recording of waiting time.

Misrecording of referral to treatment waiting times data has also been identified at the North West London Hospitals NHS Trust and Barnet and Chase Farm Hospitals NHS Trust. In addition, Colchester Hospital University NHS Foundation Trust have misrecorded their cancer waiting times. Today’s report also finds that NHS England does not have sufficient assurance about how trusts are performing. The system of checks that NHS England uses should spot some errors and inconsistencies, as well as discrepancies between trusts’ current and past reported performance. It will not, however, detect errors of the kind identified by the National Audit Office without independent validation of trusts’ data. The report recommends therefore, that NHS England should seek additional assurance, possibly through a regime of test checking.

The NAO also spoke to patients who were unaware of their rights and responsibilities, for example, their right to be treated within 18 weeks of referral, or that they may be referred back to their GP and their waiting time starts again if they fail to attend an appointment. The NAO estimates that patients missing first outpatient appointments cost the NHS up to £225 million in 2012-13. Today’s report recommends, therefore, that trusts should ensure their access policies are up-to-date, patient friendly and publicly available.

“The challenge of sustaining the 18-week waiting standards is increasing, against a background of an increasing number of patients being referred to trusts, the financial pressure on the NHS and the need to make efficiency savings. If this challenge is to be met, then performance information should be reliable. However, we have found significant errors and inconsistencies in how trusts record waiting time, masking a good deal of variation between trusts in actual waiting times. The solution is not costly new processes, rather making sure existing processes work properly and are properly scrutinized.”

Amyas Morse, head of the National Audit Office

Notes for Editors


Referrals in 2012-13, of which 61 per cent were made by GPs


Patients were waiting for treatment as of August 2013, 11 per cent higher than in August 2012


Cost of elective care in the financial year 2012-13

91.4 per cent

Of patients who were admitted to hospital against a standard of 90 per cent started consultant-led treatment within 18 weeks of being referred in October 2013 (the latest month for which data was available). The standard was met every month in the previous 12

96.7 per cent

Of other patients (for example, those receiving outpatient treatment) against a standard of 95 per cent started consultant-led treatment within 18 weeks of referral in October 2013. The standard was met every month in the previous 12

94.2 per cent

Of patients who have not yet started treatment against a standard of 92 per cent have been waiting no more than 18 weeks in October 2013. The standard was met every month in the previous 12

£225 million

Is the estimated maximum cost to the NHS of patients failing to attend first outpatient appointments in 2012-13

£51 million

The NHS could make annual savings up to this figure if the Choose and Book system was used to make all referral-to-treatment appointments

48 per cent and 40 per cent

Are the respective percentages of trusts breaching the admitted and non-admitted standards in at least one month (in any specialty) but not fined in 2012-13

1. Press notices and reports are available from the date of publication on the NAO website, which is at Hard copies can be obtained from The Stationery Office on 0845 702 3474.

2. The National Audit Office scrutinises public spending for Parliament and is independent of government. The Comptroller and Auditor General (C&AG), Amyas Morse, is an Officer of the House of Commons and leads the NAO, which employs some 860 staff. The C&AG certifies the accounts of all government departments and many other public sector bodies. He has statutory authority to examine and report to Parliament on whether departments and the bodies they fund have used their resources efficiently, effectively, and with economy. Our studies evaluate the value for money of public spending, nationally and locally. Our recommendations and reports on good practice help government improve public services, and our work led to audited savings of almost £1.2 billion in 2012.

PN: 5/14