When an elective patient has been waiting 40 weeks since referral, that is a warning to hospital managers that they need to take prompt action to avoid breaching the ‘zero tolerance’ 52 week waiting time target.

At least, that’s how it used to be. According to the latest data for the end of July, 40 week waits have become the norm across England. What use is a warning, when it sounds all the time?

There is worse to come, as waiting times continued to lengthen rapidly.

Yes, the NHS treated patients at a faster rate than at the start of the covid shutdown. Yes, those efforts are now reaching the routine patients who have waited longest.

But the sheer numbers of patients have overwhelmed those efforts – not just those waiting list patients who have already waited far too long for treatment, but also the rising number of new referrals (many of whom are urgent) as primary care recovers from the covid shutdown.

The NHS has ambitious goals to increase activity almost to last year’s levels. But the waiting list and waiting times were growing last year, because the NHS was unable to keep up with demand even before covid. So the current ambitions, heroic as they are, will not be enough to stop things from getting worse.

In the following discussion, all figures come from NHS England and NHS Improvement. If you have a national statistic that you’d like to check up on, you can download our waiting times fact checker.

For analysis of waiting times performance at a particular organisation, visit our reports page. You can also access maps of the latest waiting times across England for A&E, cancer, and RTT.

England-wide picture

The number of referrals being added to the waiting list (‘clock starts’ in RTT jargon) continued to recover since the depths of the covid shutdown. It is likely that many of the ‘missing’ referrals since March are going to bounce back at some point, but it is anybody’s guess how many or when.

Patients were discharged at a slightly higher rate following an outpatient appointment or because they no longer needed treatment for other reasons. However these ‘non-admitted clock stops’, as they are known in RTT jargon, remained well below pre-covid levels.

Patients were admitted for inpatient and daycase treatment at a significantly higher rate than the depths of the covid shutdown, but again this remained well below pre-covid levels.

This is a tug of war between two immensely strong teams – a recovery in referrals on one side, and a recovery in treatments and discharges on the other. The waiting list is the flag in the middle of the rope – sometimes moving one way, and sometimes the other. In July the referrals were the stronger team, and the waiting list got a little bit bigger.

Which side is going to win this tug of war?

It is reasonable to assume that the people of England have continued to develop ailments at about the same rate as they did pre-covid. That points to an eventual full recovery in the new referral rate, as well as a surge when many of the ‘missing’ referrals of the last few months eventually present to their GPs.

The NHS’s capacity to treat patients will, however, be constrained for some time to come. The social distancing, aerosol, and PPE requirements of covid are obvious constraints, but even pre-covid the NHS was unable to keep up with demand because of longstanding pressures in areas like workforce and beds.

If referrals can bounce back, but treatments cannot, then we can expect waiting lists and waiting times to continue rising rapidly.

The NHS managed to treat more long-waiting patients in July, but it was only enough to very slightly reduce the rate that waiting times were rising.

No specialty was spared the increase in waiting times.

The number of one year waiters rose very rapidly, as large numbers of patients tipped over the 52-week mark and the NHS struggled to treat them.

Local picture

Of over two thousand specialties within English trusts that had significant waiting lists at the end of July, fewer than a hundred – just 4.2 per cent – achieved the ’92 per cent within 18 weeks’ statutory target.

With the exception of those few local services that are still able to achieve the 18 week target, waiting times continued to rise briskly across the board, showing that this remains an NHS-wide problem.

Referral-to-treatment data for August 2020, the fifth complete month since the covid-19 elective shutdown, is due out at 9:30am on Thursday 8th October.