Recovery Watch: The ICBs on the slide against the main elective target

Bucking the national trend

Fourteen integrated care boards bucked the overall national improvement in long waiters, instead reporting increases in their 65-week breaches in 2023-24 up to February, Recovery Watch’s analysis of official data shows.

The analysis provides an insight into where national leaders will be focussing efforts as they aim to hit the revised target of virtually eliminating 65-week waiters by September – and also highlights some systems which have made huge improvements over the last year.

RW compared systems’ positions at the beginning of 2023-24 (April 2023) to where they were at nearly the end of the year, February 2024, the most recently reported month. The national position on 65-weeks reduced from around 95,000 in April 2023 to 75,000 in February 2024.

NHS England’s data will, of course, be updated tomorrow, but 11 months gives us ample information to work with. 

Kent and Medway ICB reported by far the largest increase of 65-week breaches, nearly trebling from around 1,200 to 3,400 (See Table 1).

The ICB was also among the top 10 for absolute numbers of 65-week breaches as of February 2024 (see Table 2) and for 65-week breaches as a proportion of its overall list (See Table 3).

The ICB told RW the increase in 65-week waits in February was partly due “to a temporary shortage in endoscopy capacity, which has since been resolved”. It said 65-week breaches had dropped to 2,730 in April and “all providers are on course to clear patients waiting more than 65 weeks by September 2024”.

Next in the ranking for the largest increase in the past 11 months came three London ICBs (North West, South West and North Central London), all of which posted hefty increases. Indeed, London’s five systems all featured among the 14 ICBs reporting increases in the 11 months of 2023-24.

But while South West London’s increase as a percentage is large (112 per cent), its absolute number of 65-week breaches represents a small proportion of its overall list. Indeed, its 65-week breaches comprise just 0.3 per cent of its list – the smallest proportion of any ICB – so are unlikely to figure too highly on NHSE’s problem list.

The real problem areas… And some good news

Most of the attention will be on the systems with the largest overall numbers of long waiter breaches, with just 10 systems accounting for almost half of national breaches – around 36,000 of 75,000 at the end of February.

There is some good news: eight of the 10 systems with the largest 65-week waiter backlogs as of April 2023 improved their position in 2023-24 – some of them significantly.

Birmingham and Solihull, and Leicester, Leicestershire and Rutland both cut their 65-week waiters by nearly 80 per cent. Greater Manchester, which has the longest waiting list in England, reduced its long waiters by over 50 per cent.

RW highlighted the great work being done by the providers in some of these systems in January, but it doesn’t hurt to highlight again that for all the struggles, some systems are delivering huge improvements.

But two of the top three systems based on the total number of 65-week waiters also reported increases in their longest waiters in 2023-24 –  substantial increases at that.

Sussex ICB’s 65-week breaches grew by over a quarter, from 3,736 to 4,753, meaning it had the second most 65-week breaches in absolute terms as of February 2024. Norfolk and Waveney ICB reported an increase of more than 20 per cent, 3,560 to 4,314, meaning it had the third most in absolute terms.

Norfolk also has the highest proportion of 65-week waiters as a proportion of its total list (2.9 per cent of 148,000). Sussex also performs poorly on this measure with its 1.7 per cent of 280,000 making it the fifth worst performer nationally (Cornwall, Devon, and Cambridgeshire and Peterborough take second, third and fourth place). 

Whichever way to cut it, Norfolk and Sussex have much to improve, although there are good reasons why both these systems find themselves in trouble.

Norfolk ICB declined to comment, but the county’s three acute providers (Norfolk and Norwich, Queen Elizabeth Hospital King’s Lynn and James Paget Foundation Trusts) have long struggled to deliver genuine collaboration across a challenging and large rural patch.

Despite forming a provider collaborative, the three trusts’ work on a shared patient tracking list has struggled to get past a handful of specialities.

The ICB was lifted out of national oversight group 4 in March. While this represented a commendable improvement, much of which local system leaders attribute to a new continuous flow model, there is clearly a long way to go.

The Norfolk trusts will also have the short-term impediment of implementing a new electronic patient record system over the next 24 months or so.

While such a move is to be celebrated, and long overdue, the evidence is clear that, although the long-term benefits more than make up for it, recovery takes a sizeable hit during the deployment period and often some way after it.

South East London ICB, for example, said its struggles were partly due to the strikes but also because two of its three acutes had been implementing an Epic EPR in 2023-24.

Sussex also has some clear reasons for its struggles. Its main provider, University Hospitals Sussex, is still struggling with the classic post-merger pains of bringing together systems and teams into a more cohesive form.

While the merger which created the trust took place three years ago, the bulk of this time was during covid, so there are some mitigating circumstances for slow progress.

The trust was also understood to be disproportionately hit by strikes, with every staffing group which took industrial action nationally doing so in Sussex, which was not the case at every trust. The trust’s management also had a long-running row with consultants over its rate card which dented productivity.

The ICB told RW it recognised it had 65-week breaches but was pledging to hit the national September deadline for clearing its backlog.

It said since its overall list peaked in August 2023 it had “reduced at close to double the rate seen nationally”.

It is pinning its recovery hopes on several schemes in addition to standard efforts to optimise capacity and use the private sector.

These include developing a system-wide elective coordination centre, increasing activity by its community diagnostic centres, and a range of the Getting It Right First Time productivity drivers, like day case rates and theatre utilisation.

Table 1: ICBs ranked on percentage increase or decrease of 65-week waiters

ICB	Incomplete pathways Feb 2024	65-week breaches Feb 2024	65-week breaches as a % of total list Feb 2024	65-week breaches April 2023	65-week increase or decrease between April 2023 and Feb 2024	65-week increase or decrease as a %
Kent And Medway	238,214	3,443	1.4%	1,188	2,255	189.8%
North West London	318,920	3,237	1.0%	1,484	1,753	118.1%
South West London	195,112	501	0.3%	236	265	112.3%
North Central London	184,576	1,585	0.9%	899	686	76.3%
Gloucestershire	81,201	721	0.9%	417	304	72.9%
Northamptonshire	86,748	662	0.8%	409	253	61.9%
Bedfordshire, Luton And Milton Keynes	139,116	2,127	1.5%	1,340	787	58.7%
South East London	260,562	2,525	1.0%	1,694	831	49.1%
Cambridgeshire And Peterborough	116,394	2,076	1.8%	1,569	507	32.3%
Sussex	280,494	4,753	1.7%	3,736	1,017	27.2%
Norfolk And Waveney	147,989	4,314	2.9%	3,560	754	21.2%
North East London	247,132	2,441	1.0%	2,180	261	12.0%
Hampshire And Isle Of Wight	195,502	1,943	1.0%	1,912	31	1.6%
Surrey Heartlands	152,941	904	0.6%	903	1	0.1%
West Yorkshire	245,580	1,669	0.7%	1,674	-5	-0.3%
North East And North Cumbria	356,010	1,522	0.4%	1,534	-12	-0.8%
Suffolk And North East Essex	130,824	1,453	1.1%	1,508	-55	-3.6%
Black Country	191,024	1,653	0.9%	1,736	-83	-4.8%
Mid And South Essex	187,409	2,274	1.2%	2,448	-174	-7.1%
Derby And Derbyshire	126,119	1,545	1.2%	1,813	-268	-14.8%
Buckinghamshire, Oxfordshire And Berkshire West	163,664	1,273	0.8%	1,503	-230	-15.3%
Dorset	94,436	1,218	1.3%	1,530	-312	-20.4%
Nottingham And Nottinghamshire	138,831	854	0.6%	1,076	-222	-20.6%
Lancashire And South Cumbria	243,913	1,785	0.7%	2,305	-520	-22.6%
Cheshire And Merseyside	371,542	3,736	1.0%	4,867	-1,131	-23.2%
Shropshire, Telford And Wrekin	70,988	718	1.0%	982	-264	-26.9%
Somerset	64,950	597	0.9%	886	-289	-32.6%
Frimley	82,518	644	0.8%	1,024	-380	-37.1%
Hertfordshire And West Essex	197,466	2,058	1.0%	3,354	-1,296	-38.6%
Cornwall And The Isles Of Scilly	57,809	1,065	1.8%	1,832	-767	-41.9%
South Yorkshire	187,174	755	0.4%	1,303	-548	-42.1%
Bath And North East Somerset, Swindon And Wiltshire	105,330	564	0.5%	980	-416	-42.4%
Devon	150,363	2,727	1.8%	4,754	-2,027	-42.6%
Staffordshire And Stoke-On-Trent	163,430	1,583	1.0%	2,812	-1,229	-43.7%
Herefordshire And Worcestershire	99,942	1,117	1.1%	1,995	-878	-44.0%
Coventry And Warwickshire	117,916	814	0.7%	1,604	-790	-49.3%
Greater Manchester	455,685	6,108	1.3%	12,507	-6,399	-51.2%
NHS England (Specialised Commissioning)	166,409	1,392	0.8%	3,031	-1,639	-54.1%
Humber And North Yorkshire	199,325	998	0.5%	2,337	-1,339	-57.3%
Lincolnshire	113,745	985	0.9%	2,642	-1,657	-62.7%
Bristol, North Somerset And South Gloucestershire	92,049	407	0.4%	1,409	-1,002	-71.1%
Birmingham And Solihull	196,439	1,036	0.5%	4,536	-3,500	-77.2%
Leicester, Leicestershire And Rutland	123,925	734	0.6%	3,626	-2,892	-79.8%

Table 2: ICBs ranked on total number of 65-week breaches as of February 2024 

ICB Name	Incomplete pathways Feb 2024	65-week breaches Feb 2024	65-week breaches as a % of total list Feb 2024	65-week breaches April 2023	65-week increase or decrease between April 2023 and Feb 2024	65-week increase or decrease as a %
Greater Manchester	455,685	6,108	1.3%	12,507	-6,399	-51.2%
Sussex	280,494	4,753	1.7%	3,736	1,017	27.2%
Norfolk And Waveney	147,989	4,314	2.9%	3,560	754	21.2%
Cheshire And Merseyside	371,542	3,736	1.0%	4,867	-1,131	-23.2%
Kent And Medway	238,214	3,443	1.4%	1,188	2,255	189.8%
North West London	318,920	3,237	1.0%	1,484	1,753	118.1%
Devon	150,363	2,727	1.8%	4,754	-2,027	-42.6%
South East London	260,562	2,525	1.0%	1,694	831	49.1%
North East London	247,132	2,441	1.0%	2,180	261	12.0%
Mid And South Essex	187,409	2,274	1.2%	2,448	-174	-7.1%
Bedfordshire, Luton And Milton Keynes	139,116	2,127	1.5%	1,340	787	58.7%
Cambridgeshire And Peterborough	116,394	2,076	1.8%	1,569	507	32.3%
Hertfordshire And West Essex	197,466	2,058	1.0%	3,354	-1,296	-38.6%
Hampshire And Isle Of Wight	195,502	1,943	1.0%	1,912	31	1.6%
Lancashire And South Cumbria	243,913	1,785	0.7%	2,305	-520	-22.6%
West Yorkshire	245,580	1,669	0.7%	1,674	-5	-0.3%
Black Country	191,024	1,653	0.9%	1,736	-83	-4.8%
North Central London	184,576	1,585	0.9%	899	686	76.3%
Staffordshire And Stoke-On-Trent	163,430	1,583	1.0%	2,812	-1,229	-43.7%
Derby And Derbyshire	126,119	1,545	1.2%	1,813	-268	-14.8%
North East And North Cumbria	356,010	1,522	0.4%	1,534	-12	-0.8%
Suffolk And North East Essex	130,824	1,453	1.1%	1,508	-55	-3.6%
NHS England (Specialised Commissioning)	166,409	1,392	0.8%	3,031	-1,639	-54.1%
Buckinghamshire, Oxfordshire And Berkshire West	163,664	1,273	0.8%	1,503	-230	-15.3%
Dorset	94,436	1,218	1.3%	1,530	-312	-20.4%
Herefordshire And Worcestershire	99,942	1,117	1.1%	1,995	-878	-44.0%
Cornwall And The Isles Of Scilly	57,809	1,065	1.8%	1,832	-767	-41.9%
Birmingham And Solihull	196,439	1,036	0.5%	4,536	-3,500	-77.2%
Humber And North Yorkshire	199,325	998	0.5%	2,337	-1,339	-57.3%
Lincolnshire	113,745	985	0.9%	2,642	-1,657	-62.7%
Surrey Heartlands	152,941	904	0.6%	903	1	0.1%
Nottingham And Nottinghamshire	138,831	854	0.6%	1,076	-222	-20.6%
Coventry And Warwickshire	117,916	814	0.7%	1,604	-790	-49.3%
South Yorkshire	187,174	755	0.4%	1,303	-548	-42.1%
Leicester, Leicestershire And Rutland	123,925	734	0.6%	3,626	-2,892	-79.8%
Gloucestershire	81,201	721	0.9%	417	304	72.9%
Shropshire, Telford And Wrekin	70,988	718	1.0%	982	-264	-26.9%
Northamptonshire	86,748	662	0.8%	409	253	61.9%
Frimley	82,518	644	0.8%	1,024	-380	-37.1%
Somerset	64,950	597	0.9%	886	-289	-32.6%
Bath And North East Somerset, Swindon And Wiltshire	105,330	564	0.5%	980	-416	-42.4%
South West London	195,112	501	0.3%	236	265	112.3%
Bristol, North Somerset And South Gloucestershire	92,049	407	0.4%	1,409	-1,002	71.1%

Table 3: ICBs ranked on the number of 65-week breaches as a proportion of its overall list as of February 2024 

ICB Name	Incomplete pathways Feb 2024	65-week breaches Feb 2024	65-week breaches as a % of total list Feb 2024	65-week breaches April 2023	65-week increase or decrease between April 2023 and Feb 2024	65-week increase or decrease as a %
Norfolk And Waveney	147,989	4,314	2.9%	3,560	754	21.2%
Cornwall And The Isles Of Scilly	57,809	1,065	1.8%	1,832	-767	-41.9%
Devon	150,363	2,727	1.8%	4,754	-2,027	-42.6%
Cambridgeshire And Peterborough	116,394	2,076	1.8%	1,569	507	32.3%
Sussex	280,494	4,753	1.7%	3,736	1,017	27.2%
Bedfordshire, Luton And Milton Keynes	139,116	2,127	1.5%	1,340	787	58.7%
Kent And Medway	238,214	3,443	1.4%	1,188	2,255	189.8%
Greater Manchester	455,685	6,108	1.3%	12,507	-6,399	-51.2%
Dorset	94,436	1,218	1.3%	1,530	-312	-20.4%
Derby And Derbyshire	126,119	1,545	1.2%	1,813	-268	-14.8%
Mid And South Essex	187,409	2,274	1.2%	2,448	-174	-7.1%
Herefordshire And Worcestershire	99,942	1,117	1.1%	1,995	-878	-44.0%
Suffolk And North East Essex	130,824	1,453	1.1%	1,508	-55	-3.6%
Hertfordshire And West Essex	197,466	2,058	1.0%	3,354	-1,296	-38.6%
North West London	318,920	3,237	1.0%	1,484	1,753	118.1%
Shropshire, Telford And Wrekin	70,988	718	1.0%	982	-264	-26.9%
Cheshire And Merseyside	371,542	3,736	1.0%	4,867	-1,131	-23.2%
Hampshire And Isle Of Wight	195,502	1,943	1.0%	1,912	31	1.6%
North East London	247,132	2,441	1.0%	2,180	261	12.0%
South East London	260,562	2,525	1.0%	1,694	831	49.1%
Staffordshire And Stoke-On-Trent	163,430	1,583	1.0%	2,812	-1,229	-43.7%
Somerset	64,950	597	0.9%	886	-289	-32.6%
Gloucestershire	81,201	721	0.9%	417	304	72.9%
Lincolnshire	113,745	985	0.9%	2,642	-1,657	-62.7%
Black Country	191,024	1,653	0.9%	1,736	-83	-4.8%
North Central London	184,576	1,585	0.9%	899	686	76.3%
NHS England (Specialised Commissioning)	166,409	1,392	0.8%	3,031	-1,639	-54.1%
Frimley	82,518	644	0.8%	1,024	-380	-37.1%
Buckinghamshire, Oxfordshire And Berkshire West	163,664	1,273	0.8%	1,503	-230	-15.3%
Northamptonshire	86,748	662	0.8%	409	253	61.9%
Lancashire And South Cumbria	243,913	1,785	0.7%	2,305	-520	-22.6%
Coventry And Warwickshire	117,916	814	0.7%	1,604	-790	-49.3%
West Yorkshire	245,580	1,669	0.7%	1,674	-5	-0.3%
Nottingham And Nottinghamshire	138,831	854	0.6%	1,076	-222	-20.6%
Leicester, Leicestershire And Rutland	123,925	734	0.6%	3,626	-2,892	-79.8%
Surrey Heartlands	152,941	904	0.6%	903	1	0.1%
Bath And North East Somerset, Swindon And Wiltshire	105,330	564	0.5%	980	-416	-42.4%
Birmingham And Solihull	196,439	1,036	0.5%	4,536	-3,500	-77.2%
Humber And North Yorkshire	199,325	998	0.5%	2,337	-1,339	-57.3%
Bristol, North Somerset And South Gloucestershire	92,049	407	0.4%	1,409	-1,002	-71.1%
North East And North Cumbria	356,010	1,522	0.4%	1,534	-12	-0.8%
South Yorkshire	187,174	755	0.4%	1,303	-548	-42.1%
South West London	195,112	501	0.3%	236	265	112.3%