NHS activity and performance summary: July and August 2021

This statistical release provides a summary of NHS Wales activity and performance data.

New data relating to calls to the ambulance service, emergency department attendances and admissions to hospital from major emergency departments are provided for the month of August 2021.

New data relating to referrals for first outpatient appointments, diagnostic and therapy waiting times (DATS), referral to treatment times (including both closed patient pathways and patient pathways waiting to start treatment) and patients who started their first definitive cancer treatment in the month are provided for the month of July 2021.

Data for each topic area is also available in more detail on our StatsWales website and on our interactive dashboard.

Note that data included in this statistical release covers a time period during the coronavirus (COVID-19) pandemic, which has affected both how some NHS services have been offered and people's choices regarding health services. Further information is available in the quality information section.

Statistician’s comment

The latest data shows a continued trend of high demand in both unscheduled and scheduled care.

More calls were made to the ambulance service this summer than in any other and median response times have got slower for both red and amber calls. Attendances at emergency departments stabilised in August, but performance against both the 4 and 12 hour targets were the worst on record.

Waiting lists for scheduled care treatments continue to grow, with a record number of patient pathways waiting longer than 36 weeks. Although average waiting times for treatment remain above pre-pandemic levels, they are on a downward trend. High levels of activity in cancer services remain, but performance against the 62 day target for cancer services decreased in the latest month.

• Demand for the ambulance service remained high in August 2021. Although the daily average calls in all categories decreased compared to July 2021, more calls were made than in any other August since comparable data has been collected.
• In August 2021, for the third month in a row, there was an average of more than 100 immediately life-threatening (‘red’ calls) a day.
• The percentage of red calls receiving a response within 8 minutes was 57.6% in August 2021, down marginally from the previous month, lower than pre-pandemic levels and below the 65% target for the thirteenth consecutive month.
• The average number of attendances per day at emergency departments decreased from July 2021, but were in-line with pre-pandemic levels.
• Performance against both the 4 hour and 12 hour targets decreased in August 2021, with a record low percentage of patients spending less than 4 hours in emergency departments and a record high number of patients spending longer than 12 hours in emergency departments.
• Average (median) time spent in emergency departments remains the longest since comparable data was first collected in April 2012.
• The number of patient pathways waiting for diagnostic tests increased in July 2021 compared to the previous month and the number waiting longer than the target time also increased. The number of patient pathways waiting for diagnostics remains markedly higher than before the pandemic started.
• The number of patient pathways waiting for therapies has increased every month in 2021 and is at its highest level since November 2017. While the 14 week performance target continues to be missed, performance has remained fairly stable in recent months, relative to the increased number of pathways waiting for therapies.
• The total number of patient pathways who had been referred for treatment but were waiting to start has risen each month since April 2020. In July 2021, there were over 640,000 patient pathways waiting to start treatment, the highest since comparable data was first collected in 2011.
• The number of closed pathways in the month has been on an upward trend since April 2020, but fell slightly in July 2021, with just under 65,000 pathway closures.
• COVID-19 has had a clear effect on performance against both of the referral to treatment targets. The number of pathways waiting longer than 36 weeks, continues to be a record high; however, a higher percentage of patient pathways were waiting less than 26 weeks and the average (median) waiting time for treatment decreased slightly when compared to the previous month.
• In July 2021, activity levels in cancer services were high with the second highest number of patients informed they did not have cancer and the third highest number of patients newly diagnosed with cancer who started their first definitive treatment in the month, since the suspected cancer pathway data collection began.
• Performance against the 62 day cancer target decreased with just under 62% of patients starting their first definitive treatment in the month within the target time.

Emergency calls to the ambulance service

Activity

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Emergency ambulance calls and responses to red calls, by local health board and month on StatsWales

Note: An update to call handling practices in May 2019 appears to have resulted in a change to red incident volume. Therefore, it is not possible to compare red incident volumes prior to this time.

The total number of emergency calls received by the Welsh Ambulance Services NHS Trust (WAST) had been increasing gradually over the long term. The number of calls fell in most months since the pandemic started; however since March 2021 the number of calls have been close to or have exceeded pre-pandemic levels.

In August 2021, more than 41,500 emergency calls were made to the ambulance service. This is an average of 1,341 calls per day, 74 (5.2%) fewer calls per day than the previous month, but 36 (2.8%) more calls than the same month last year. There were more calls in August 2021, than in any other August, since comparable data was first collected in October 2015.

Calls to the ambulance service are categorised as red, amber or green depending on the urgency of the call. In August 2021, the proportion of all calls that were immediately life-threatening (red calls) was 8.1%, marginally down from 8.2% in July 2021 which was the highest monthly percentage of red calls since comparable red call data was first available in May 2019.

Target

• 65% of red calls (immediately life-threatening, someone is in imminent danger of death, such as a cardiac arrest) to have a response within 8 minutes.

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Emergency responses: minute-by-minute performance for red calls by local health board and month on StatsWales

Note: An update to call handling practices in May 2019 appears to have resulted in a change to red incident volume. Therefore it is not possible to fairly compare performance against the target after this date, with performance prior to this date.

Whilst the COVID-19 pandemic is ongoing, emergency response teams have to complete additional procedures including wearing extra personal protective equipment which impacts on the speed at which they can respond to a call.

Performance against the red call target has been mixed over the COVID-19 period. The target was met for each month between April and July 2020; however, performance has since decreased and the target has not been met for the last 13 months.

In August 2021, 57.6% of emergency responses to immediately life threatening (red) calls arrived within 8 minutes. This is 0.2 percentage points lower than last month, more than six percentage points lower than in August 2020 and more than 11 percentage points lower than in August 2019.

Analysing average response times provides wider context to performance data. The median response time varies from month-to-month, but in the four years prior to the pandemic, had tended to range between 4 minutes 30 seconds and 6 minutes for red calls. However, it has been above 6 minutes for each month since August 2020, reaching a high of 7 minutes 28 seconds in December 2020. In August 2021 the median response time to red calls was 7 minutes and 3 seconds. This is 3 seconds slower than in July 2021, and 39 seconds slower than in August 2020.

The majority of calls to the ambulance service are categorised as amber calls. There is no target associated with response times for amber calls but contextual information shows that in August 2021 the median response time for amber calls was 77 minutes and 4 seconds. This is 94 seconds slower than in July 2021, and more than 40 minutes slower than in August 2020.

Emergency department attendances and admissions to hospital

‘Emergency department’ refers to attendances and admissions at both major accident and emergency departments (A&E), other A&E departments and minor injuries units (MIUs), unless otherwise stated.

A wider range of emergency department performance statistics are now published on the National Collaborative Commissioning Unit (NCCU) website, as management information. This includes measures on the time from patient arrival to triage, the time from patient arrival to contact with a clinical decision maker and analysis of the patient’s discharge destination when they leave the emergency department. These will be updated every month on the same day as this National Statistics publication.

Activity

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Number of attendances in NHS Wales accident and emergency departments by age band, sex and site on StatsWales

Note: Chart 3 shows the number of attendances at both major emergency departments and minor injuries units, and the number of admissions resulting from attending major emergency departments only. Admissions from minor injuries units are not recorded on a consistent basis throughout Wales and are therefore not counted in this chart.

While attendances to emergency departments fluctuate each month, attendances are generally higher in the summer months than the winter.

Attendances to all NHS Wales emergency departments have been affected by the COVID-19 pandemic which started in early 2020, with sharp falls in attendances in the following spring and winter months, coinciding with waves of the pandemic. Attendances have increased markedly since February 2021, and are now in-line with or have surpassed pre-pandemic levels.

The latest data shows that there were just over 89,000 attendances to all NHS Wales emergency departments in August 2021. This is 5.3% lower than the previous month (4,959 fewer attendances), 12.5% higher than in the same month last year (9,904 more attendances) but 3.9% lower (3,647 fewer attendances) than August 2019.

The average number of emergency department attendances per day in August 2021 was 2,878. This is 160 fewer attendances per day on average than in the previous month, 319 more than in the same month in 2020 but 118 fewer than in August 2019.

The total number of emergency department attendances in the year to August 2021 was 892,200. This is 0.9% lower than the previous year (year ending August 2020) and 16.6% lower than the last 12 month period before the pandemic (March 2019 to Feb 2020).

The trend for admissions to hospital resulting from attendances at major emergency departments, is similar to the trend for attendances to all emergency departments since the pandemic.

In August 2021, 15,328 patients were admitted to the same or a different hospital following attendance at a major emergency department. This is 5.5% lower than the previous month, 6.2% lower than the same month in 2020 and 8.7% lower than the same month in 2019.

Performance

Targets

• 95% of new patients should spend less than 4 hours in emergency departments from arrival until admission, transfer or discharge.
• No patient waiting more than 12 hours in emergency departments from arrival until admission, transfer or discharge.

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Performance against 4 hour target by hospital on StatsWales

Note that this is not a unique count of patients; the same patient will be counted multiple times if they make multiple attendances. The time spent in an emergency care facility starts when the emergency care facility is informed of the patient’s arrival at the hospital and stops when the patient is admitted, transferred or discharged.

In the five years prior to the pandemic, the percentage of patients admitted, transferred or discharged within 4 hours of attending an emergency department has fluctuated from month-to-month but has tended to be close to 80%. However, during the year prior to the COVID-19 pandemic, the percentage decreased most months, reaching a low point in December 2019, before increasing in early 2020.

During the early months of the pandemic performance against the 4 hour target time improved, reaching a high of 87.7% in May 2020. Since then the trend has been broadly downward and in August 2021, monthly performance was the lowest since comparable data was first recorded in April 2012.

The latest month’s data shows that 68.7% of patients in all NHS emergency departments spent less than 4 hours in the department from arrival until admission, transfer or discharge. This is 1.6 percentage points lower than the previous month, 11.3 percentage points lower than the same month in 2020, and 8.8 percentage points lower than the same month in 2019. The 95% target continues to be missed.

Contextual information shows that the median time which patients spend in emergency departments has increased gradually from under 2 hours in most months in 2012 and 2013 to around 2 hours and 30 minutes throughout 2019, prior to the COVID-19 pandemic.

During the early part of the pandemic, as attendances decreased the median time spent in the department decreased, to a low point of 1 hours 47 minutes in April 2020. Since then, median times have increased alongside increasing attendances and reached a record high for the fourth consecutive month in August 2021.

In August 2021, the median time spent in the department was 2 hours 53 minutes. This was up from 2 hours 48 minutes from the previous month, up from 2 hours 20 minutes in August 2020 and up from 2 hours and 24 minutes in August 2019.

The median time spent in emergency department varies by age. Prior to the pandemic, children generally spent between 1 hour and 30 minutes and 2 hours in emergency departments, while older patients (aged 85 or greater) generally spent between 3 hours and 30 minutes and 5 hours in emergency departments. However in August 2021, children aged 0 to 4 spent an average of 2 hours and 29 minutes and adults aged 85 and over spent an average of 6 hours and 33 minutes in emergency departments.

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Performance against the 12 hour target by hospital on StatsWales

Note that this is not a unique count of patients; the same patient will be counted multiple times if they make multiple attendances. The time spent in an emergency care facility starts when the emergency care facility is informed of the patient’s arrival at the hospital and stops when the patient is admitted, transferred or discharged.

The number of patients who spent 12 hours or more at an NHS emergency department from arrival until admission, transfer or discharge varies each month but had been on an overall upward trend prior to the COVID-19 pandemic.

Just before the pandemic in January 2020, a little under 7,000 patients spent 12 hours or more in emergency departments. This fell to fewer than 500 in April 2020, during the early stages of the COVID-19 pandemic. Since that record low point, the number spending 12 hours or more has increased and in August 2021 reached just under 8,000 patients, the highest since current reporting began in April 2012.

In the majority of scheduled care datasets, activity and performance is measured by counting patient pathways. This is the specific route a patient follows from their first referral through to the commencement of treatment. Referrals can come from a variety of health professionals, but most commonly come through GPs. Patient pathways are measured rather than patients, as a single patient can have multiple referrals for multiple pathways. Therefore counting pathways better reflects the activity within NHS services.

Outpatient referrals

Activity

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Outpatient referrals on StatsWales

There was a large reduction in the number of referrals for first outpatient appointments in March 2020, following the start of the COVID-19 pandemic. Activity has increased in the months since and the number of referrals has now returned to pre-COVID-19 pandemic levels.

An average of 3,508 referrals for first outpatient appointments were made per day in July 2021. This is a decrease of 7.6% (287 fewer referrals per day on average) compared to June 2021 and a decrease of 12.4% (497 fewer referrals per day on average) compared to July 2019.

Diagnostic and therapy waiting times

Activity

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Diagnostic and Therapy Services Waiting Times by week on StatsWales

Note: The low point in April 2020 for therapies is in part due to Betsi Cadwaladr not submitting data for this month. To provide likely scale of the impact, data for Betsi Cadwaldr in the two months either side showed that 7,519 were waiting for therapies in March 2020 and 9,840 were waiting in May 2020.

Prior to the COVID-19 pandemic, the number of patient pathways waiting for diagnostics had been on an upward trend, while the number waiting for therapies had been on a downward trend.

The latest data for July 2021 shows that there were over 100,000 patient pathways waiting for diagnostics, an increase of 0.9% compared with the previous month. The number of pathways waiting for diagnostics is lower than the peak in September 2020 but has increased in recent months and is 44.0% higher than the same month before the pandemic (July 2019).

The latest data for July 2021 shows that there were just over 50,000 patient pathways waiting for therapies, an increase of 7.1% compared to the previous month. Following the record low in April 2020, the number of patient pathways waiting for therapies was relatively stable for the remaining months of 2020, but has increased in every month in 2021 and is at its highest level since November 2017.

Performance

Targets

• The maximum wait for access to specified diagnostic tests is 8 weeks.
• The maximum wait for access to specified therapy services is 14 weeks.

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Diagnostic and Therapy Services Waiting Times by week on StatsWales

Note: Betsi Cadwaladr did not submit data for April 2020, so are not included in the Wales figures for this month.

The COVID-19 pandemic has had a clear impact on the number of patient pathways waiting longer than the target times for diagnostic and therapy services. More details are available in the quality information.

The largest number of pathways waiting longer than the target time for diagnostics was recorded in May 2020. Since then, the trend has been downwards, however the number has increased in each of the last three months.

At the end of July 2021, just over 45,000 patient pathways waited longer than the target time, this was an increase of 6.8% compared to the previous month and almost eleven times greater than the same month before the pandemic (July 2019).

The largest number of pathways waiting longer than the target time for therapies was recorded in June 2020. Since then, this number has fallen in most months and at the end of July 2021 there were just over 3,000 patient pathways waiting longer than the target time for therapies. This is an increase of 17.8% compared to June 2021 and almost ten times greater than the same month before the pandemic (July 2019).

Contextual information shows that until the COVID-19 pandemic, median waiting times had been relatively stable for diagnostic tests since 2017 and for therapy services since 2018. Both services saw peaks in median waiting times in June 2020, but median waiting times have generally decreased since then.

In July 2021 the median waiting time for diagnostic tests was 6.3 weeks. This is an increase from 5.8 weeks in June 2021 and 2.7 weeks in July 2019.

In July 2021 the median waiting time for therapy services was 4.4 weeks. This is an increase from 3.8 in June 2021 and 3.5 weeks in July 2019.

Referral to treatment time

The referral to treatment time statistics show monthly data on the waiting times for both open and closed pathways following a referral by a GP or other medical practitioner to hospital for treatment in the NHS in Wales.

Data for Welsh residents treated or waiting for treatment outside of Wales are not included.

A patient is defined to have been treated, or their pathway closed if either, following consultation with a hospital specialist, no hospital treatment is necessary or if treatment begins. This could include:

• being admitted to hospital for an operation or treatment
• starting treatment that does not require a stay in hospital (for example, medication or physiotherapy)
• beginning the fitting of a medical device such as leg braces
• starting an agreed period of time to monitor the patient’s condition to see if further treatment is needed

COVID-19 has impacted the way treatments are offered. More details are available in the quality information.

Note that the day of referral is defined as the day that the referral letter is received by the hospital.

Activity

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Patient pathways waiting to start treatment by month, grouped weeks and stage of pathway on StatsWales

The number of patient pathways waiting to start treatment typically varies each month throughout the year, and prior to the COVID-19 pandemic, numbers tended to be highest in late summer and lowest in January.

The COVID-19 pandemic has impacted on the total number of patient pathways waiting to start treatment, with the number increasing steadily every month since May 2020, reaching more than 640,000 by the end of July 2021. This is the highest since comparable data was first collected in 2011.

The number waiting in July 2021 was 2.9% higher than in the previous month and 39.2% higher than in the same month before the pandemic (July 2019).

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Closed patient pathways by month, local health board and weeks waiting on StatsWales

Note: Cwm Taf Morgannwg health board have been unable to provide closed pathway data since September 2018. Data for this health board is excluded from the Wales total in the chart to allow for trend analysis.

The number of closed patient pathways varies considerably each month and tends to be lower in April and December, but remained at a broad level close to 80,000 per month for the 3 years prior to the COVID-19 pandemic.

At the start of the pandemic, the number of closed pathways fell sharply with the fewest closed on record in April 2020. In most months since then the number of patient pathways closed has increased, but it has not returned to the pre-COVID-19 level.

The number of patient pathways closed during July 2021 was nearly 65,000. This is an average of nearly 3,000 patient pathways closed per working day during, a decrease of 6.5% from June 2021 and a decrease of 24.6% from July 2019.

Performance

Targets

• 95% of patients waiting less than 26 weeks from referral.
• No patients waiting more than 36 weeks for treatment from referral.

During the COVID-19 pandemic, health boards have not performed the same level of validation on referral to treatment performance data as they had previously. Therefore, caution is advised when comparing statistics from March 2020 onwards with previous months. Additional information is provided in the quality information.

Prior to the COVID-19 pandemic, performance against both referral to treatment targets was fairly stable between 2016 and early 2019, but had been deteriorating since mid-2019.

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Percentage of patient pathways waiting to start treatment within target time by month and grouped weeks on StatsWales

The percentage of patient pathways waiting less than 26 weeks decreased at the start of the COVID-19 pandemic, reaching the lowest level on record in September 2020. There has been slight improvements in the percentage of patients waiting less than 26 weeks in recent months, but it is still markedly lower than in the pre-pandemic period.

Of the 643,108 patient pathways waiting to start treatment by the end of July 2021, 55.0% had been waiting less than 26 weeks.

This is 1.0 percentage points higher than in June 2021, but 32.3 percentage points lower than in July 2019.

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Percentage of patient pathways waiting to start treatment within target time by month and grouped weeks on StatsWales

The number of patient pathways waiting more than 36 weeks has increased since the start of the COVID-19 pandemic. There was a gradual fall between November 2020 and March 2021, however the number has since increased and reached the highest level on record in July 2021.

Further information on the clinical prioritisation of waiting times are can be found in our quality information.

In July 2021, nearly 240,000 patient pathways had been waiting more than 36 weeks from the date the referral letter was received by the hospital. This represents 37.2% of all patient pathways waiting to start treatment.

This is nearly 6,000 (or 2.6%) more than in June 2021 and over fifteen times more than in July 2019.

Contextual information shows that the median waiting time to start treatment had generally been around 10 weeks between late 2013 and February 2020 but has increased since the COVID-19 pandemic and peaked at a record high of 29 weeks in October 2021. Since then, average waiting times have decreased in most months but remain above pre-pandemic levels.

In July 2021, the median waiting time was 21.4 weeks, a slight decrease from 21.6 weeks in June 2021.

Cancer services

Cancer services have remained open throughout the pandemic but have needed to operate at reduced capacity.

The target for suspected cancer pathway was introduced on 18 November 2020, and effective for all patients treated on the suspected cancer pathway from 1 December 2020. This publication now solely includes data from the suspected cancer pathway data collection.

The ‘number of patients entering the single cancer pathway’ will continue to be published on StatsWales. These data are currently still collected directly from health boards, using aggregate data collection forms, while development work is ongoing to include it as part of the new centralised data collection using the National Data Resource through Digital Health and Care Wales.

More detail is available in the quality information.

Suspected cancer pathway (experimental statistics)

The suspected cancer pathway starts at the point of suspicion (for example when a GP makes a referral) and this is when the recorded waiting time starts. The pathway is closed, and the waiting time ends, if the patient:

• starts their first definitive treatment
• is told they do not have cancer (downgraded)
• chooses not to have treatment
• if the patient dies

The data does not include suspensions and for this reason, the data is only comparable with the historical single cancer pathway data collection for the number and percentage of patients starting treatment within 62 days without suspensions.

This publication focusses on data relating to three headline statistics on the suspected cancer pathway, these are:

• number of patients informed they do not have cancer
• number of patients treated who started their first definitive treatment
• number and percentage of patients who started their first definitive treatment within the 62 day target time (without suspensions)

A number of wider measures from the suspected cancer pathway produced by Digital Health and Care Wales have been published alongside this statistical release, to provide more context to the activity and performance of cancer services in Wales.

Activity

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Suspected cancer pathway (closed pathways) on StatsWales

Prior to the COVID-19 pandemic, on average there were just under 1,500 patients starting their first definitive treatment per month. This number fell at the start of the pandemic to a low point of 925 in May 2020 but has been on an upward trend since and in recent months has been in-line with or exceeded pre-pandemic activity levels.

In July 2021, 1,600 patients newly diagnosed with cancer started their first definitive treatment in the month, the third highest on record since the suspected cancer pathway data collection began.

This is a decrease of 2.9% from June 2021 (the second highest month on record) but an increase of 7.3% from July 2019.

In July 2021, 11,795 patients were informed they do not have cancer. This is a decrease of 4.4% compared to June 2021.

Performance

Target

• At least 75% of patients should start treatment within 62 days (without suspensions) of first being suspected of cancer. Data published for time periods before December 2020 are not subject to the target.

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Suspected cancer pathway (closed pathways) on StatsWales

The percentage of patients that started treatment within 62 days of first being suspected of cancer improved slightly during the initial few months of the pandemic, peaking in July 2020, when fewer patients entered the single cancer pathway. Performance has remained broadly above pre-pandemic levels in most months since.

In July 2021, 61.8% of patients (988 out of 1,600) newly diagnosed with cancer started their first definitive treatment in the month within 62 days of first being suspected of cancer. This is 5.6 percentage points lower than in June 2021 but 0.3 percentage points higher than July 2019. 

Changes to NHS Wales Informatics Service (NWIS)

On 1 April 2021 the function of NHS Wales Informatics Service was replaced with a new organisation called Digital Health and Care Wales. It has been created to take forward digital transformation and provides the national technology and data services needed by patients and clinicians. They operate as a Special Health Authority with an independent Chair and Board. There has been no impact on the data supplied to the Welsh Government for this statistical release.

Data quality during the COVID-19 pandemic

During the COVID-19 pandemic resources across all NHS organisations have been stretched, including those responsible for recording, processing and validating data. This means that some of the data included in this statistical release may not have been subject to the same rigorous validation checks that would normally have occurred prior to the pandemic. While data submitted during the pandemic is of broadly good quality, there are some data specific data quality issues. 

• Betsi Cadwaladr health board did not submit data for the number of pathways waiting for therapy services in April 2020. This affects diagnostic and therapy services activity and performance data in that month only.
• Neath Port Talbot hospital was unable to submit blood pressure monitoring, echo cardiogram and heart rhythm sub-specialty data for August and September 2020.
• Princess of Wales hospital was unable to submit consultant, gastroscopy and MRI sub-specialty data for August and September 2020. This affects diagnostic and therapy services activity and performance data in Cwm Taf Morgannwg, Swansea Bay and at a Wales level in those months.
• While referral to treatment waiting lists remain active, clinicians have had to review all patients on the waiting lists at various stages to identify clinical priorities. The amount of validation performed by local health boards on waiting list data has been reduced as the same resources are also focused on supporting the new ways of working. This affects the referral to treatment activity and performance data.
• While not COVID-19 specific, Cwm Taf Morgannwg has not submitted closed pathways data since September 2018 (Cwm Taf health board between September 2018 and March 2019). Therefore closed pathways data only refers to the six other health boards to allow for trend analysis at a national level.

Ambulance response times

During the COVID-19 pandemic emergency response staff have been required to wear additional personal protective equipment which will impact how quickly they can respond to a call. In addition, after an ambulance has been dispatched to the scene, it must then go through additional cleaning processes to prevent the spread of the virus. This results in the vehicle being taken off the road for a time which may also affect response times during this period.

As part of the continual review of the clinical response model, the Welsh Ambulance Service Trust regularly reviews call handling practices and the categorisation of incidents. An update to call handling practices in May 2019 appears to have resulted in a change to red incident volume. Therefore, it is not possible to compare red incident volumes prior to this time. Increases in red incident volumes may also impact on performance due to the additional resources required to attend a red incident.

The clinical response model for ambulance services was introduced in Wales from 1 October 2015. The trial, initially scheduled for 12 months, was extended for a further 6 months, but, following receipt of the independent evaluation report commissioned by the Emergency Ambulance Services Committee (EASC), the clinical response model was implemented (February 2017). See the quality report for more details.

There are three overarching call categories.

1. Red: Immediately life-threatening (someone is in imminent danger of death, such as a cardiac arrest).
2. Amber: Serious, but not immediately life-threatening (patients who will often need treatment to be delivered on the scene, and may then need to be taken to hospital).
3. Green: Non urgent (can often be managed by other health services and clinical telephone assessment).

The categorisation of a call is determined by the information given by the caller in response to a set of scripted questions, which is then triaged by the automated Medical Priority Dispatch system (MPDS). Call handlers are allowed up to two minutes to accurately identify both the severity and nature of a patient’s condition (for those calls that are not immediately life threatening). An ambulance or other appropriate resource is dispatched as soon as the severity and condition are identified. In high acuity calls, this may be whilst the caller is still on the line. There are two occasions where the priority of a call could be changed; when new information from the caller is assessed via the MPDS system, or where a nurse or paramedic has gathered further information about the patient’s condition over the phone.

For the purposes of the 8 minute target, the clock starts when the patient’s location and chief complaint has been established.

Revisions: Any revisions to the data are noted in the ‘Notes for this month’s publication’ and in the information accompanying the StatsWales cubes each month.

Ambulance services: StatsWales

Ambulance services: Quality report

Ambulance services: Annual release

Emergency departments

The term ‘emergency department’ captures activity at major accident and emergency (A&E) departments, other A&E departments and minor injury units (MIUs).

Note that the number of admissions to hospital are based on attendances at only major emergency departments in Wales. This is because admissions to hospital from attendances at minor injuries units are not recorded consistently across Wales.

On 17 November 2020, a new major emergency department opened at the new Grange University hospital in the Aneurin Bevan health board. The Grange University Hospital contains a host of specialist services in one place, including a 24 hour emergency department and assessment unit for major emergencies and resuscitations which could require onward intensive care.

In data referring to December 2020 onwards, both Royal Gwent and Nevill Hall hospitals have been re-classified to “Other emergency department/Minor Injury Units - Other emergency department/Minor Injury Units” following the opening of the Grange University hospital. This category of hospital is defined as all other emergency department/casualty/minor injury units which have designated accommodation for the reception of accident and emergency patients and can be routinely accessed without appointment, but which do not meet the criteria for a major emergency department. This also means that statistics for admissions from major emergency departments will not include admissions from attendances at Royal Gwent or Nevill Hall hospitals from December 2020s data onwards.

Major emergency departments are defined as a consultant led service with resuscitation facilities and accommodation for the reception of emergency department patients. Major emergency departments must provide the resuscitation, assessment and treatment of acute illness and injury in patients of all ages, and services must be available continuously 24 hours a day.

During the COVID-19 pandemic, several minor injury units (MIUs) temporarily closed, but some have since reopened. These are Barry hospital (closed in March 2020; reopened in September 2020); Bryn Beryl Hospital (closed in May 2020; reopened in September 2020); Dolgellau and Barmouth District Hospital (closed in April 2020; remains closed); Tywyn & District War Memorial Hospital (closed in June 2020; remains closed); and Llandovery Community Hospital (closed in April 2020; remains closed).

Since 5 August 2020 the CAV24/7 service has been in operation in Cardiff and Vale University Health Board, which affects how services are delivered in its emergency departments. The ‘Phone First’ model encourages patients who think they have an urgent need to attend an emergency department but do not have an immediately life threatening condition to call ahead to be pre-triaged. Depending on the severity of the condition, they may be encouraged to self-care; signposted to a more appropriate service in their local community; or directly booked in to a timeslot in an emergency department if they need further assessment and treatment.

Other health boards are working towards introducing similar services but none are yet in operation.

In terms of measuring the time a patient spends waiting, the clock start time remains unchanged: the time starts when the patient physically arrives at the emergency department. While the service is in its infancy extra validations will be performed on Cardiff and Vale’s data to assess the impact of the changes. To date, neither the level of activity or performance against the two emergency department targets has changed markedly since the service was introduced.

Alongside these National Statistics three new measures have been developed as part of the Emergency Department Quality Delivery Framework (EDQDF). This framework developed a broader range of measures, to provide more context about delivery of care in emergency departments. These include measures on the time from patient arrival to triage, the time from patient arrival to contact with a clinical decision maker, and analysis of the patient’s discharge destination when they leave the emergency department.

As the datasets and data collection processes for these measures are developed, they are published as management information on the National Collaborative Commissioning Unit (NCCU) website on the same day as this publication. Dependent on data being robust and meeting the requirements of the Code of Practice for Statistics, Welsh Government intend to publish these alongside our official statistics in 2021, with an experimental statistics status in the first instance.

From March 2021, amendments have been made to the NCCU’s data extraction methodology, meaning their figures for the number of attendances to major emergency departments will match those published in this National Statistics publication. Figures published by NCCU for previous months have also been revised based on their new methodology.

Digital Health and Care Wales provide the data from the Emergency Department Data Set (EDDS). This is a rich source of patient level data on attendances at emergency care facilities in Wales that tends mainly to be used for the performance targets.

Targets: Time spent in emergency departments.

• 95% of new patients should spend less than 4 hours in emergency departments from arrival until admission, transfer or discharge.
• No patient waiting more than 12 hours in emergency departments from arrival until admission, transfer or discharge.

Revisions

Some figures are likely to be revised in future months. Each submission from health boards contains data for up to the last 12 months. This may contain minor revisions to previously published periods. The revised data will be published on StatsWales with the latest month. Any substantial revisions will be footnoted and mentioned in the statistical release.

Performance data from January 2020 to August 2021 for Ysbyty Glan Clwyd was revised this month. The error occurred due to server change in the health board and as a consequence the appropriate "stop clock" events applied locally were not reported in the data which the health board provides to DHCW. This affected the performance data which was supplied to the Welsh Government and published in this release. As a result of the revision, at the Wales level, the percentage of patients spending less than four hours in emergency departments has increased by an average of 0.6 percentage points, and the number of patients spending longer than 12 hours in emergency departments has decreased by an average of 38 per month for the affected months. The changes in performance data published on StatsWales for Betsi Cadwaladr health board and Ysbyty Glan Clwyd are greater. Note that the overall number of attendances reported were correctly originally and have therefore not been revised.

Comparability and coherence

Figures produced for Wales, Scotland and Northern Ireland are National Statistics. All four UK countries publish information on the time spent in emergency departments/Accident and Emergency (A&E), though this can be labelled under Emergency Department (as in Scotland) or Emergency Care (as in Northern Ireland). The published statistics are not exactly comparable because: they were designed to monitor targets which have developed separately within each country; the provision and classification of unscheduled care services varies across the UK; the systems which collect the data are different.

Time spent in emergency departments: StatsWales

Time spent in emergency departments: Quality report

Time spent in emergency departments: Annual release

Outpatient referrals

Revisions: From December 2015, the revisions policy is to revise back every 12 months on a monthly basis.

Aneurin Bevan health board had previously not provided data for the adult mental illness treatment speciality for March and April 2021, but this has now been provided and data has been revised.

Comparability and coherence: Similar information is available from other parts of the UK but the data is not exactly comparable due to local definitions and standards in each area. Data standards and definitions have been agreed across health boards ensuring that data is collected on a consistent basis across Wales.

Outpatient referrals: StatsWales

Outpatient referrals: Quality report

Diagnostic and Therapy waiting times (DATS)

The increased number of pathways waiting for diagnostics is directly linked to the impact of COVID-19 with all non-urgent outpatient appointments suspended in March 2020 in order to prioritise urgent treatments. In addition, while more services have since restarted, additional infection, prevention and control measures have been implemented that has affected the amount of diagnostic testing activity that can be carried out.

Conversely, the lower level of patient pathways waiting for therapies during the height of the pandemic is in part due to carrying out many of these services virtually. As a result, a higher volume of patients received an appointment than if they were all conducted in-person at a hospital setting.

Note that Betsi Cadwaladr health board did not submit therapies data for April 2020. This affects the number of total patient pathways waiting in the month and data for this month should not be compared with other months, at the Wales level. To give an estimate of the scale of the impact, there were 25,501 pathways waiting in the other six health boards in April 2020, while in the two months either side, there were 7,519 patient pathways waiting in March 2020 and 9,840 in May 2020, in Betsi Cadwaladr.

This will also affect the number and percentage of pathways waiting longer than the target time. Performance data for April 2020 is only representative of the six health boards which provided data for that month. No data has been estimated for the missing data in this release or on StatsWales.

Targets: Waiting times for access to diagnostic and therapy services (operational standards for maximum waiting times).

• The maximum wait for access to specified diagnostic tests is 8 weeks.
• The maximum wait for access to specified therapy services is 14 weeks.

Revisions: Any revisions to the data are noted in the ‘Notes for this month’s publication’ and in the information accompanying the StatsWales cubes each month.

Comparability and coherence: See notes for Referral to Treatment.

Diagnostic and Therapy waiting times: StatsWales

Diagnostic and Therapy waiting times: Quality report

Diagnostic and Therapy waiting times: Annual release

Referral to treatment times

A referral to treatment pathway (RTT) covers the time waited from referral to hospital for treatment and includes time spent waiting for any hospital appointments, tests, scans or other procedures that may be needed before being treated. Definitions of terms used and quality information are in the quality report.

Targets: Referral to treatment times:

• 95% of patients waiting less than 26 weeks from referral to treatment.
• No patients waiting more than 36 weeks for treatment.

Cwm Taf Morgannwg (and Cwm Taf prior to April 2019) have been unable to provide closed pathway data since September 2018 because of IT problems following a software update. Therefore, all numbers and comparisons for closed pathways from the October 2018 release onwards exclude Cwm Taf Morgannwg. The data for Cwm Taf for previous months are available on StatsWales.

At the end of June 2019, Cwm Taf Morgannwg advised the Welsh Government that they thought there was an issue with the reporting of certain RTT waiting lists. They asked the NHS Wales Delivery Unit to carry out a review and this resulted in a total of 1,783 additional patients being added to the RTT waiting list for the publication of July 2019 data in October 2019. In addition, the Delivery Unit also carried out a review of the diagnostic waiting list and found an additional 1,288 patients should have been reported. These patients were also added to the official figures for the end of July 2019 that were reported in October 2019. Whilst the patients were not reported as part of the official statistics they were being reported internally to the health board. Welsh Government has contacted other health boards and has been advised that all waiting lists are being reported as per the Referral to Treatment Guidelines.

Treatments conducted virtually are counted the same as in-person activity, and since the COVID-19 pandemic, a higher volume of treatments have been conducted virtually.

As all non-urgent outpatient appointments were suspended in March in order to prioritise urgent appointments, the length of waiting times for patients referred for treatment has increased markedly. In addition, while more services have since restarted, additional infection, prevention and control measures have been implemented that has affected the amount of treatment activity that can be carried out.

At present, clinicians are reviewing patients on waiting lists at various stages to identify clinical priorities using the latest Federation of Surgical Specialty Associations – COVID-19 documents clinical prioritisation national clinical guidance. This means that there is greater emphasis on treating patients in order of clinical priority, and can result in patients with lower clinical priority waiting longer. Whilst there has always been an element of clinical priority, the available capacity before the COVID-19 pandemic allowed for patient who had experienced longer waits to be treated sooner. However, since the COVID-19 pandemic, available capacity has reduced substantially.

While referral to treatment waiting lists remain active, the amount of validation performed by local health boards on waiting list data has been reduced as resources are also focused on supporting the new ways of working. Caution should be taken when comparing performance statistics from March 2020 onwards with previous months due to these changes.

Data previously collected via the long-standing PP01W data collection for treatment specialties not included in RTT ceased following an impact assessment, therefore statistics based on this collected have also ceased.

Revisions: Any revisions to the data are noted in the ‘Notes for this month’s publication’ and in the information accompanying the StatsWales cubes each month.

Comparability and coherence: England, Scotland and Wales publish referral to treatment waiting times that measures the complete patient pathway from initial referral e.g. by a GP, to agreed treatment or discharge, in addition to certain stages of treatment waiting times. Northern Ireland publish waiting times statistics for the inpatient, outpatient and diagnostics stages of treatment that measures waiting times for the different stages of the patient pathway, typically specific waits for outpatient, diagnostic or inpatient treatment, or for specific services such as audiology.

To increase consistency across health board data, all new treatment codes have been amended to their pre-April 2016 equivalents. This has now been actioned for all historic RTT and referrals data. This will be implemented until all health boards are able to report using the new codes consistently. For more information, see this Data Set Change Notice (2014/08) (NHS).

In relation to referral to treatment waiting times, whilst there are similar concepts in England, Wales and Scotland in terms of measuring waiting times from the receipt of referral by the hospital to the start of treatment, and, the types of patient pathways included, there are distinct differences in the individual rules around measuring waiting times. This is particularly important regarding ‘when the clock stops or pauses’, exemptions, and the specialities covered.

Referral to treatment: StatsWales

Referral to treatment: Quality report

Referral to treatment: Annual release

Cancer Services

Cancer patients are treated by clinical urgency rather than length of wait. COVID-19 has affected how cancer services are delivered. Health boards have needed to adapt through various means including implementing additional infection, prevention and control measures to ensure they are delivering safe services while reducing the risk of patients contracting COVID-19. This has meant services have been operating at reduced capacity.

The number of patients starting treatment within the target time will also likely to be affected by the periods where some patients were shielding and by patient choices.

Suspected cancer pathway

From February 2021, data is only published for the suspected cancer pathway. For more information on the pathway, see this Data Set Change Notice (NHS Wales) with these key documents (NHS Wales).

The suspected provides a more transparent and meaningful method for measuring performance of cancer services, compared to the previous urgent and non-urgent pathways. It does this by measuring the time on the cancer pathway from the point a patient was suspected of having cancer rather than the point at which the decision to treat is made. All patients are included regardless of their routes of referral who have started their first definitive treatment in the reporting period. This includes patients who were referred to secondary care in Wales but may receive treatment outside of NHS Wales (in both a different country and private hospitals), but does not include patients with a recurrence of the original primary cancer.

This data collection is based on closed pathway data and measures activity through the number of patients being treated or being informed by a specialist that they do not have cancer, rather than the number of patients entering the pathway.

The suspected cancer pathway target is: At least 75% of patients should start their first definitive treatment within 62 days (without suspensions) of first being suspected of cancer. This target was effective from 1 December 2020.

Targets for the urgent and not via the urgent pathway have ceased and no new data will be collected or published for these pathways. Historical data remains available on the StatsWales website.

The ‘number of patients entering the single cancer pathway’ will continue to be published on StatsWales. These data are currently still collected directly from health boards, using aggregate data collection forms, while development work is ongoing to include it as part of the new centralised data collection using the National Data Resource through Digital Health and Care Wales. Data for the number of patients entering the pathway has experimental statistics status as it may contain some duplicate referrals or may not contain data from all referral sources. For these reasons, the data will provide a broad idea of scale and trend but is limited in its use and more detailed inferences would be of low reliability.

Alongside the move to solely reporting on the suspected cancer pathway, a range of wider contextual performance measures have been developed. An analysis of these measures has been brought together using the National Data Resource at Digital Health and Care Wales and has been published by Welsh Government as an Digital Health and Care Wales product. This dashboard is in continuous development and will aim to contain analysis of: the median time to first appointment, the median time for patients to be informed of a positive diagnosis for cancer, and the median number of days to a patient’s first diagnostic test when data are of sufficient quality. Breakdowns by age group and sex are also presented. This data is also published with experimental statistics status.

Revisions: Any revisions to the data are noted in the ‘Notes for this month’s publication’ and in the information accompanying the StatsWales datasets each month.

Comparability and coherence: Other UK countries also measure cancer waiting times. However, the outputs differ in different countries because they are designed to help monitor policies that have been developed separately by each government. Further investigation would be needed to establish whether the definitional differences have a significant impact on the comparability of the data.

A detailed analysis of historical cancer waiting times is also published in an annual statistical release.

Historically, data for Powys for those patients who entered the pathway only showed patients who were later downgraded as not having cancer, and this continues with the suspected cancer pathway collection.

Specialist Child and Adolescent Mental Health Services (sCAMHS)

From 16 June 2021 onwards, data relating to Specialist Child and Adolescent Mental Health Services (sCAMHS) has been published alongside other mental health data as StatsWales open data tables.

Delayed transfers of care (DToC)

At the start of the COVID-19 pandemic, the Welsh Government suspended delayed transfers of care reporting requirements, along with many other datasets. In the interim, Welsh Government introduced the COVID-19 Discharge Requirements, which included an updated discharge process with increased focus on rehabilitation and reablement to improve patient flow and support better outcomes.

The NHS Delivery Unit has been collecting interim weekly delayed discharge data to provide Welsh Government with management information to support the new arrangements. This data does not measure delayed transfers of care in the same way as the previous data collection, and has not been assessed against the standards of the Code of Practice for Statistics. Options for future collection and publication of data and performance measures will be developed as soon as possible, as work in this area has been delayed due to other priorities relating to COVID-19 pandemic.

In light of recent questions about discharge data, we will shortly be publishing an ad-hoc release of the interim discharge data.

Sources

Ambulance response data is provided by the Welsh Ambulance Service NHS Trust (WAST).

All other data summarised here is collected from local health boards by the Digital Health and Care Wales. Full details are provided in the Quality reports for each service area.

Timeliness

Publishing our monthly NHS activity and performance releases on the same day provides users with a more rounded and integrated picture of activity and gives a more coherent view of the NHS in Wales.

Not all datasets have the same processing timelines. To make the data available as soon as we can, we publish the unscheduled care data for, say, October alongside the planned care data for September.

Data

Online tool, an interactive online tool has been developed with three sections.

1. Demand and activity, for example, emergency departments attendances, ambulance calls, referrals.
2. Performance, for example, performance against emergency departments targets, RTT etc.
3. Context, for example, median time in emergency departments, median ambulance response times, median RTT waits

All charts show the latest five year period, if data has been collected on a comparable basis for that long. Note the exception to this are the ambulance activity and performance charts, where an update to call handling practices in May 2019 appears to have resulted in a change to red incident volume. Therefore, it is not possible to compare red incident volumes prior to this time.

Further detailed datasets can be found, downloaded or accessed through our open data API from StatsWales.

Percentage point changes are calculated using unrounded figures.

Contextual information

Charts presented in the online tool provide additional activity information to complement the NHS performance information shown above.

Some charts include median and mean times. For example, in relation to ambulance response times.

• The median response time is the middle time when all emergency responses are ordered from fastest to slowest, so half of all emergency responses arrive within this time. It is commonly used in preference to the mean, as it is less susceptible to extreme values than the mean.
• The mean response time is the total time taken for all emergency responses divided by the number of emergency responses. The mean is more likely to be affected by those ambulances which take longer to arrive at the scene.

Revisions

Information relating to revisions is presented in the ‘Notes for this month’s publication’ and in the information accompanying the StatsWales datasets each month.

Relevance

What are the potential uses of these statistics?

These statistics will be used in a variety of ways. Some examples of these are:

• advice to ministers
• to assess, manage and monitor NHS Wales performance against targets
• to inform service improvement projects for areas of focus and opportunities for quality improvement
• by NHS local health boards, to benchmark themselves against other local health boards
• to contribute to news articles on waiting times
• to help determine the service the public may receive from NHS Wales

Who are the key potential users of this data?

These statistics will be useful both within and outside the Welsh Government. Some of the key potential users are:

• ministers and their advisors
• members of the Welsh Parliament and the Members Research Service in the Welsh Parliament
• local health boards
• local authorities
• The department for Health and Social Services in the Welsh Government and other areas of the Welsh Government
• National Health Service Wales
• Public Health Wales
• the research community
• students, academics and universities
• individual citizens and private companies
• media

The statistics may also be useful for other UK governments

Northern Ireland Executive’s Department of Health, Social Services and Public Safety

Scottish Government

Department of Health in England

Comparability

All four UK countries publish information on a range of NHS performance and activity statistics. The published statistics are not exactly comparable because: they were designed to monitor targets which have developed separately within each country; the provision and classification of unscheduled care services varies across the UK. Statisticians in all four home nations have collaborated as part of the ‘UK Comparative Waiting Times Group’. The aim of the group was to look across published health statistics, in particular waiting times, and compile a comparison of (i) what is measured in each country, (ii) how the statistics are similar and (iii) where they have key differences. That information is available on the Government Statistical Service website. Information on ambulances can be found at:

Ambulance services in England

Ambulance services in Scotland

Ambulance services in Northern Ireland

National Statistics status

Aside from single cancer pathway statistics, the Office for Statistics Regulation has designated all other statistics presented in this release as National Statistics, in accordance with the Statistics and Registration Service Act 2007 and signifying compliance with the Code of Practice for Statistics.

National Statistics status means that our statistics meet the highest standards of trustworthiness, quality and public value, and it is our responsibility to maintain compliance with these standards.

All official statistics should comply with all aspects of the Code of Practice for Statistics. They are awarded National Statistics status following an assessment by the UK Statistics Authority’s regulatory arm. The Authority considers whether the statistics meet the highest standards of Code compliance, including the value they add to public decisions and debate.

It is Welsh Government’s responsibility to maintain compliance with the standards expected of National Statistics. If we become concerned about whether these statistics are still meeting the appropriate standards, we will discuss any concerns with the Authority promptly. National Statistics status can be removed at any point when the highest standards are not maintained, and reinstated when standards are restored.

NHS Wales Cancer Waiting Times, Ambulance Services in Wales, Time Spent in NHS Wales Accident and Emergency Departments, NHS Referral to Treatment Times, NHS Wales Diagnostic & Therapy Services Waiting Times and Delayed Transfers of Care in Wales are National Statistics.

The continued designation of these statistics as National Statistics was confirmed in 2011 following a compliance check by the Office for Statistics Regulation. These statistics last underwent a full assessment against the Code of Practice in 2011.

Experimental Statistics

Statistics relating to the suspected cancer pathway are Experimental Statistics. This is to inform users of the data and its reported statistics are still in a developmental phase and may have issues pertaining to data quality. However, the statistics are still of value provided that users view them in the context of the data quality information provided. As the dataset matures the coverage and the quality of the data being reported will improve enabling the data to become fit for a wider variety of beneficial uses.

These are official statistics which are published in order to involve users and stakeholders in their development and as a means to build in quality at an early stage.

All official statistics should comply with all aspects of the Code of Practice for Official Statistics. They are awarded National Statistics status following an assessment by the UK Statistics Authority’s regulatory arm. The Authority considers whether the statistics meet the highest standards of Code compliance, including the value they add to public decisions and debate.

More information on the use of experimental statistics (Government Statistical Service).

Well-being of Future Generations Act (WFG)

The Well-being of Future Generations Act 2015 is about improving the social, economic, environmental and cultural well-being of Wales. The Act puts in place seven well-being goals for Wales. These are for a more equal, prosperous, resilient, healthier and globally responsible Wales, with cohesive communities and a vibrant culture and thriving Welsh language. Under section (10)(1) of the Act, the Welsh Ministers must (a) publish indicators (“national indicators”) that must be applied for the purpose of measuring progress towards the achievement of the Well-being goals, and (b) lay a copy of the national indicators before Senedd Cymru. The 46 national indicators were laid in March 2016.

Information on the indicators, along with narratives for each of the wellbeing goals and associated technical information is available in the Wellbeing of Wales report.

Further information on the Well-being of Future Generations (Wales) Act 2015.

The statistics included in this release could also provide supporting narrative to the national indicators and be used by public services boards in relation to their local wellbeing assessments and local wellbeing plans.

Next update

21 October 2021

We want your feedback

We welcome any feedback on any aspect of these statistics which can be provided by email to stats.healthinfo@gov.wales.

Statistician: Rhys Strafford
Telephone: 0300 025 0058
Email: stats.healthinfo@gov.wales

Media: 0300 025 8099

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SFR 288/2021