Geographic inequalities in diagnostic testing delays in England before and after COVID

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Skip to main content Home About Submit ALERTS / RSS Search for this keyword Advanced Search Geographic inequalities in diagnostic testing delays in England before and after COVID View ORCID Profile Becky White , View ORCID Profile Matt Barclay , Georgios Lyratzopoulos , View ORCID Profile Ruth Swann , View ORCID Profile Igor Francetic , View ORCID Profile Matt Sutton doi: https://doi.org/10.1101/2025.11.06.25339656 Becky White 1 Epidemiology of Cancer Healthcare and Outcomes (ECHO) Research Group, Department of Behavioural Science and Health, University College London , UK Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Becky White For correspondence: becky.white.19{at}ucl.ac.uk Matt Barclay 1 Epidemiology of Cancer Healthcare and Outcomes (ECHO) Research Group, Department of Behavioural Science and Health, University College London , UK Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Matt Barclay Georgios Lyratzopoulos 1 Epidemiology of Cancer Healthcare and Outcomes (ECHO) Research Group, Department of Behavioural Science and Health, University College London , UK Find this author on Google Scholar Find this author on PubMed Search for this author on this site Ruth Swann 2 Cancer Intelligence Team, Cancer Research UK Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Ruth Swann Igor Francetic 3 Health Organisation, Policy and Economics (HOPE) research group, University of Manchester , UK Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Igor Francetic Matt Sutton 3 Health Organisation, Policy and Economics (HOPE) research group, University of Manchester , UK Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Matt Sutton Abstract Full Text Info/History Metrics Supplementary material Preview PDF Abstract Diagnostic testing delays worsened during the COVID-19 pandemic, but it is unclear whether geographic inequalities have deepened. Using publicly-available data in England for nine tests, we compared waiting times across 106 local areas in 2019 and 2024–25. The national median proportion of patients waiting over six weeks increased from 2.2% to 18.8%, while geographic variation tripled. The greatest variation in 2024–25 occurred for flexible-sigmoidoscopy, colonoscopy, and echocardiography. These findings show that pandemic-related diagnostic delays persist and pre-existing geographic inequalities have deepened. Further research should examine how widening inequalities in waiting times influences downstream test demand and disease outcomes. Introduction When patients present in primary care with symptoms of possible disease, timely use of relevant hospital-based tests is key to early diagnosis of life-threatening conditions such as cancer. Since before the COVID-19 pandemic, England has consistently lagged behind comparable European countries in terms of its diagnostic capacity. This, combined with rising demand, is thought to contribute to worsening delays in testing. 1 According to NHS England’s targets for 15 diagnostic tests, fewer than 1% of referred patients should wait 6 weeks or longer. 2 This target has not been met since 2013. In January 2020, 4.4% of patients waited at least 6 weeks, peaking during the COVID pandemic and remaining high, at 18.4% in March 2025. 2 These statistics on national performance mask substantial inequalities by local area. Although relevant data is routinely published, 3 reports have not quantified geographic variation since the pandemic. We examined whether absolute and relative geographic inequality in waiting times for diagnostic tests worsened since the pandemic, and for which tests inequality is greatest. Methods We used data published by NHS England 3 of the monthly number of patients waiting 6 weeks or longer for diagnostic tests. Data are reported for local areas, known previously as Clinical Commissioning Groups (CCGs) and recently as sub-Integrated Care Board locations (sub-ICBs). Mergers took place from 2020-21, reducing the number of areas from 197 in 2019 to 106 by 2025. We aggregated data for the areas that merged so that the same 106 units were followed throughout the period. We examined data on fifteen tests combined, and individual data for nine individual tests: MRI, CT, non-obstetric ultrasound, echocardiography, DEXA (bone density) scan, gastroscopy, flexible sigmoidoscopy, colonoscopy, and cystoscopy. We plotted the monthly proportion (including median and interquartile range) of patients waiting at least 6 weeks since 2013, by local area. To quantify whether absolute variation increased for each test, we fitted two hierarchical linear regression models, one for January – December 2019 (pre-pandemic) and one for August 2024-July 2025, where the outcome was the monthly proportion of patients waiting 6 or more weeks. Predictors included a categorical fixed effect for month, and a random effect for local area. To adjust for the relative importance of data points, we weighted by the monthly total number of patients waiting in each area by month. We compared the standard deviation (SD) of the random effect (sigma), with confidence intervals calculated using the Profile Likelihood method. 4 We derived 10 th / 50 th / 90th percentiles by combining the average predicted probability across all 12 months with the SD of the random effect for local area. 5 We also compared relative variation by fitting two binomial regression models; for these, we back-transformed percentiles to probabilities using the inverse logit function. Patient consent and research ethics approval was not required, as the study used publicly available data. Results The proportion of patients waiting 6 weeks or longer for a diagnostic test, and associated variation, has been much higher since 2020 (the peak of the pandemic) ( Figure 1 ). In July 2019, in the median local commissioning group, 2.2% of patients waited 6 weeks or longer for all tests combined, ranging from 1.2% (25 th percentile) to 4.4% (75 th percentile). By July 2025, the median was 18.8% (12.1% - 27.3%) (Online Supplemental Appendix 1). Download figure Open in new tab Figure 1. Percentage of patients waiting 6+ weeks for a test, by Local Commissioning Group Individual lines (grey), median (blue), mean (red dashed), IQR (blue ribbon). Total not available in publicly available data before 2018. Absolute variation between local group in the proportion of patients waiting 6 weeks or more (represented by random effect standard deviation (SD)) increased three-fold (3.3 to 9.8) from 2019 to 2024-25 for all tests combined. Absolute variation also increased for all nine individual tests studied (Online Supplemental Appendix 2). In 2024-25, the largest geographic variation was for flexible sigmoidoscopy (SD: 15.8; LCI-UCI: 13.7 - 18.1), colonoscopy (15.4; 13.4 – 17.7), and echocardiography (14.9; 13.0 – 17.2). The tests with the lowest variation were CT (6.8; 5.9 – 7.9), and MRI (8.4; 7.3 – 9.7) (Online Supplemental Appendix 2). In additional analysis, relative variation on the log-odds scale between commissioning groups either remained similar over time, or decreased for CT, echocardiography, and gastroscopy (Online Supplemental Appendix 2 & 3). Discussion Large nationwide increases in the percentage of patients experiencing delays for diagnostic investigation post-pandemic have been accompanied by increasing geographic inequality. These could widen geographic inequalities in how quickly time-sensitive diseases, such as cancer, are diagnosed, and subsequent outcomes including disease-specific mortality. We might also expect downstream system-wide impacts, such as variation in how many patients general practitioners (GPs) refer in future (‘demand elasticity’). Evidence about this phenomenon so far is mixed and not yet been applied specifically to waiting times for diagnostic tests. 6 Geographic inequality in diagnostic delays has not worsened in relative terms since the pandemic. This suggests widening absolute inequality is a product of a worsening national average and persistent inequalities, which need to be understood. Inequalities might be driven by factors affecting demand or supply. Local demand may be affected by population need, long-term impacts of local COVID lockdowns (i.e. release of “suppressed demand” or increased incidence of preventable diseases), 7 GP referral practices, 6 screening 8 or primary care-based triage tests (e.g. Faecal Occult Immunochemical Testing (FIT) for patients with colorectal cancer symptoms). Supply might be affected by scanner availability, efficiency or staffing. New service configurations can have complex effects; Community Diagnostic Centres could enhance capacity or, counterintuitively, stimulate demand. 9 Our modelling approach allowed us to compare geographic variation over time, while accounting for chance variation. Our main analysis used linear mixed effects models to directly estimate variation on the percentage scale, and this may have been impacted by ‘floor effects’ particularly for 2019. This is unlikely to be important for interpretation given the substantial increase in geographic variation in more recent data; further, percentiles derived from models of variation on the log-odds scale were similar (Online Supplemental Appendix 2). While the increase in delays associated with the COVID pandemic is striking, co-occurring events could also explain delays, such as budgetary pressures, or hospital service reconfigurations. Additionally, changes were made to geographic boundaries in four areas in 2022, which we did not account for in our analysis. 10 The data include tests conducted for any reason, including diagnosing non-life-threatening conditions, and screening programmes. In those circumstances, delays over 6 weeks may not be as consequential. Quantification is needed of delays specifically in patients where a life-threatening disease (e.g. cancer) was suspected. In summary, COVID disrupted diagnostic services in England, with delays persisting nearly four years later. Existing geographic inequalities in delays have worsened in absolute, though not relative, terms. Post-pandemic recovery should prioritise reducing waiting times nationwide while investigating how local service provision, demand, and referral behaviour shape disparities. Contributors BW conceived the study. BW, MB and GL designed the study. BW managed and analysed the data, and RS quality assured data analysis. BW drafted the manuscript. MB advised on statistical methods. MS, IF, and RS advised on interpretation and discussion. All authors contributed to interpretation and revisions to the manuscript. Funding BW receives funding from a Cancer Research UK International Alliance for Cancer Early Detection (ACED) Pathway Award (EDDAPA-2024/100015). This project is also funded by the NIHR Policy Research Programme (Policy Research Unit on Cancer Awareness, Screening and Early Diagnosis, reference PR-PRU-NIHR206132). The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care. Conflict of interest All authors declare no competing interests. Data availability statement Data are publicly available from https://www.england.nhs.uk/statistics/statistical-work-areas/diagnostics-waiting-times-and-activity . A fully compiled and processed dataset, and all analytical code, is available at https://github.com/rmjlrwh/DxWaitingTimes . Key points - Delays for diagnostic tests in the NHS in England increased during the pandemic and have not recovered as of July 2025. - Geographic variation in how many patients wait longer than six weeks for a test has increased three-fold since the pandemic. - The largest geographic variation in 2024-25 is for flexible sigmoidoscopy, colonoscopy, and echocardiography. - National policy should focus on reducing diagnostic delays across the country and reducing the size of persistent geographic inequalities. - Research is needed to understand the drivers and impact of current diagnostic delays on patients subsequently diagnosed with serious disease, and the impact of delays in GPs’ referral behaviour. Acknowledgements This study is based on data published by NHS England. Dr Arman Motesharei downloaded the publicly available data. References 1. ↵ Richards M , Maskell G , Halliday K , Allen M. Diagnostics: a major priority for the NHS . Future Healthc J . 2022 ; 9 ( 2 ): 133 . Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC9345238/ OpenUrl PubMed 2. ↵ House of Commons Library . NHS Key Statistics: England [Internet] . 2025 . Available from: https://researchbriefings.files.parliament.uk/documents/CBP-7281/CBP-7281.pdf 3. ↵ NHS England . Monthly Diagnostics Waiting Times and Activity (DM01) (2008/09 - 2024/25) [Internet] . Available from: https://www.england.nhs.uk/statistics/statistical-work-areas/diagnostics-waiting-times-and-activity/ 4. ↵ Venzon DJ , Moolgavkar SH . A Method for Computing Profile-Likelihood-Based Confidence Intervals . J R Stat Soc Ser C Appl Stat . 1988 ; 37 ( 1 ): 87 – 94 . Available from: /doi/pdf/10.2307/2347496 OpenUrl 5. ↵ Abel G , Elliott MN . Identifying and quantifying variation between healthcare organisations and geographical regions: using mixed-effects models . BMJ Qual Saf . 2019 ; 0 : 1 – 7 . Available from : doi: 10.1136/bmjqs-2018-009165 OpenUrl Abstract / FREE Full Text 6. ↵ Hayes H , Meacock R , Stokes J , Sutton M. The effect of local hospital waiting times on GP referrals for suspected cancer . PLoS One . 2024 ; 19 ( 5 ): e0294061 . Available from: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0294061 OpenUrl PubMed 7. ↵ Tan YY , Chang WH , Katsoulis M , Denaxas S , King KC , Cox MP , et al. Impact of the COVID-19 pandemic on health-care use among patients with cancer in England, UK: a comprehensive phase-by-phase time-series analysis across attendance types for 38 cancers . Lancet Digit Health . 2024 ; 6 ( 10 ): e691 – 704 . Available from: https://www.sciencedirect.com/science/article/pii/S2589750024001523 OpenUrl 8. ↵ Hubers J , Sonnenberg A , Gopal D , Weiss J , Holobyn T , Soni A. Trends in Wait Time for Colorectal Cancer Screening and Diagnosis 2013-2016 . Clin Transl Gastroenterol . 2020 ; 11 ( 1 ): e00113 . Available from: https://journals.lww.com/ctg/fulltext/2020/01000/trends_in_wait_time_for_colorectal_c ancer.2.aspx OpenUrl CrossRef 9. ↵ Sivey P , Wen J. The effect of community diagnostic centres on volume and waiting time for diagnostic procedures in the UK . Health Policy (New York) . 2024 ; 147 : 105101 . Available from: https://www.sciencedirect.com/science/article/pii/S0168851024001118 OpenUrl 10. ↵ Department of Health and Social Care . Integrated care systems boundaries review: decision summary - GOV.UK [Internet] . 2021 . Available from: https://www.gov.uk/government/publications/integrated-care-systems-boundaries-review-decision-summary/integrated-care-systems-boundaries-review-decision-summary#overview View the discussion thread. Back to top Previous Next Posted November 07, 2025. Download PDF Supplementary Material Email Thank you for your interest in spreading the word about medRxiv. 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