It is safe to state that many of us played our part in helping to protect the NHS during the pandemic. From restraining to call our GPs for “manageable” conditions, to not visiting A&E for our more pressing health concerns, we allowed the NHS to focus on those with Covid. During the pandemic, the NHS re-directed resources away from its normal activities and mandated other services to take a back seat. However, what is concerning is that this re-direction doesn’t seem to be rebalancing itself anytime soon. With the new variant Omicron taking hold we are, yet again, experiencing a re-direct of our services to Covid, the starting point being GP’s effort to administer vaccinations. The unforeseen and often unpublicised impact of this never returning redirection is directly impacting our life expectancy and can pose a bigger future challenge than the pandemic itself, if immediate action isn’t taken.
Waiting is normal – but how long is too long?
Waiting for care or treatment is a normal feature of all public healthcare systems; usually determined by the number of patients on the list and their clinical urgency. Keeping patients waiting comes with a direct impact – both clinically and financially. Clinically, the longer a patient waits for treatment, the higher the chances of diagnosis delay, increasing recovery times and procedure times, clinical complexity and deterioration in quality of life Not to mention, for conditions such as cancer, this can cause permanent reductions in life expectancy. Financially, this increases GP and hospital visits, plus it increases the risks of patients getting “lost in the system” – placing further and usually, a heavier and costlier strain on the NHS.
The impact: how long is too long?
To ensure patients are seen in “good time”, the NHS has established standards for both elective and cancer care.
For elective care, the NHS standard states that 92% of people waiting for treatment should wait no longer than 18 weeks from their referral to their first treatment. In 2013/14 NHS England introduced a policy mandating that no one should wait more than 52 weeks from referral to first treatment. However, this standard has not been met since February 2016; deteriorating steadily since then until the start of the pandemic, and thereafter performance fell off a cliff. The number of patients waiting for elective care in February 2020, before the start of the pandemic, was 4.43 million, with a performance of 83% on the 18-week target.
During the pandemic, this dropped to its lowest recorded level ever of 66% getting their first treatment from diagnosis under the 18-week target by September 2021. With halted activity, the waiting list grew enormously to 6 million patients by September 2021. Since patient waiting times have fallen through the roof, 18-week waits are no longer the biggest concern and 52-week, and even 104-week waits are looked at instead. Hospitals are currently looking at hiring “104-week planners” who will solely focus on reducing the 2-year waits. 52-week breaches increased from 6,000 patients in February 2020 to 301,000 patients in September 2021.
The national target used to measure cancer care performance is clear – a minimum 85% of patients need to commence treatment within 62 days of urgent referral and once diagnosed, patients need to commence treatment within 31 days. Between August 2018 and February 2020, 96% of patients met the 31-day target. As the NHS mounted an emergency response to the pandemic, it proved impossible to keep to these performance levels. Nationally in September 2021, only 68% of patients were treated within 62 days, with a sub-regional variation between Birmingham and Solihull at 43% compared with Surrey Heartlands at 80%.
Current numbers: not the full story
Although current numbers are already nerve-wrecking, there are millions of patients are yet to enter the system, referred to as “missing patients”:
- Patients that have avoided seeking health care and are now entering the system, more likely with more complex care and treatment requirements
- Patients that have been unable to enter the system via primary care due to the re-direction of GP resources and the “halt” on referrals
- Patients that have been removed from existing patient lists through “stats massaging” but still require care, in most cases, more complex care
- Patients that are yet undiagnosed/unidentified as requiring treatment (including a new cohort of long-Covid patients)
It is not clear when and how all these “missing” patients will enter the system, but it is inevitable that they will. Estimates tell us that up to 740,000 urgent GP referrals were missing for suspected cancer during the pandemic. In addition, there were over 7 million ‘missing’ referrals for elective care over the same period.
With these numbers in mind, if 50% of missing referrals return to the NHS and activity grows only in line with pre-pandemic plans, the waiting list would reach 12 million by March 2025.
It doesn’t require a scientist to understand the detrimental health impact all this halted activity currently has, and will continue to have, on the health of our population. A study published in Lancet Oncology the end of 2020, demonstrated that in the first pandemic year alone, there was a 7.9 – 9.6% increase in number of deaths due to breast cancer diagnosis delay, 15.3% – 16.6% in colorectal cancer, 4.8% – 5.3% in lung cancer and 5.8 – 6.0% in oesophageal cancer. Clearly, more people have suffered from covid-induced delays vs actual covid itself, but the real impact of the pandemic hasn’t arrived yet!
Why is performance so low?
Even before the pandemic, the demand for health care has been increasing rapidly with the supply of resources not keeping pace with demand causing the backlog to grow. Although the NHS has been doing more work year-on-year, there has been an annual average growth in emergency admissions of more than 3%, and in urgent cancer referrals from GPs of more than 10%. While there has been an uneven rise in resources across different sectors, allowing the NHS to treat more patients each year, particularly for cancer, this level of increase has been insufficient to keep pace with demand.
With the NHS already maxed out, adding a pandemic creates the perfect storm. The demand on healthcare increases, and on top of that, give away at least 35% of the unoccupied general and acute beds, many more theatres, clinic rooms and waiting rooms. Add onto those additional inefficiencies due to social distancing rules and an overworked workforce. That is the ideal recipe for an ever-increasing waiting list and, therefore, inadequate performance.
To resolve pre-existing challenges and covid-induced challenges, the core of the solution has two elements; reducing demand for care, and simultaneously increasing resources and efficiency of resources.
The NHS England & Improvement have already allocated funding for the following initiatives:
- Waiting list validation and management
- Demand management
Increasing physical capacity
- Elective recovery fund (ERF)
- Elective accelerators programme
- Targeted Investment Fund
- Increasing capacity framework (ICF) with independent providers
- Increasing and upgrading diagnostic capacity
- Transforming outpatient care
- Getting it right first time (GIRFT) programme
While all above initiatives are necessary, the danger here is two-fold. On one hand, the pandemic has exacerbated health inequalities since waiting lists are growing more quickly in deprived areas. The allocation of these initiatives in these areas are not proportionate to its demand. On the other hand, in areas where resources are maximised, this is done with insufficient focus on fundamental system-wide change, the efficiency of resources viewed with a long-term prevention perspective.
System-wide change is required to maximise the use of existing capacity. This means the integrated care systems (ICSs) need to be empowered to hold the authority to direct, manage and validate waiting lists for a wider benefit instead of individual fiefdoms. They should be solely responsible for performance, finances, and activity to allocate all patients to existing capacity across trusts. However, there is a recovery driven responsibility that must be prioritised; when managing a waiting list with such large numbers, it should be an ICS priority to focus on clinical need, not just time of waiting – unless we are to create even greater harm.
Increasing efficiency, support and incentives
An emerging challenge at present and, undeniably, in the future is the pandemic-induced mental health impact on our overworked workforce. With higher attrition rates in an already understaffed workforce, the pandemic has induced unbearable mental health pressure across all workforce teams and catalysed the idea to rethink their career paths. Therefore, more now than ever, the mental health and wellbeing of the workforce must be a priority across all health systems. To address these workforce shortfalls and reduce staff pressures, mental health and general wellbeing initiatives should be incorporated into personal development and competency processes across all clinical and non-clinical teams.
Introducing performance-based incentives for surgeons tactically without baking this into the system can optimise NHS surgeons’ performance e.g. payment per patient instead of per day. In the same way surgeons can be rewarded for good practice, “consequences” can be introduced for clinical teams/surgeons for not performing, hitting performance targets or efficiency baselines.
To increase bed capacity, the challenge of discharge and patient flow must be solved. There have been long-standing system-wide challenges between community care and hospitals – including communication between community partners and hospital teams, lack of ownership of pathways and patients, insufficient community capacity, excessive ward moves and inefficient discharge-to-assess models. Not only should there be a reassessment of community capacity but, more importantly, the efficiency of existing capacity and pathways must be reassessed. With centralised ownership and integration of systems, the discharge pathways must be rebuilt around the patient with their care and comfort at the centre of decisions.
Long-term prevention approach
The NHS is not, today, a health service. While it was founded with that aim, it has, over time and under pressure, become a treatment service with a clear expectation that the NHS can continue to build capacity to meet demand for ever increasing volumes and range of treatments. For patients, most engagements with the NHS revolve around diagnosing and responding to acute episodes, a proportion of which could have been avoided, or reduced, if increased investment and stronger policy and focus were in place to improve overall population health across society. While elective care demand in the short-term can be reduced by reviewing and improving primary care services and pathways, a focus on prevention is now key. This will also aid in the challenge of addressing the significant environmental impact of healthcare, and associated negative health impacts, through delivery of a net zero NHS.
The backlog problem is not one that is unfamiliar to the NHS. However, the danger is that the response to the problem remains the same throughout the years. While old solutions only managed to maintain the status quo – new solutions MUST go above and beyond any previous efforts. There are key activities that need to be carried out (as listed above) but these must be accompanied by system-wide change – one in which ICSs sustain authority for the wider good rather than individual fiefdoms, manage waiting lists according to clinical need and treating the workforce as the valuable assets that should also be used and managed system wide. How the NHS responds to this ever-growing challenge directly impacts population’s health and all our wellbeing – we must therefore act now!