NHS delivery plan for tackling the Covid-19 backlog of care

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The long-awaited NHS elective recovery plan was published in full earlier this month and sets out plans to tackle England’s elective care backlog over the next three years.

The plan sets out aspirations to restore standard operating conditions and reduce staff absences, subject to ongoing progress in managing the pandemic. Whilst the plan is national, local circumstances will be considered. NHS England expects that the waiting list will only begin to reduce by around March 2024 and on that basis, the strategy includes an estimate that the overall size of the waiting list will most likely increase in the short term, anticipating supressed or “missing” demand from the pandemic results.

Of particular note are measures setting out the expansion of community diagnostic centres (CDCs), which it is planned will deliver nine million more diagnostic tests and treatments per year (see page 32 of the report). The aim is to ensure that by March 2025 95% of patients needing a diagnostic procedure receive it within the six-week standard. These CDCs will deliver multiple tests in a single appointment, including core diagnostic services across imaging, physiological measurement, pathology, and endoscopy. Investment in digitising cell pathology services across the NHS is intended to enable reporting clinicians in pathology and imaging services to access technology for diagnosis, and share images via country-wide radiology networks to allow swift access to specialist opinions.

Restoring, and in some places increasing, direct access to a wider range of investigations initiated by general practice, particularly imaging, make sense for GPs, patients and hospital clinicians. Testing closer to community points of care such as general practice significantly improves the patient journey in every sense and should mean that patients aren’t subject to delays due to unnecessary referrals. The plan lacks detail of how community testing centres will benefit general practices and patients in London, and Londonwide will continue to engage to ensure that any additional resources required are not taken from the already overstretched and insufficient core funds available to GPs.

The recovery plan also sets out measures to improve access to specialist advice, including £10m funding to support seeking specialist advice prior to or instead of making a referral or whilst a patient is awaiting an appointment following a referral, further development of the NHS e-Referral service, enabling image sharing to support more effective triage, and accelerating adoption of tele-dermatology services to increase specialist advice for suspected skin cancers with investment planned for 2022/23.

The plan also outlines goals by 2024/25 to increased elective activity to 30% more than before the pandemic by increasing health service capacity, prioritising diagnosis and treatment, transforming elective care provision, and providing better information and support to patients:

  • Ending waits of more than a year for elective care by March 2025, including specific targets to eliminate two-year waits, 18 month waits, and 65+ week waits;
  • Ensuring sufficient diagnostic testing within six weeks for 95% of patients by March 2025;
  • Ensuring that by March 2024, 75% of patients who have been urgently referred by their GP for suspected cancer are diagnosed or have cancer ruled out within 28 days;
  • Using technology and transformation of care models to reduce waits for outpatient appointments.

It contains ambitious aspirations to grow, retain and support the workforce, using digital technology and systems to free up capacity. Whilst the plan recognises that there are serious workforce challenges that need to be addressed and that staff sickness and absence levels are high, the measures set out regarding plans for utilising the capacity of independent sector as part of a coordinated approach will no doubt be critically received when considering service, financial and workforce planning in the round. Specific measures identified to address workforce concerns include greater flexibility to work remotely, more opportunities to develop skills and progress careers, better integration and deployment of allied health professionals in critical care settings, and an increased focus on wellbeing.

In-year workforce commitments set out in the plan are wide ranging and ambitious and include recruiting more than 10,000 nurses, 5,000 healthcare support workers, accelerating the introduction of roles such as anaesthetic associates, first contact practitioners, and advanced clinical practitioners, and contingency staffing utilising over 17,000 “NHS reservists”.

There is a significant focus/ reliance on the use of digital and AI technologies, perceived as freeing up/ releasing clinical capacity. Including reprofiling the NHS App to provide a personalised access point to records and services, and increasing monitoring and analysis of data from healthcare settings.

The plan outlines several ‘ambitions’ on reducing waiting list, with target dates been set out:

  • By July 2022: eliminate the longest waits of over two years (except where this is the patient’s choice) and reduce the number of people waiting more than 62 days to start cancer treatment;
  • By April 2023: eliminate waits of over 18 months;
  • By March 2025: eliminate waits of over 12 months (except where patients choose to wait longer or in specific specialties);
  • ‘Long waiters’ will be offered better advice and options for their care, including through a new national network for long waiters including NHS or NHS-funded ISP capacity;
  • Patients will be able to travel to different areas to receive treatment if waiting lists are lower there. Those doing so will be offered a comprehensive support package, including transport and accommodation where necessary;
  • Targeted support will be offered to local areas with specific challenges in treating patients waiting for two years or more. This may involve brokering the movement of clinical teams into local systems to undertake complex procedures, or support to establish local management functions to co-ordinate the movement of services and patients.

The roll out of surgical hubs is also broadly welcome and the model has the potential to help reduce the backlog in elective care, whilst also simplifying access to treatment for some patients. However, the critical issue is how the hubs will be staffed given wider staff shortages. Staff asked to work at hubs in new locations will also be supported to do so, including assistance with transport costs.

Similarly, the pathway improvement programme has the potential to improve the experience of patients and to simplify often complex processes. However, additional detail on how the programme will work in practice and, crucially, how it will interface with existing pathway management systems is needed.

Providing better information and support to patients

  • Creation of a transparent process for service users to communicate with the health service, including the ability to view guidance on self-management of symptoms and information on wait This will be developed as a short-term temporary solution – a platform called ‘my planned care’ to go live in February 2022 whilst work continues exploring long-term solutions such as the NHS app
  • Requirement on providers to adopt two-stage shared decision making across all admitted non-day case pathways by April 2023 and all admitted pathways by April 2024, enabling patients to have a short period of reflection when deciding on treatment and giving consent
  • NHS England will work with patient charities and stakeholders to do the following:
    • develop better measures of patient experience, including on communications and the nature of care and support, building on leading practice around the country
    • Use technology to gather and respond to patient feedback, so that services can quickly build on what is working and act where improvement is required
    • work with partners to ensure that we get a better understanding of the experience of patients waiting over six months – we expect this will draw on feedback from a large number of
  • From April 2023, providers to be asked to establish perioperative care multi-disciplinary co-ordination teams to proactively inform pre and post-operative care and identify surgical risk factors, enabling patients to be treated in the most appropriate place for their condition, with a focus on developing elective hubs for high volume low complexity surgery
  • Support perioperative pathways through increased use of data sharing and digital tools to better prepare patients for treatment
  • Consider implementation of digital patient-led perioperative questionnaires to capture risk factors not traditionally included in health

BMA commentary

Building on proposed digital infrastructure commitments, this section seeks to improve communication channels and data capture for patients considering elective procedures. Ostensibly, this would help inform clinical decision making and patient choice, although it is crucial that these measures not be used to deter patients from going ahead with elective procedures for demand or capacity reasons.

The introduction of ‘my planned care’ has promise and should deliver on the BMA’s call for a service allowing patients to check the status of their referral easily, without directing those queries to overstretched GP practices.

The latest data (December 2022) shows that the NHS waiting list is at a record high of over 6 million people, of whom over 2.1 million people have been waiting 18+ weeks for treatment and 310,000 people have been waiting more than a year treatment (212 times the number waiting in December 2019).

NHS England estimates that over 10 million patients who might otherwise have come forward for care did not during the pandemic, which means that the total waiting list could reach 14 million, were all of these patients to seek care.

You can see the BMA response here.