Recovery Watch: NHSE’s elective strategy is ‘fuelling inequality’

Aims but no hard targets for delivering a ‘fair recovery’

If I were to ask you, dear reader, what targets were set in the NHS’s flagship 2022 backlog recovery plan to ensure the health inequalities gap in elective waiting times is addressed, would you be able to give me the correct answer?

Confession time: I found I couldn’t answer this question myself this week despite having written a lot of words on, and spent many hours contemplating the contents of, the 49-page joint government and NHS document, published in February.

But when I re-read the document, it struck me the parts on health inequalities weren’t really that memorable.

This is not to excuse my oversight. But the lack of an eye-catching, ambitious target on health inequalities feels indicative of a broader sense that closing the health inequalities gap – while seen as a hugely significant challenge by the NHS and its senior leadership – is still not given the very top billing when it comes to the key operational orders.

Trust managers of all ranks are acutely aware of their duty to eliminate two-year waiters by this month – after which attention will swiftly shift to doing the same for 78-week waiters by next March. But are they as aware about what they should be doing to ensure their recovery plans are not worsening health inequalities?

The plan says the NHS will put “a ‘fair recovery’ at the core of our approach”, which should be taken as given, but perhaps needed saying.

However, in stark contrast to the striking targets for eliminating long waiters, there is little in the way of tangible flagship targets to back up this laudable ambition.

The plan says: “Systems will be expected to analyse their waiting list data by relevant characteristics, including age, deprivation and ethnicity, and by specialty.

“The aim is to develop a better understanding of the local variations in access to and experience of treatment, and start developing detailed clinical and operational action plans to ensure treatment is based on clinical need.”

These aims are sensible, but compared to the hard targets outlined for waiting times, they are clearly something of a supporting act to the main show in town: eliminating long waiters.

A warning that waiting list approach is ‘fuelling in equality’

But far from closing the health inequalities gap, some senior NHS figures are concerned the elective strategy’s central fixation of dealing with the longest waiters first, is in fact having a hugely unintended impact of doing the very opposite: “fuelling inequality”.

Kiran Patel, who is leading some innovative work on the subject at University Hospitals Coventry and Warwickshire Trust, raised his concerns in stark terms during internal NHSE webinar, seen by HSJ, last month.

The fact Professor Patel was on the webinar, which was also addressed by NHSE elective chief Sir Jim Mackey and Bola Owolabi, NHSE’s director of health Inequalities, is indicative of how importantly the senior leadership view the issue. 

But his warning is grave all the same. The UHCW chief medical director said: “Our fear is that if we restore NHS services simply based upon waiting times alone, so, 104, 78, 52 weeks, we will widen health inequality.

“And I put it to you if we want equity, we have to give people a differential access to elective care, so actually, we need an inequity of access to restore an equity of health outcomes.”

Under a slide in his presentation titled “Why waiting lists and RTT fuel inequality”, he explained research had shown more affluent patients were generally better at advocating for themselves and therefore gained swifter access to elective services. Patients from more deprived areas were also more likely to have other health conditions which could impact their outcomes.

So, placing disproportionate emphasis on waiting times and not factoring in social issues when scheduling patients will only further widen the health inequality gap. 

However, Professor Patel said his trust’s “agile waiting list” software programme could play a vital role in addressing these issues and help “level up” waiting times. And he told HSJ the trust is now looking to roll out the software at around 70 other NHS providers.

The programme, developed by UHCW, “weights” a wide range of clinical and non-clinical factors, including “social value judgements” and postcodes, to schedule patients.

You can read more about the details here in our exclusive interview with Professor Patel here.

The project is being closely watched by other senior leaders, with significant support for its aims, and praise for UCHW for grasping the nettle on a tricky topic.

But as one senior trust figure put it to me: “The social value angle will be fraught with differences of opinion, so it could be challenged if not well researched. Most people would accept a wait for someone ‘more needy’, but we may all have different opinions about how that need is defined.”

While Professor Patel accepted patients from more deprived postcodes had been scheduled ahead of similar patients from more affluent areas because of the weighting system, he stressed it was “not actively making people wait longer if they are from a middle class background”.

“What we are doing is saying outcome determines your clinical prioritisation.”

Bringing social factors into consideration for scheduling patients of course needs robust evidence base, but this is still only a work in progress, with a long way to go. It is also likely that such models will need constant updating and finessing.

While huge credit should go to UHCW for grasping this incredibly feisty nettle, it does raise the question why more progress hasn’t been made on this agenda elsewhere and in the past — there were undoubtedly inequalities in elective access before covid, too.

Huge ethical questions and logistical challenges

But as King’s Fund chief analyst Siva Anandaciva told me, identifying these other factors that could be used to prioritise patients aside from length of time on the list, deciding the weight to give those factors, and determining who should have a say in this process “will be a relatively new task for NHS trusts and systems”.

He added: “It will be important to convene patient panels and get the views of local communities and clinicians on these decisions, but that will take time.

“Then knitting all this information together is a challenge both technically and operationally. At some trusts it means amending patient tracking list systems that have been in operation for well over a decade.”

These are clearly early days for the NHS on this agenda and the task represents both significant ethical and logistical challenges. But if system leaders want to be true to their “fair recovery” mantra, then progress on such projects is needed, and quickly.

Recovery Watch looks forward to tracking the progress of UHCW’s agile waiting lists and similar projects.