Recovery watch: Let’s drop the ‘near normal’ pretence

The pretence that non-covid services can widely return to near normal levels any time soon is part of dangerous disconnect between the expectations from the top of the service and the reality on the ground which desperately needs addressing.

Everyone’s realities have become more disconnected since covid arrived. Those people shielding of course face the most extreme challenge. But working from home, being unable to see friends and family, and being in social bubbles all further starves us of shared experience and disconnects our realities. It’s all very unhealthy.

There also appears to be dangerous disconnects developing between the realities and targets set by the top of the NHS and those running services on the ground (although, even within that latter group, there are a wide variety of perceived realities).

NHS veterans might well argue such disconnections have always been there. But the severity of the current climate means such issues matter even more acutely. Never has there been a greater need for the NHS to pull together from top to bottom.

And these disconnects risk being further exacerbated by two ongoing issues. Firstly, the spending review process, which, although far less predictable than usual this year due to the fiscal uncertainty, often prompts the NHS to commit to high expectations to secure maximum funding.

Secondly, there is the crucial commitment to keep the NHS open for core business. Of course it’s right that trust leaders bang the drum and stress patients must not be given the impression that non-covid services will completely shut down during a second covid wave. The last thing patients or the service needs is more unnecessary delays to vital non-covid care.

But the ability to provide “near normal” services varies hugely depending on where you are in the country, and patients’ expectations need to be managed accordingly. Restoration will feel far more difficult to those in the North West, than the South West, for example, due to the hugely different infection rates.

Communication between the NHS and an increasingly anxious public will be even more critical than usual over the coming months.

MPs demand a grand plan

The latter issue of the impact of covid on the NHS’ core services was tackled in the health select committee’s report published today. The report gave a sensible appraisal of the damage being done to non-covid patients and the scale of the challenge ahead.

However, one recommendation stuck out as a particularly tall order. It demanded NHS bosses and ministers publish a plan quantifying the impact of the pandemic on waiting times and unmet demand and how this will all be managed…by next month.

The report says: “We recommend the Department of Health and Social Care and NHSE/I provide an update on what steps they [are planning] to quantify and address the overall impact of the pandemic on waiting times, the backlog of appointments and pent-up demand, and as yet unknown and unmet patient demand for all health services…

“We also ask the department and NHSE/I to provide a comprehensive update on what steps are being taken and what steps will be taken in the future to manage the overall level of demand across health services. We request this information by the end of October 2020.”

Accountability, not unrealistic expectations

The NHS must of course be held accountable for how it manages the coming months. And it should be able to set out, in broad terms at least, what it believes to be the scale of the problem and what it plans to do about it.

Bosses cannot simply collectively shrug their shoulders and say: “We’ve got no idea what will happen or how we’ll cope. All this is unprecedented, don’t you know?”

But, equally, a collective suspension of disbelief about what is realistically deliverable during the coming months, promoted perhaps because no one wants to be the person to admit the system simply cannot universally deliver the levels the public want and deserve, is equally damaging.

NHSE/I’s phase 3 guidance in July set out the ambition for “near normal” non-covid service levels. It demanded trusts deliver at least 90 per cent of last year’s activity for overnight electives and 100 per cent of MRI/CT and endoscopy procedures by next month.

This was swiftly followed by the unprecedentedly poor waiting time data for electives, diagnostics and cancer in August, which prompted think-tanks to warn the prospect of near normal services was nigh on impossible. 

The anecdotal evidence suggests while some are on trajectory, the majority are not, and performance is only set to deteriorate over winter. Yet still the pretence is being maintained.

Bold promises win cash prizes

The debate about what NHS leaders believe to be possible and what funding they need is of course going on right now behind the scenes as part of the spending review process.

It remains uncertain what form the review will take, with a multi-year settlement announced this autumn highly unlikely. The NHS, like many parts of the state, has a habit of committing to almost unattainable targets from ministers to secure maximum funding.

It is perfectly reasonable that taxpayer funding comes with strings tightly attached, but a wide disconnect between the expectations from on high and the reality on the ground will do no one any favours.