Coordination of waiting lists and elective treatment across health systems and regions should be ‘far more systematic’, and could have happened earlier, chief executives of some of the hardest hit trusts have told HSJ.

In interviews for the HSJ Health Check podcast, the CEOs of King’s, Croydon, Chester and Sandwell and West Birmingham hospital trusts spoke about their experience in the pandemic and what could be learned from it.

These included the need for faster decision making; resources for deprived and diverse areas, which are often hardest hit; the need for basic staff facilities such as parking and eating areas for staff; longer-term attention to the wellbeing of staff who were most affected; and to give time for trusts to recover.

The four trusts are among those most heavily hit by covid throughout the pandemic so far, according to HSJ analysis. Three of them had more than a fifth of their beds occupied by covid patients for at least five entire months, between 20 March 2020 and 30 April 2022. 

Podcast interviews: CEOs of four hospital trusts hit heavily by covid

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On elective care, the CEOs highlighted how the length of lists and waits, and the NHS’s ability to keep up, are now much worse in some areas than others. Some of those with the longest waits and lists at present – such as Countess of Chester and Birmingham – were also heavily hit by covid; for others this is not the case.

There were moves, particularly later in the pandemic, for patients who were on the elective waiting list of one trust to be treated at another, for example if they needed urgent treatment and faced harm if delayed, while other hospitals were still able to treat less urgent cases. Combining lists, often known as “shared patient tracking (or treatment) lists”, could also mean capacity being managed more efficiently across providers. 

Sandwell and West Birmingham chief Richard Beeken, who joined from Walsall Hospital Trust in early 2021, said: “I think the coordination of what we might term system PTLs or the delivery of true needs-led waiting time recovery across systems, or even across regions, needs to be far more systematic than it is at the moment. 

“It very much feels from my perspective that we’re still trying to manage that by organisation.”

It required, he said, “[integrated care boards] being told and also having the bandwidth to be able to essentially coordinate elective recovery in a not dissimilar way to the way we coordinated the urgent care response in the pandemic.

“I can feel that improving, but it’s playing catch up, beyond some immediate long cancer waits we’re not quite feeling that nirvana in the West Midlands yet. But it has to come because otherwise those [elective recovery] trajectories just won’t be met.”

Coordination of treatment lists is variable between systems, but several sources said it was piecemeal in most areas, and that nowhere has moved to a full “shared PTL”. 

Countess of Chester chief executive Susan Gilby said trusts in her system were now collaborating well on electives, but added: “What in hindsight I think we could have done sooner and stronger, and I remember suggesting this in April 2020, was recognise we needed to combine the patient treatment lists, and we needed to make some very brave decisions about treating those, not who had been waiting longest, but with the highest clinical priority, treating those irrespective of where they lived.

“For Cheshire and Mersey, we combined our cancer PTLs eventually. But if we were going into this again I think there’s a strong argument for doing that sooner.”

King’s College Hospital chief Clive Kay said more collaboration was happening on elective care and leaders should continue to push it.

“Patients, with their consent, are starting to move from department to department, hospital to hospital; clinicians are starting to work in different institutions in a way which pre-pandemic was really difficult to do [and] not the norm… It is about saying, ‘we’re responsible for this population of patients’, as opposed to saying, ‘these are our patients and we’re only looking after our patients’.

“Through the pandemic that was a different mindset, and we as senior leaders have a responsibility to keep that mindset developing.”

Critical care

Several of the chief executives said service changes – such as splitting elective “cold” from emergency “hot” care within hospitals, as Croydon has pioneered – were taking place to make more of current NHS capacity but also said additional funded capacity was needed.

Mr Beeken made a particular point about intensive care capacity which was dramatically expanded, by diluting staffing ratios and converting other ward areas, during covid.

He said: “I do think bed occupancy in critical care is dangerously high and there is a lack of directive coordination of mutual aid in critical care networks at times of stress, so we’ve got to plan in policy and investment terms for an improvement in both of those, should and when such a situation strike again.”

Dr Gilby, who is a critical care and anaesthesia doctor by background, said arranging critical care transfers became more complex during covid, and the huge focus on intensive care unit compromised considerations about patients needing non-covid care.

She said: “In every critical care network we have always had a practice of what we’d now call mutual aid, but in previous years it would just be [called] an inter-hospital transfer or referral. I’ve been working in critical care for decades and that would be the norm.

“But people outside the critical care networks were now [early in the pandemic] getting involved, through things like ‘gold command’, and this [transferring] was now regarded as something that needed an awful lot of input.

“[This] actually distracted from looking at the wider problem which was the impact on general hospitals [and] also on those [patients] who were going to have to wait unacceptable lengths of time for [non-covid] care.

“And that was – I think because of my [medical] background – becoming more and more apparent and more and more concerning. And yet we were still being told there were certain [elective] procedures and certain pathways that we needed to stand down, and the impact of that in the longer term has been very significant.”

HSJ understands plans are being developed to expand “enhanced care” beds for post-surgical recovery. Several sources said no expansion of full critical care was taking place. In the later stages of the pandemic, critical care transfer services were developed in each region, which are being maintained and may help with coordination in future.

Intensive Care Society president elect Steve Mathieu said: “We continue to experience ICU bed capacity issues across the UK, which are being further compounded by the pressures of needing to reduce the extensive backlog of patients needing elective surgery.

“Mutual aid transfers, to enable emergency critical care to be delivered equitably, worked well during the pandemic. The further development of regional transfer services will help support the timely transfer of patients requiring any specialist care or to help decompress units that are full because of emergency demand.”

He warned against some signs hospitals would like to use them more routinely to free up ICU beds for elective operations. “The solution to any unmet demand because of predictable need at this point is urgent investment to fund and staff more intensive care beds,” he said.

NHS England was asked if it wanted to comment.

Podcasts: Hospitals hardest hit by covid

You can also listen to the two podcast episodes on SpotifyApple PodcastsAmazon Music, and all the other popular podcast platforms.

Revealed: The trusts hit hardest by covid