Recovery Watch: ‘Hoping for six feet of snow to keep everyone at home’

Ministers are set to publish an “elective recovery plan” later this month, with senior figures speculating it could land as early as next week. So, what will it mean for trusts?

The government are very concerned about the NHS’ mushrooming waiting list, which stood at 5.7 million in August. Even the right-wing press are accusing the prime minister of having “no answer to the backlog crisis”.

We are at a critical juncture in its pandemic response, as the government looks to shift focus more from directly dealing with covid and on to clearing up the collateral damage. We can reportedly expect to see a minister specifically tasked with overseeing the tackling of the backlog. But what else should trust leaders expect from this latest plan?

The backdrop: tired workforce, tired patients

It is first important to note the plan will be shaped in part by the conditions the NHS is working under, which were starkly laid out by NHS England’s national clinical director for elective care at the Future Surgery 2021 conference this week.

In comments that will resonate with local managers, Stella Vig warned: “People talk about the NHS claps, well, now we’re getting the NHS slaps. People are no longer tolerant about what we are doing and they want their treatment because they are getting sicker waiting.”

Of equal concern, said Miss Vig, was how mentally and physically exhausted staff were: the desire to work additional shifts has dissipated. There is simply nothing left in the tank – and the plan will need to address this burnout.

So, the government’s plan must balance both the needs and wants of a public and an already under-resourced workforce which is dog tired. In short: tough decisions and compromises must be made.

Another major problem is that all the traditional levers pulled to ramp up elective output, which surround squeezing the pips out of the existing model (running more clinics, sending more patients to privately run units etc) have already been yanked pretty hard.

There is an acceptance that traditional waiting list initiatives simply won’t get the system anywhere near parity, as the already insufficient workforce numbers have been further constricted by higher-than-usual staff sickness and infection control protocols.

The mood in hospital land, as illustrated by a spate of alarming stories such as one chief executive telling staff he was “scared” his trust was “ceasing to function”, is dark. 

When I asked another hospital boss, who is usually more of ‘glass half full’ type, what the government’s plan could introduce to release the pressure, even just a bit, they said they were already cancelling electives and that “six foot of snow to keep everyone at home [was] about the best we can hope for”.

The short term: spinning plates and cleaning up

Whatever the government’s plan sets out, the NHS’ main priorities for the second half of 2021-22 have already been set out in the H2 planning guidance published in September. Here’s a quick recap of the top lines:

• Eliminate 104 weeks breaches by March 2022 completely
• Hold or reduce 52 weeks breaches to September 2021 levels
• Hold or reduce overall list size to September 2021 levels
• Return to, or exceed, pre-pandemic levels of activity

As of the last official data (the latest will be published tomorrow), 9,754 patients had waited over two years for their procedures as of August, while 292,138 of the 5.7 million cases on the total waiting list have waited at least a year.

The H2 targets represent a switch of the focus since the first half of 2021-22, when a lot of emphasis was rightly placed on clearing backlogs of so-called P2 patients (those who should be seen within a month) over the summer.

With the dizzying array of focus areas, some trust leaders have felt pulled in all directions in terms of elective targets since the list ballooned.

A focus on multiple priorities simultaneously – a very different mindset from a laser focus on an 18-week standard – is likely to continue.

This won’t be framed by leaders as “chaos” but as trusts being asked to be more “agile” in how they approach their elective backlogs. For example, if the system does eliminate its 104-week breaches by March (far from a given), that would be struck off the ‘to do’ list and the focus would move on elsewhere. However, while focusing on the 104s, trusts will also have to continue spinning the other plates.

Another big job for the second half of this year (which will have to be maintained – it’s a Forth Bridge job) is cleaning up and validating the waiting lists. Miss Vig also said this week that “probably 20 per cent of waiting lists are actually inaccurate and are double counts”.

If ministers think they can simply lop 20 per cent off the RTT list by an administrative clean-up, they’re likely to be sorely mistaken (it’s never that simple).

But senior waiting list experts did tell me the figure tallies with estimates on internal NHS data quality dashboards. However, a trust CEO cautioned that lists can go up as well as down as a result of validation, so it’s not a reduction to bank on.

As well as list validation, work is also ongoing to try to tighten up the clinical validation system which sees patients prioritised between P1 (an emergency patient) and P6 (patient wishing to delay surgery), with P2 being that a patient should be seen within a month. National leaders are concerned by how wide variation is in the use of the system.

Lots of hubs but what are the game changers?

The above plans are all useful, but won’t get the system anywhere near stable. System leaders talk about still needing to find some profound “game changers” to achieve this feat.

Some (most?) of the “game changer” initiatives are yet to be identified – with much of the focus of generating these ideas being placed on the elective recovery accelerator programme – but we can expect a few of the following to be in the mix.

Much of the focus will be on outpatient transformation.

NHS England elective supremo Jim Mackey has already spoken about a desire to have an “industrial drive” to cut the number of “pointless reviews” by giving patients more control over their care via patient-initiated follow-ups.

As well as making the NHS’ antiquated outpatient system more efficient, this could also free up staff to focus on patients on the referral to treatment pathway.

Then there are the range of schemes which underpinned the £5.9bn elective fund earmarked in the spending review. The funding breaks down as follows:

• £2.3bn for “at least 100 community diagnostic centres across England”.
• £1.5bn over three years for new surgical hubs, increased bed capacity and equipment. Recovery Watch understands these could be organised nationally to treat patients in specialised areas.
• £2.1bn for technology schemes like faster broadband and more accessible digital patient records.

Finally, NHS leaders are also cognisant that they must make much better use of the circa 8,000 beds in the private sector, with significant discontent on both sides about the levels of NHS independent sector activity. But this is a knotty issue for another day.