Reform Watch: What the new elective plan means

There was a hefty gap between the prime minister’s rhetoric that the plan he unveiled on Monday would “end NHS waiting list backlogs”, and its contents. The plan was, in most part, a collection of policies which are already in progress, albeit with some interesting shifts.

The biggest change was a change of focus to the overall size of the elective care waiting list (and linked to that, the 18-week referral-to-treatment target), away from the longest waiters.

You can read all our coverage so far of the Reforming elective care for patients plan via the links at the end of this article.

Many senior NHS figures are privately sceptical the plan will achieve its goal of returning the NHS to meeting the 18-week referral-to-treatment standard by 2029 without significant further action.

But that is not to dismiss the plan’s contents or validity. The challenging financial and operational climate means the emphasis has to be on pragmatism. It is also the case that any radical ideas are probably being stored up for June’s 10-year health plan.

Most importantly, we still don’t know what allocations commissioners and providers will have to work with next year, or exactly what the promised new NHS operating model will look like. Both that model, and the planning guidance, have been delayed.

One thing which is clear, however, is that the elective recovery drive — as government’s main operational focus — is likely to suck up resources from elsewhere, leading to concerns about the prospects for urgent and emergency care, as well as other areas like mental health and community services.

The King’s Fund incoming director of policy Siva Anandaciva told Reform Watch recovering the RTT by 2029 was “not in the bag by any means” but he noted the plan had “some quietly subversive elements to it”.

“There are changes to how everything from referrals to reimbursement will work, and a re-commitment to tackling health inequalities on waiting lists and improving the ‘customer experience’ of being on a waiting list,” he said.

Even the relatively modest improvement demanded on the main elective measure, increasing 18-week performance nationally from 59 per cent to 65 per cent next year, represents a pretty challenging ask.

As one former NHS England insider observed, the government’s lofty talk of reform and generous financial settlements may well create a public messaging problem for the NHS in the future.

If progress takes as long as officials forecast, patients still facing unacceptably long waits in a few years’ time may start to think: “But I thought the government said this had been sorted out?”

Pivoting from long waiter focus back to RTT

The return to focusing on the RTT standard has been long telegraphed, but it has not been clear how the profiling would work. The new 65 per cent target for 2025-26, exclusively revealed by HSJ on Friday, received a mixed response.

Waiting list expert Rob Findlay raised doubts over whether it was realistic, while the Royal College of Surgeons was more confident the 2025-26 target could be met – but warned this would leave the system with too much to do in future years to get to 92 per cent by 2029.

The move towards a more holistic approach to managing the entire waiting list, and a move away from tail-gunning long waiters, has been widely welcomed.

However, the decision to ditch targets for long waiters does dilute accountability for what is still one of the NHS’s most serious problems. The 2022 plan pledged to eliminate year-plus waiters by March 2025, and, despite significant progress, this mission will remain uncompleted.

There are legitimate clinical reasons for not having targets for long waiters. They can skew attention from the most clinically relevant cases to simply those waiting longer. But some sort of backstop seems a legitimate requirement.

ICBs’ commissioning role beefed up

The plan could also signal a significant shift in the role integrated care boards play. Although light on detail, the document suggests ICBs are set to act as beefed-up commissioners with an increased focus on contracting.

This seems distinctly different from recent noises from the centre that their main role will be as system conveners and “strategic commissioners”.

Providers will “continue to be paid in line with the number of patients they treat”, the plan says, but it adds that the money they get will be based on a “planned level of activity with commissioners”.

Nuffield Trust senior policy analyst Sally Gainsbury told Reform Watch commissioners could be tempted to “overestimate” the impact of pathway reforms given the tight financial envelope.

She said: “The relationship between activity levels and waiting times isn’t easy to predict, and therefore isn’t easy to contract for or budget for – particularly when there are new unknown variables, such as the extent to which incentivising GPs to use Advice and Guidance will translate into a lower demand for hospital-based care.

“[Commissioners] will be in a very difficult situation if trusts discover they’re doing more activity than their ICB is funded to meet because there isn’t this blank check that [there] has been this last year.”

ICBs are to be expected to manage this increased workload despite having lost 30 per cent of their management capacity in the previous government’s cost-cutting exercise (criticised at the time by a certain Wes Streeting).

One system finance leader said the plan felt like a financial risk transfer from NHSE to ICBs, which would now be expected to manage elective payments and contracts with NHS and independent providers after three years of running cost cuts. “The old [payment by results] management teams are no longer there,” they said.

“At best, it’s a good opportunity for greater commissioner control but it’s risky unless we can have a relatively small increase in management overhead to manage it properly. At worst, it will push ICBs into deficit.”

Advice and guidance

The government wants to supercharge the “advice and guidance” scheme, under which GPs contact a hospital consultant before making a referral to secondary care to check if the symptoms can actually be dealt with another way.

On paper, trusts have a significant incentive: for every patient that is diverted from hospital, they receive around £200, the average cost of an outpatient appointment.

In contrast, most GPs get nothing, despite what is often more work than a referral. The British Medical Association has highlighted examples of some trusts forcing all referrals in certain specialities to go through the route.

There is little detail yet on how the scheme will operate but broadly GPs will be paid £20 each time they make an A&G request, funded by £80m from elective budgets.

It’s not clear what the metrics for success will be, and whether expenditure will be capped. If GPs respond to the incentive too vigorously, it could end up being another financial headache for ICBs.

Read more here:

Every trust given individual elective waiting time target

Major pricing shake-up for elective care announced

Trusts given deadline to roll out new NHS app features

GPs to be paid to seek consultant opinion before referring

Next year’s elective target revealed