Essential insight into England’s biggest health economy, by Ben Clover.

There is some disquiet among the capital’s hospital leaders about the homework they’ve been set for next Monday.

Plans for restarting work which was deferred or cancelled in the covid-19 response need to be on Sir David Sloman’s desk by May 11, but there are a number of significant factors outside of managers’ control.

Although the system is confident enough to effectively mothball the Nightingale, for the time being, the challenge of restarting work, particularly surgery, in covid-free areas is a big challenge.

As one hospital leader told HSJ last week, restarting work is going to be much more complicated than stopping it.

For a start, without a vaccine it’s not actually possible to guarantee somewhere is covid-free. Lifts, corridors, waiting areas, these are all areas where it is difficult to control the mingling of patients – which represents a big problem for re-starting surgery.

A second peak whilst also trying to run theatres could be a disaster.

Hospitals managers have spent years trying to run these precious facilities as hot as they can and having them sit empty while all the cancer surgery goes to a specialist site with no accident and emergency (Marsden for south west and north west London, Guy’s for south east, and everywhere else into UCLH) was difficult but necessary.

And that’s providing patients can even be persuaded to go to a hospital in the first place. The arrangement for dividing this work will need to command the confidence of the public. They’ll need to be persuaded that a trip to a hospital doesn’t risk a one-way ticket to ICU.

And treatment is only one part of the pathway.

The grim total of life years lost to stopped chemo, to delayed diagnosis of cancers will need to be tallied soon, if only to make sure the follow-ups and catch ups are quick and comprehensive.

And this is a real issue. The worrying reduction in referrals on the two-week-wait is a real issue, and saw questions asked at a Parliamentary committee.

One hospital boss told London Eye his team had seen only 10 per cent of the referrals they might expect under the urgent two-week cancer pathway.

Primary care sources point out that the suspicion risk is only 3 per cent, so the remaining 97 per cent are not cancers.

Even so, April 2019 saw London GPs make 30,576 referrals on the two-week cancer pathway – assuming the 3 per cent figure, that’s 917 cancer diagnoses. If the 10 per cent figure was anything like universal for London then hundreds of people have a cancer they would otherwise have learnt about and been put on a waiting list for.

If the true figure was actually 50 per cent fewer, that’s still nearly 500 people going unreferred, and that’s before you even get to treatment.

It is one of many time-bombs, too serious to be called merely a “backlog”.

Lead providers

So, one of the things to be ironed out once trusts have submitted their positions for next Monday is who and where can safely do the work.

This will likely see lead providers appointed to run whole workstreams, across organisational borders, a culture shock for some but necessary.

A complication in terms of getting back to normal is delays from the Royal Colleges.

Several sources mention, some with a degree of frustration, that the professional bodies that issue accreditation for services like endoscopy need to give their go-ahead.

When this high-volume specialty can be restarted is a key question hospital leaders need answering, ditto some ear, nose and throat services.

How much work the private sector did for the NHS during the first peak is also something we need to know to allow the planners to plan.