Hospital group chief: NHS needs to limit referrals to deal with ‘wicked’ covid problems

Raj Jain, chief executive of Salford Royal Foundation Trust and the Northern Care Alliance, said the presence and risk of coronavirus will severely limit capacity for diagnostics and surgical theatres, meaning trusts will have to work with GPs to find ways to reduce referrals.

“Keeping the public with us will be challenging” over the winter months, he added.

The NHS has reported a huge drop in referals and treatments for non-urgent care since March, as staff have focussed on responding to the coronavirus pandemic. Although activity is creeping back up, there are major concerns over the amount of care the NHS will be capable of delivering and the extent to which waiting times will lengthen as a result.

In an interview with HSJ, Mr Jain said: “Some estimates say we could lose 60 per cent of our productivity in theatres and diagnostics because of the cleaning regimes happening in between.

“This is part of the wicked problem we are grappling with…If we lose half our capacity in imaging — and we haven’t got enough now — we need to rapidly increase capacity but also transform current pathways, and work with the public and patients to manage this problem.

“The answer, in significant part, lies with demand management and secondary prevention strategies, and this is where place-based working comes to the fore.

“With a waiting list that’s going to increasingly age, primary, community, secondary and social care are thinking through how patients can be offered alternatives to alleviate pain, increase mobility et cetera, without the recourse to hospital-based services.

“Our view is you have a to take a multi-disciplinary view, so we’ve got consultants together with GPs to work towards the soundbite ‘you only get referred to the hospital if you truly need the specialist care that can only happen in the four walls of a hospital’….so that is generally going to be because it needs specialised scarce equipment or facilities, such as an operating theatre.”

Mr Jain, who leads the hospitals and community services in Salford, Oldham, Rochdale and Bury in his NCA role, said endoscopy could be a prime example, as there are “whole groups of [low risk] patients we think could be managed differently” with therapeutic input, such as from dieticians.

“Therefore we need more dieticians, physios and other therapists… They will be working in different ways and expanding their scope of practice,” he said.

HSJ has spoken to several senior trust leaders in other parts of England who said they are currently making similar assumptions and plans.

Primary care leaders agreed GPs will have to play a central role in helping hospitals recover services, but said there would be concerns if this led to new workloads and activity.

Professor Martin Marshall, chair of the Royal College of GPs, said: “The RCGP is keen to work with colleagues across the NHS, but general practice cannot become responsible for delivering services we are not set up or appropriately trained to deliver.

“GPs will already only refer to specialist care if they think there is a good reason to and it is in the best interests of their patient.”

He said the college had long called for better access to diagnostic testing in the community, to specialist advice through dedicated phone lines, and to services such as pain management programmes, but said “these are yet to be appropriately addressed”.

NHS England, which is preparing to issue further guidance on recovering services to more typical levels, as well as seeking to negotiate additional funding from the Treasury for another block booking of independent hospital capacity, and other measures, was approached for comment.