Performance Watch: Will there be mass elective cancellations this winter?

Among the increasingly panic-stricken demands coming from system leaders, an NHS England figure recently asked an acute provider to calculate the ramifications of cancelling elective care for the entire fourth quarter of 2017-18, HSJ has learned.

This week, we revealed this week that of the £1.6bn of additional revenue funding allocated in the chancellor’s budget for 2018-19, £1bn will be earmarked for getting the referral to treatment 18 week standard back on track (with the rest for four hour performance).

An extra billion for electives will begin to flow on 1 April 2018 – almost exactly a year after electives were de-prioritised by Simon Stevens at the launch of the Next Steps document. This suggests either system leaders’ views on how much emphasis should be placed on RTT will have to turn on a sixpence come April, or there is a lack of alignment between government and NHS England’s ambitions. Or, most likely, a bit of both.

(The budget also presented a £335m winter pressures fund for this year. Given that it is being made available far too late in the year to be used optimally and will mainly be used for accident and emergency and to support trusts’ bottom lines, any major movement on electives will have to wait until April.)

With all that in mind, it seems pertinent to re-visit the question of how many operations could get cancelled this winter, not least after the Royal College of Surgeons’ warning last week that significant cancellations are on the cards.

NHS Improvement’s orders last year to “cease most inpatient elective activity” over Christmas and new year to cut bed occupancy and protect the flow of emergency patients are likely to be repeated this winter.

But requests to consider cancelling operations for the entire last quarter of 2017-18 do not appear to be widespread, based on soundings from other trust and STP chiefs by HSJ this week.

The request was however a good indicator of the extreme lengths system leaders are prepared to consider in their pursuit of getting a grip on four hour performance.

How to avoid cancelled operations

Trusts can still restrict access to elective care without it showing up in the cancellation figures, however

The consensus among leading experts was that the number of cancelled operations was not likely to be significantly worse than previous winters, unless there is a serious flu outbreak or particularly cold winter.

King’s Fund director of policy Richard Murray told me that while there was likely to be a large drop in elective activity over winter this would not necessarily mean more cancellations.

The former Department of Health director of strategy said: “Operations are only cancelled if they have been booked in the first place. So, the only way there will be more cancellations is if winter is worse than the NHS has forecast, and trusts have predicted it will be pretty bad.”

Waiting times expert Rob Findlay, founder of Gooroo and HSJ contributor, added that “trusts would be keen to limit the duration of any slow-down in elective admissions, which would mean an elevated risk of cancellations over the rest of winter”.

He added that many cancellations would however be made before the day of surgery, and so would not show up in the national statistics for last minute cancellations (which are a poor indicator of the overall cancellations which often happening before the day itself).

New money welcome but not enough

As for the prospect of an additional £1bn for RTT in 2018-19, Mr Findlay said that if it were all spent on elective care then it could be enough to stop the underlying waiting time pressures from growing, but not enough to restore the 18 week standard by 2020 as the current NHS mandate requires.

Another perhaps unintended consequence of pumping £1bn into addressing RTT is that a significant proportion of the additional cash could end up going into private providers, because there is very little capacity within the NHS to deal with more demand, so it will most likely need to be sub-contracted. 

The funding is unlikely to be ringfenced in such a crude way as to ensure exactly £600m is focused on A&E and £1bn on RTT - the values are more a symbolic indication of priorities. As Mr Murray told me: “The Treasury will want to know that they are getting something for their money, and the biggest public concerns are around A&E and RTT targets.”