Performance Watch: What covid's done to capacity

There is a range of opinion, but Performance Watch understands the view at the centre is the NHS will only be operating at 50 per cent of elective capacity when the many constraints of covid-19 are taken into account.

London is working towards an 8 June restart for the work deemed “non urgent” and which was halted, at the latest, from mid April (urgent procedures have been performed).

By that point, the national data indicates, 33,000 people may have been waiting more than a year (3,000 confirmed at 52-week+, another 30,000 were between weeks 43 and 52 in the run up).

Because restarting elective waiting lists is complicated by infection control, testing, scheduling and capacity issues there have been a number of more and less optimistic forecasts for what kind of capacity the NHS will have as it attempts to catch up on its backlog.

As the Health Foundation pointed out: “Even before the covid-19 pandemic, to meet the 18-week standard for newly referred patients and clear the backlog of patients who will have already waited longer than 18 weeks, the NHS would have needed to treat an additional 500,000 patients a year for the next four years.”

It put the cost of meeting the constitutional 18-week target at between £5.2-£6.8bn over the next four years.

As to what level of previous elective activity can be returned to in the new world, Performance Watch has heard estimates as low as 40 per cent and as high as 80 per cent (that is, assuming there is no second peak).

Either end of the scale is a serious problem for a service that already had a growing waiting list and steadily deteriorating performance against the main waiting time target.

The prioritisation process is still being worked out but it sounds as if some “low value” procedures may not happen at all; and less urgent cases might routinely take more than a year.

Planners point to the fact that some referrals which would have happened in a normal March, April and May did not take place, due to coronavirus restrictions, which has reduced pressure.

This is the same with the disastrous collapse in urgent two-week cancer waits — and in both cases there is no reason to think this demand won’t merely lead to increased referrals when things are nearer to normal.

Some patients have also removed themselves from waiting lists as they did not want to come anywhere near a hospital. The full effect of this and how quickly it might change is not clear, but one senior manager said there was a risk of some non-urgent cases becoming urgent as conditions deteriorate.

In London, planners are optimistic that providers could operate at 80 per cent of previous capacity if “high volume, low complexity” procedures can be concentrated in “cold” sites which are clean of covid, patients having been tested before being brought in.

Even so, there will be an “ask” of the centre in terms of money and workforce to achieve this rate.

In terms of money, with trusts now working on block contracts instead of tariff, it’s not clear how the NHS will work with the private sector, and how far it could make up for the shortfall in NHS operating capacity.

With their accident and emergency-free hospitals, private providers have already been block-booked for NHS-funded work until the end of June. Fairly soon the government will have to decide whether to pay for the private sector to do set volumes of work on a block contract; or incentivise higher volumes but risk losing control of cost by using the tariff.

Either way would likely have to recognise that the old tariff system’s prices reflected procedures performed in a much less expensive world.

One bright spot in all of these longer waits: it might put paid to some procedures that are genuinely of little clinical value. The risk of getting covid, and it causing poor outcomes after surgery, may tip the risk balance for some. And with theatre time an even more valuable resource than it was before, medics will find it very difficult to justify some work.

Return to work

A further complication are the potential safety implications of surgeons returning to complex work after the longest breaks in practice in their career.

An orthopod told a Public Policy Projects webinar recently he normally did about 10 operations a week, and the longest break he had ever had in his practice previously had been two weeks.

A break like that just experienced is something most surgeons have never faced before. There will be a knock-on effect on training. Royal Bournemouth have introduced virtual sessions so their surgeons can try and stay in practice remotely and I’d be interested to hear how other places have addressed this issue – ben.clover@wilmingtonhealthcare.com.

The medium term

There are already signs that the whole way electives are managed might be overhauled in the wake of covid-19.

For a start it looks like the rest of England might follow London’s lead in soon calculating its waiting list by integrated care system rather than individual provider.

If this is the case it’s important that the new system isn’t dogged by poor data, routine discovery of forgotten waiters and avoidable harm like the old one was.

Perhaps the new system could even measure waiting times for follow-ups?

The mess that is ophthalmology follow-ups is just one example of the avoidable harm the NHS allows through not keeping track of patients properly.

Creating new waiting list procedures might unearth more patients who have simply been lost by the old system. But if the disruption leads to more people losing their vision or similar it will be inexcusable.