David Hare on how a focused approach in securing additional support from the independent sector will be needed to stabilise the waiting list position
The exact amount of additional elective activity promised in the recent NHS planning guidance “refresh” has not been spelled out. But, if the demand forecasts are broadly accurate, the NHS is going to need to deliver a few hundred thousand extra elective procedures and a few million extra outpatient attendances over the course of 2018-19. Otherwise, it will not be able to meet the objective of holding the waiting list steady by March 2019, as well as halving the number of over 52 week waiters.
Measures to be taken
Given the current pressures across the NHS, it is unlikely that the public provider sector on its own will be able to scale up activity sufficiently to meet these objectives. Therefore, a focused approach in securing additional support from the independent sector will be needed to stabilise the waiting list position, whilst of course avoiding destabilising the wider system. To achieve this, we would urge the following measures be taken:
- Sensible and honest adjustments of planning assumptions for 2018-19 – where commissioners need extra capacity to hold the position steady it must be ensured that local providers can deliver what is needed. This is something underdelivering elective block contracts can really get in the way of achieving – money for treatment can’t be spent twice and if a commissioner has agreed a block contract with one provider which then can’t perform the treatment it becomes much more difficult to reroute the funding to a provider who can.
- Strong encouragement of long term local partnerships where providers work together to resolve challenges. If integrated care systems are to be meaningful then they must be integrating – or coordinating – care across all provider groups, including with the non-statutory provider sector. NHS England and NHS Improvement can both play a vital role at the regional level for those systems that need additional support.
- Targeting capacity at those trusts with the biggest number of over 52 week waiters. This can be done by coordinating capacity information through local systems or regional teams to see how much of the care needed for over 52 week waiters could be delivered by an independent sector operator. Given that just 10 trusts are responsible for over half of the national total, significant wins can be made if we focus on these areas.
- Equally, if we want to tackle the over 52 week waiters, we need to address the tail of people who get beyond 40 weeks – when something unexpected crops up after 40 weeks, it’s easy to slip beyond 52 weeks, with all the associated consequences this can have for patients.
In addition, trusts should be given every possible support in maximising patient flow. This could include working with independent sector partners in areas such as step down and clinical home healthcare to assist with delayed transfers of care. The independent sector can also help improve operational efficiency in areas like diagnostics, and can offer mobile capacity to assist with short term spikes in demand.
All of this will help with the aim of holding the waiting list steady whilst also building local collaborative systems that work for patients. What would not help – and yet which is creeping into a number of local areas – is artificially restricting access to treatment, for instance through clinically inappropriate exclusions or minimum waiting times, both of which are bad for patients and simply exacerbate the problems of tomorrow.
We are certainly not arguing that holding the elective waiting list steady over the next 12 months will be simple and nor are we claiming that the independent sector has all the answers. But having reached an agreement with the government over what the new funding in last November’s budget will buy, NHS leaders will be under pressure to deliver and all parts of the system, including the independent sector, need to be supporting them to do this.