Written evidence submitted by the Federation of Specialist Hospitals (DEL0343)
- The Federation of Specialist Hospitals is a coalition of some of the country’s best known and regarded hospitals, which provide specialist services to patients across the UK. A list of members is given in the Appendix to this submission.
- Given their focus on particular specialties, members of the Federation occupied a unique position in supporting the NHS’s response to the pandemic. It was therefore decided to conduct a short quantitative and qualitative survey to inform understanding of the response to date and best use of the sector in future.
- We hope the Health and Social Care Select Committee will find this information helpful with regard to its terms of reference for the ongoing inquiry and in particular:
- How to achieve an appropriate balance between coronavirus and ‘ordinary’ health and care demand
- Meeting the wave of pent-up demand for health and care services that have been delayed due to the coronavirus outbreak
- How to ensure that positive changes that have taken place in health and social care as a result of the pandemic are not lost as services normalise.
We would be happy to provide additional detail on request.
- NB the paper uses weighted averages, unweighted averages and median figures depending on which is most representative in each case.
- Although specialist hospitals are alike in focusing on particular specialties, the nature of those specialties and the care involved, together with the history of the institutions concerned, makes for considerable diversity in other respects.
- The number of beds among Federation members ranges from a low of 12 to a high of 470 with an average of 236 measured across 10 trusts, excluding St Mark’s Hospital, whose numbers cannot be easily separated from the wider North West London University Healthcare NHS Trust.
- Workforce size ranges from 1300 to 5000 with an average of 2620 across 10 trusts.
- Outpatient attendance before the pandemic ranged from 30,000 to 637,000 per annum with an average of 232,000 across eight trusts.
Care for Covid Patients
- Nine out of 11 members provided care for Covid patients during the first phase of the pandemic. This ranged from one hospital which was largely re-assigned to such care by its parent trust, through others which drew on their fields of expertise to help treat the most complex cases, for example in the respiratory field, to those which only treated their own patients who happened to become infected with Covid.
- The proportion of Intensive Care Unit (ICU) beds allocated to Covid patients ranged from 19% to a high of 164% in one trust which increased its capacity specifically for the purpose. The crude, unweighted average across eight trusts was 69%.
- The proportion of normal beds allocated in those same trusts ranged from 0.5% to 62%, with a median of 10%.
- The proportion of overall capacity accounted for by Covid patients ranged from 4.6% to 70%. While six of the eight reporting hospitals were at or below 20%, one observed that the knock-on impact of Covid on usable capacity was far greater (see section on core business below).
- The survival rate of patients in ICU ranged from a low of 50% to a high of 100% with a median of 75.5% and crude average of 72% between the eight hospitals concerned. This compares well with performance across the wider NHS, taking no account of the casemix.
- Five hospitals advised the wider NHS on treating complications of Covid in their specialty at ICS and regional levels, four of these nationally, with respiratory and cardiovascular to the fore.
Impact on Core Business (April-June 2020 v 2019)
- We asked members to quantify the impact of the pandemic on core business. This was far greater than the number of beds and other resources assigned to Covid would imply.
- Elective treatment was down between 28.5 and 92% with a median of 74.5% across nine trusts
- Non-elective treatment ranged from a reduction of 35.9% to an increase of 269% with a median of 0% across the same trusts
- Outpatient appointments were down between 12% and 80% with a median of 31%.
- The mode of interaction with patients in delivering outpatient appointments changed sharply, as follows:
- Face-to-face appointments were down between 17% and 82.3% with a median of 41%.
- Phone appointments were down 15% in one case but otherwise up by between 29.1% and 1162% with a median increase of 400%
- Video appointments were generally up less and from a lower level ranging between 0% to 22400%, the latter from a starting point of 0.1% to 22.41% of all appointments.
Overall, use of the phone was far more significant than video during the pandemic.
- Referrals were down between 22.6% and 76% year on year with a crude average of 43.7% across eight trusts. This has brought about a reduction rather than an increase in many waiting lists, though waits for surgery may have increased within some of these totals, ranging from a reduction of 20% to an increase of 21.5% with little or no change in most cases. At the same time, it has been pointed out that waiting times are likely to have increased even with an unchanged list because of the impact of Covid.
- As an aside, the assumption in NHS England’s Phase 3 plans that referrals and outpatient activity should necessarily return to historical levels may be mistaken where closer working with primary care enables a mutually beneficial reduction.
Financial impact (April-June 2020 v 2019)
- NHS income earned by most specialist trusts would have been sharply down for the period had it not been for block contracts. For those trusts depending on significant private patient income to sustain their finances, steep declines of between 33% and 100% are an additional source of concern. Research income has also been adversely affected with declines of up to 68% and a median fall of 46%. The impact on charitable income will take longer to assess.
- While trusts are expediting their financial recovery plans, typically targeting Q3 or Q4 of the 2020/21 financial year, much will depend on the future course of the pandemic, while some permanent effects can be expected. For example, increased absence and shielding are having an ongoing effect on productivity with an associated lowering of targeted activity levels. Access to robust point of care testing will help raise productivity, while funding which bridges the remaining productivity gap will be vital.
- All 11 of the Federation’s members played a leadership role in sustaining services within their specialty at ICS level, falling to nine at regional and six at national level. Unsurprisingly, the trusts specialising in cardiac and respiratory medicine played a particularly prominent role in treating patients most severely affected by Covid with a major surge in related capacity and outstanding survival rates. This leadership was replicated elsewhere in other ways, whether in developing cancer hubs and maximising surgery levels or enabling patients nationally to access treatment for intestinal failure.
- Cancer hubs were led by trusts specialising in cancer, working with partners and the independent sector. The hubs ensured patients from across the regions could receive urgent and time-critical cancer surgery while their local Trusts were focused on the response to Covid. Through the creation of the cancer hubs, specialist hospitals showed their leadership to create a national template for the wider NHS to follow, demonstrating key knowledge and experience of their specialty for the benefit of patients across the country.
- Despite the immense pressures of dealing with the pandemic, the opportunity to introduce beneficial change at pace and scale has been widely remarked upon and applies equally to the specialist sector.
- The use of the telephone and digital technology to replace face-to-face interaction with patients for outpatient appointments has been remarked upon earlier. Trusts were however able to increase its use for other purposes including remote monitoring and some forms of therapy.
- Less remarked upon has been the use of digital technology to enable far more remote working by staff, both clinical and non-clinical. As with other types of organisation, this will lead to a new equilibrium in the medium term and may even free up previously non-clinical space for clinical use in due course.
- Enhanced system coordination has also been a feature of the pandemic to date. Combined with new diagnostic and treatment pathways, this should allow improved use of capacity should a second surge materialise, as expected.
- At the same time, several members remarked on the benefit they reaped from maintaining a clear focus and relationships at trust level for example in the procurement of PPE.
- The pressures on staff resulting from the pandemic have been immense, whether through re-assignment to Covid care or adjustment to remote working. This will require new forms of support as indeed have been pioneered by some of the Federation’s members.
- The importance of better communications in preparation for a second surge is clear. Several trusts remarked on the proliferation of sometimes confusing NHS communications particularly at regional level. Better communication will also be required to ensure that patients feel confidence in accessing services and will be reliably referred thereafter.
- The last six months have shown that it is easier to cease than re-start activity. Where not already the case, no time should be lost in ensuring that elective and non-elective pathways are discrete in a way which will sustain the former and command confidence internally and externally. The same applies to the better maintenance of research.
- Specifically in the field of paediatrics, it has been pointed out that a pandemic carrying little risk for children led to the severe rupture of services with an impact on issues like safeguarding and vaccination rates. Furthermore, isolating for 14 days before treatment was both less necessary for children and a serious deterrent for poorer families.
- Specialist trusts played a varied and important role in the NHS’s response to the pandemic in the first half of 2020. They are well placed to provide system leadership in relation to their specialties but this should ideally be with a clear mandate. For example, specialist hospitals can help develop and test key clinical models to support recovery and sustainability. In doing so, important decisions need to be taken about how specialist trusts can best support the NHS as a whole. At one extreme, this may involve maintaining Covid-free status and focusing on their core expertise. At the other, that expertise has and will lend itself to being at the forefront of treatment for Covid. In any event, the opportunity to progress integration of the expertise and excellence of specialist hospitals with the NHS at local, regional and national levels is to be welcomed and has great additional potential.
Christie NHS Foundation Trust
Clatterbridge Cancer Centre NHS Foundation Trust
Great Ormond Street Hospital for Children NHS Foundation Trust
Liverpool Heart and Chest Hospital NHS Foundation Trust
Moorfields Eye Hospital NHS Foundation Trust
Royal Brompton and Harefield NHS Foundation Trust
Royal Marsden NHS Foundation Trust
Royal National Orthopaedic Hospital NHS Trust
Royal Papworth Hospital NHS Foundation Trust
St Mark’s Hospital and Academic Institute
Walton Centre NHS Foundation Trust
Children’s Hospital Alliance
Specialist Orthopaedic Alliance