NHS0002

Written evidence submitted by The Royal College of Obstetricians and Gynaecologists (RCOG)

About the RCOG

The Royal College of Obstetricians and Gynaecologists (RCOG) is a professional membership organisation made up of over 16,000 members worldwide. We work to improve the health of women, by setting standards for clinical practice, providing doctors with training and lifelong learning, and advocating for women’s health care.

Background

In April 2022, RCOG published its ‘Left for too longreport which looked at the scale and impact of waiting lists for elective gynaecology services. The findings of the report were stark, exposing a specialty which had been disproportionately impacted by a lack of capacity in the NHS long before the start of the COVID-19 pandemic.

The report set out the state of UK gynaecology waiting lists, and highlighted both huge disparities between gynaecology and other specialties in waiting list growth during the pandemic, and significant geographic disparities in waiting lists in the specialty, creating a postcode lottery for gynaecological care.

As part of insight gathering for the report, we surveyed over 800 women who were currently or had recently been on a waiting list for gynaecology services, and then undertook a series of in-depth interviews with individual women who shared their stories with us to understand the true impact of waiting longer for care. Alongside this, we also surveyed 135 RCOG members to understand the challenges from their perspective, followed up by over 25 interviews with consultants and trainees working in gynaecology.

Key updated statistics on gynaecology waiting lists in England

As of September 2022:

-          The CCG with the smallest number of people by population size (NHS Frimley) only has 74 people in every 100,000 waiting, whereas the CCG with the highest number of people by population size (NHS Liverpool) has over 2000 people in every 100,000 waiting. This is a 185% difference.

-          The North West continues to have the highest waiting lists by population size, with seven out of 10 of CCGs with the longest waiting lists within the North West region.

The impact of gynaecology waiting lists

Prior to the pandemic, the Public Accounts Committee concluded on NHS waiting times that ‘national health bodies lack curiosity about the impact for patients of longer waits and how often this leads to patient harm’. In our Left for too longreport, RCOG wanted to understand in more detail what the impact was on women and their health of waiting longer for gynaecological care.

Some of the key findings from the report on the impact of waiting longer for care included:

The design of national recovery plans

RCOG members surveyed and interviewed as part of our ‘Left for too long’ report highlighted that the barriers to reducing the backlog in elective gynaecology services aligned with those across the wider system; a lack of access to theatre space, staffing (in particular nursing staff in theatres and on wards) and availability of beds.

The elective recovery plan set out its key approaches to increasing capacity, which included a focus on growing and supporting the workforce, encouraging systems to build local partnerships to make use of local independent sector capacity, and expanding the role of surgical hubs to improve access to ‘cold sites’ and better protect space for elective care.

RCOG members surveyed for the original report were very supportive of the use of ‘cold sites’ and members who were working in a Trust with access to a site with no emergency services tended to report that continuing and restoring surgery over the course of the pandemic more manageable.  The RCOG plans to undertake further work to understand the benefits and drawbacks of surgical hubs and use of independent sector capacity in the context of elective gynaecology, and will share any findings with the committee.

RCOG members continue to report lack of staff as a significant challenge to increasing capacity in elective care, and availability of nurses and anaesthetists limiting surgical capacity and resulting in less available surgical lists. Without a fully-funded, long-term plan for the NHS workforce, elective recovery is going to continue to be slowed by a lack of staff. Members also continue to raise concerns about the impact of pension tax regional remuneration caps on additional working hours on the ability to increase surgical capacity, with this particularly affecting anaesthetic capacity.

Clinical prioritisation of care

The elective recovery plan reaffirmed continuation of the use of prioritisation frameworks based on clinical need that were developed to manage and allocate capacity during the height of the pandemic. The surgical framework was developed by the Federation of Surgical Speciality Associations (FSSA) to which the RCOG contributed. The framework based clinical need reflects the risk to patients in terms of morbidity and risk to life if left untreated. This puts many gynaecological conditions further down the list for prioritisation because lack of treatment is very unlikely to result in very rapid deterioration or death if left untreated, but we know that managing many of these symptoms long term still has a profound impact on women’s health and their lives. RCOG members surveyed for ‘Left for too long’ felt strongly that the continued use of this strict framework for clinical prioritisation has given way to a de-prioritisation of many procedures for gynaecological conditions.

The framework was also developed at pace. It was considered at the time to be a short-term solution to manage limited capacity and there was an assumption that those waiting for the surgical procedures put into categories 3 and 4 would still be able to access their care in a relatively timely manner, but this has not been the case. The lack of capacity across the system means that the conditions that were de-prioritised in the short-term have been neglected in the longer-term, leaving many women living with debilitating symptoms for months and  years

The RCOG has called for prioritisation of care to include consideration of the wider impacts on patients, considering the impact of ongoing symptoms on an individual’s physical and mental health, their quality of life, fertility and their ability to participate in their work, family and social life.

Early progress made in recovering services

There has been little national progress in recovering elective gynaecology services. Against the ambitions set out in the elective recovery plan:

As of September 2022, there were 40,076 women waiting over 52 weeks for gynaecology services. This is the highest number there has ever been.

As of September 2022, there were 4,961 women waiting over 78 weeks for gynaecology services. This is the highest number there has ever been.

Recent analysis has shown that gynaecology is only operating at 66% of pre-pandemic levels[2], showing poorer recovery compared to other specialties. This is especially concerning given the fact that growth in gynaecology waiting lists has been outstripping all other specialties consistently since April 2018[3], suggesting pre-pandemic levels of activity in gynaecology were already too low to stop exponential growth of waiting lists.

We are deeply concerned that the patterns of disproportionate growth prior to and during the pandemic in elective gynaecology as compared to other specialties are continuing into recovery. Waiting lists continue to grow rapidly in gynaecology, but with data showing current levels of activity far below pre-pandemic levels, this growth is likely to become exponential, with more and more women being added to the list each month and far less capacity to meet their needs.

November 2022


[1] https://www.lcp.uk.com/media-centre/2021/07/women-bearing-brunt-of-indirect-impacts-of-covid-19-pandemic-as-new-analysis-shows-gynaecology-waiting-lists-have-shot-up-by-60-in-three-years/

[2] Elective procedure activity in England in Jun-Aug 2022 as a proportion of pre-pandemic activity (June-Aug 2019)

[3] https://www.lcp.uk.com/media-centre/2021/07/women-bearing-brunt-of-indirect-impacts-of-covid-19-pandemic-as-new-analysis-shows-gynaecology-waiting-lists-have-shot-up-by-60-in-three-years/