NHS0020

Written evidence submitted by NHS Providers

NHS Providers is the membership organisation for the NHS hospital, mental health, community and ambulance services that treat patients and service users in the NHS. We help those NHS trusts and foundation trusts to deliver high-quality, patient-focused care by enabling them to learn from each other, acting as their public voice and helping shape the system in which they operate. NHS Providers has all trusts in voluntary membership, collectively accounting for £92bn of annual expenditure and employing more than one million staff.

Key messages

1.       The current pressures facing the NHS can be traced back over the last decade as four long-term fault lines, all of which have been exacerbated by the pandemic:

1. the longest and deepest financial squeeze in NHS history
2. a growing mismatch in capacity and demand resulting in pressure on national performance standards pre pandemic
3. staff vacancies and the need for better workforce planning
4. an underfunded social care system in need of reform.

2.       The provider sector has made positive headway in making early progress in recovering services, bringing down the bulk of the longest waits. However, the recovery of elective care and cancer services is reliant on several interdependencies including surges in Covid-19 hospital pressures, Covid-19-related staff absences, pressures across the urgent and emergency care pathway, workforce constraints and access to capital funding. These key factors, along with the availability of other services including patient transport services and the right community care, all impact a trust’s capacity and capability to deliver planned elective and cancer care.

3.       Trusts are ambitious about reducing care backlogs and they are caring for more patients, but some targets will be challenging to deliver. Findings from two NHS Providers surveys in the past six months show an increasing concern from trust leaders that national targets may not be achievable. Trust leaders told us they are optimistic that their trust can deliver this over the next three to five years but not at the pace the plan requires.

4.       Trusts are considering how to restore their services equitably and take advantage of opportunities to reduce inequalities facing those from deprived backgrounds, minority ethnic groups, autistic people and people with learning disabilities, and other protected characteristics. This includes carrying out analysis to identify disparities in access, outcomes and experience, and committing to narrowing these gaps through their prioritisation of waiting lists. 

5.       The national focus on bringing down the elective and cancer waiting list does not tell the whole story – there are also increasing pressures on the ambulance sector, and care backlogs across community and mental health services. Trust leaders are reporting an increase in the complexity and acuity of patients across both mental and physical healthcare services, including within the community. Community trusts and mental health and learning disability trusts also report considerable increases to caseloads and are experiencing similar issues moving patients between services. Capacity constraints have meant that out of area placements for people with mental health conditions have also increased, reversing progress made on this issue before the pandemic. Elective recovery targets and pathway changes require support from primary care and community services and therefore recovery of planned care cannot be viewed in isolation. 

The design of national recovery plans

6.       The operational ask, set out in the 2022/2023 planning guidance and subsequent guidance on elective recovery, requires trusts to balance a number of priorities: to continue to respond to Covid-19 pressures, to tackle long waits across all services and to push forward with the next phase of implementing the NHS long-term plan.

7.       Trust leaders know that many people are waiting longer than they should to access mental and physical health services and are working hard with system partners to help mitigate the risks for patients. The national focus on bringing down the elective care waiting list of over 7 million (October 2022) does not tell the whole story – there are also increasing pressures on the ambulance sector, and care backlogs across community and mental health services.

8.       NHS Providers hosted a roundtable between a small number of trust leaders and NHS England in December 2021 to inform the development of the elective recovery plan, with attendees calling for the plan to:

1. be grounded in reality, which means recognising the extraordinary pressures trusts are facing;
2. take a system-wide view of the care backlog across acute, mental health, community and ambulance services;
3. address health inequalities (there was a strong feeling that otherwise we run the very real risk of exacerbating what is already entrenched); and
4. be carefully communicated to politicians and the public, so that everyone has a shared understanding of what is realistically achievable over the next three years.

9.       Attendees also highlighted the challenges presented by national and system capital expenditure limits, and how these hold trusts back from investing in their estates to support elective recovery. We set out our detailed views on the plan after it was published.[1]

The implementation of the recovery plans including the use of independent sector providers

Provider sector views

10.   In the last few months NHS Providers has conducted two surveys covering the operational and financial challenges across health and care systems. Questions were included about waiting lists and the barriers impacting backlogs.

11.   In June 2022 NHS Providers published NHS Reality Check: The financial and performance ask for trusts In 2022/23.[2] This survey showed how the pandemic has deepened existing fault lines, leaving trusts facing a tough task in 2022/23 to meet patient need within the financial envelope and to deliver stretching waiting times and efficiency targets.

12.   In relation to recovery targets:

1. 67% of trust leaders who provide elective care said they are very confident or confident that they will be able to eliminate long waits of over 52 weeks by March 2025.
2. 42% of respondents from trusts that provide elective care are not at all confident or not confident that they will deliver their recovery targets to reduce long waits in 2022/23.
3. 37% of respondents who provide elective care are confident they will be able to deliver 104% of pre-pandemic elective activity by the end of 22/23.
4. The biggest barriers reported were staff shortages, burnout, capacity constraints, challenges in patient flow and increasing clinical complexity, limiting trusts' ability to make activity gains during 2022/23. 
5. Half of trust leaders (49%) are very confident or confident that their trust will carry out 95% of diagnostic tests within six weeks by March 2024.
6. 60% of respondents are very confident or confident that their trust will ensure 75% of patients who have been urgently referred by their GP for suspected cancer are diagnosed or have cancer ruled out within 28 days.
7. 45% of respondents are confident that their trust will reduce the number of outpatient appointments. Trust leaders told us they are optimistic that their trust can deliver this over the next three to five years but not at the pace the plan requires. Some trusts highlighted the importance of follow-up appointments in closing off patient pathways, and that the transition to reduced appointments needs to be realistic. Respondents also stressed that the target to reduce outpatient appointments needs to be appropriate to the care pathway, particularly for specialist services where treatments are primarily outpatient based.

13.   National RTT data[3] confirms that only a very small number of providers have been able to exceed activity so far this year, indicating the 104% target is currently out of reach for the majority of providers.

14.   Key findings from our latest survey of trust leaders published in November 2022 include[4]:

1. Nearly half (46%) of trust leaders strongly agreed or agreed they were on track to meet the key end of year elective recovery and cancer targets.
2. Most (86%) trust leaders were very worried or worried about their trusts having the capacity to meet demand for services over the next 12 months.
3. Almost four in five trust leaders (77%) were very worried or worried about their trust having the right numbers, quality and mix of staff to deliver high quality healthcare currently.
4. Almost all (93%) trust leaders were extremely or moderately concerned about the current level of burnout across their workforce, and eight in ten (80%) were extremely or moderately concerned about their workforce morale.
5. Over four in five trust leaders (84%) said it was very unlikely or unlikely that their trust will end 22/23 in a better financial position than it ended 21/22.
6. Two thirds of all trust leaders (66%) said there were issues facing their trust in terms of accessing operational and national capital funding over 22/23.

Operational and financial pressures in 2022/23

15.   At the beginning of the financial year, NHS England set out a broad range of targets for trusts to ensure delivery of the elective recovery plan and to restore activity to pre-pandemic levels. The latest performance data outlines the sheer scale of the challenge for trusts in tackling the care backlog as the size of the waiting list has grown to over 7 million.

16.   While performance against many of the existing waiting time standards has fallen across nearly all metrics, activity levels across services have improved, exceeding pre-pandemic levels in some specialities including cancer services and diagnostics. Although widespread activity gains in surgical elective care have not been made, these other activity gains are a significant achievement, particularly factoring in the complexities and obstacles trusts are facing.

17.   Many of the financial assumptions which underpinned much of the financial planning for 2022/23 have not borne out. Finance teams within trusts were instructed to base their financial plans on the assumption that inflation would remain around 2% and that the impact of Covid-19 would be greatly reduced. These assumptions are no longer backed up by the evidence.

18.   The key message we are hearing from trust leaders is that they are becoming increasingly concerned that the operational ask for 2022/23 is proving too difficult to meet. As we move further into the second half of the financial year, the feasibility of delivering on elective recovery targets set in April seems increasingly less likely.

19.   Trusts are continuing to report a number of barriers which are inhibiting their ability to ramp up activity levels, such as staff absences, estate-related constraints in increasing capacity, the continued prevalence of Covid-19 and the inability to discharge medically fit patients into social care.

20.   The Elective Recovery Fund (ERF) which is £2.3bn for 2022/23, has been allocated to ICBs if they deliver 104% of 2019/20 levels of value-based activity across elective care. However, due to a wide range of operational challenges which are limiting trusts’ capacity to increase activity levels, these performance targets are proving difficult to achieve. As a result, trusts across the country are deeply concerned that they will be penalised for failing to meet targets. It is also unclear whether the funding allocated to ICBs will be clawed back should performance targets not be met, or whether the 104% target will be amended to ensure the operational ask is realistic.

21.   As we move focus towards 2023/24, trusts would value receiving early and unambiguous guidance on the financial framework underpinning the elective recovery plan. One of the issues with the elective recovery plan for 2022/23 is that much of the guidance and funding was only confirmed in April 2022, leaving trusts with little ability to build elective activity targets into their financial plans.

22.   Additionally, significant inflationary pressures have eroded the spending review cash settlement for the NHS. Trusts have welcomed the additional £6.6bn announced in the autumn statement which will be allocated to the NHS in 2023/24 and 2024/25. This will go some way to plugging the budget shortfall created by inflationary pressures, and is meant to improve performance across emergency, elective and primary care. However, there are still concerns that planned transformation spending on community diagnostics – which would support trusts to bring down the care backlog – as well as investment in mental health services may have to be cut to close the funding gap for 2023/24.

Approaches to tackle the waiting list and recover services

In line with the elective recovery plan, trusts have been busy implementing a multipronged approach to recover services and to increase activity on pre-Covid-19 baselines.  These include:

1. Implementing good waiting list management – ‘back to basics’ including waiting list validation and clinical validation.
2. Outpatient transformation – the majority of (around 4 in 5) patients on the elective care waiting list are waiting for tests or outpatient appointments. Therefore, by reducing routine and unnecessary follow up appointments, consultant time can be freed up. There is a target in the 22/23 planning guidance asking trusts to reduce follow up outpatient appointments by 25% compared to a 19/20 baseline.
3. Diagnostic transformation – the expansion of community diagnostics hubs on cold sites across systems. Keeping diagnostic tests away from hospitals means there is less interruption by emergency care, fewer cancellations and it is easier to manage capacity. This follows Sir Mike Richards’ review of diagnostics.[5]
4. Expansion of surgical hubs (linked to the Getting it Right First Time Programme (GIRFT) programme[6]). There are 50 hubs due to open across England. The plan is for these to help manage high volume, low complexity cases, freeing hospital theatres to focus on more complex cases. They will also be cold sites and less affected by Covid-19 as there is no interruption by emergency care.
5. Managing waiting lists across provider collaboratives and systems – trusts are working together across systems to better manage their waiting lists. This can cover a range of things, including moving those waiting longest to trusts with shorter waits or trusts specialising in certain procedures carrying these out at higher volume and sharing the waiting lists over the whole system.
6. Mutual aid – trusts working together across and between systems. This has worked in several places, including trusts in the South West working with a trust in the East Midlands to help tackle the longest waits. Trusts can offer virtual appointments to help manage waiting lists or carry out procedures where patients are happy to travel.
7. Independent sector provision – commissioning the independent sector to carry out diagnostic and surgical procedures.
8. New technology and digital transformation – for some specialisms, new technology is changing how routine procedures are conducted or how patients are monitored at home.

The independent sector

23.   Trusts have mixed views about the use of the independent sector in tackling the waiting list. Firstly, private sector provision is not uniform across the country and therefore access to the independent sector isn’t always available. There is a concern that a reliance on the independent sector could further widen health inequalities as independent sector provision is more likely to be present in affluent areas.

24.   Independent sector procurement is carried out at both a national and local level. Where trusts do have local relationships with the independent sector, trusts have told us they would like to retain the abilities to contract what they need. However, there was a sense the NHS needs to treat the independent sector as a strategic partner with multi-year plans and not a short-term solution to cover winter cycles or Covid-19 backlogs.

25.   The role of the independent sector is limited in terms of what it can offer the NHS in tackling the backlog. Independent sector provision largely covers high volume, low complexity cases as most independent sector providers do not have intensive care capacity. Therefore, independent sector provision can only really accommodate low risk patients and focus on lower risk procedures. This means that the most complex cases will usually need to be provided by the NHS.

Health inequalities

26.   Within the elective backlog is an underlying picture of substantial inequality between those living in the most and least deprived areas. The Strategy Unit carried out analysis of the drivers of inequality in access to planned hospital care (May 2021)[7]. It found that rates of access to planned care overall are higher among those living in the most affluent areas. When adjusted for levels of need, however, activity was skewed towards the early stages of care pathways for the most deprived communities – for example primary care management – for each of four common conditions (chronic obstructive pulmonary disease, heart failure, arthritis of the hip and cataracts). Meanwhile, secondary care treatment including surgery was skewed towards the most affluent areas. The report notes that, in some cases, levels of emergency hospital spells and deaths in hospital are higher among those living in more deprived areas, suggesting that intervention earlier in the care pathway had not necessarily had the impact of reducing unplanned care.

27.   The report suggests that policies which may disproportionately impact those living in the most deprived areas include referral management and lifestyle-based eligibility criteria, while waiting time targets and patient choice policies, as well as NHS-funded access to private treatment, may have disproportionately benefited the least deprived populations.

28.   There is a section in the elective recovery plan relating to reducing health inequalities in the approach to tackling the waiting list. Trusts are considering how to restore their services equitably and take advantage of opportunities to reduce inequalities facing those from deprived backgrounds, minority ethnic groups, autistic people and people with learning disabilities, and other protected characteristics. This includes carrying out their own analysis of their waiting lists to identify disparities in access, outcomes and experience, and committing to narrowing these gaps through their prioritisation of their waiting lists. 

Early progress made in recovering services

29.   As set out above, trusts are making good progress on reducing the number of people waiting over 104 and 78 weeks. However, trust leaders are increasingly concerned they may not continue to meet the targets set out in the elective recovery plan due to the ongoing capacity and workforce constraints across health and care systems. Winter is a particular concern. Despite months of planning to expand capacity and implement NHS England’s winter plan[8], many trusts are fearful that spikes in emergency care demand, as well as high rates of flu and Covid-19, will mean they have no choice other than to cancel operations due to needing beds for critically ill patients.

30.   Issues with patient flow remain a challenge across health and care systems. Recent data from NHS England showed that, in October 2022, an average of 22,253 patients no longer met the criteria to reside in hospital and an average of 13,613 patients remained in hospital each day. This means an average of 60.1% of medically fit patients remained in hospital per day.[9] The driver continues to be social care provision not keeping up with demand, including at-home care packages and care homes. Gridlocked hospitals reduce available capacity for planned care and will remain a serious threat to the provider sector in continuing progress on backlog recovery.

31.   As highlighted by our surveys, trust leaders continue to report that workforce shortages are holding back recovery across all physical and mental health care services. Early progress made delivering national targets may be further interrupted this winter with industrial action for some nurses already confirmed to take place across the country with other professions balloting. Trust leaders are planning how to maintain services during industrial action and will prioritise emergency care, potentially impacting services for routine and planned care. NHS Providers has welcomed the chancellor’s commitment to publish an independent assessment of NHS workforce needs next year. As a next step, it is essential that this assessment is published in full with an explicit commitment to provide the necessary funding.

Case studies

32.   We have been collating a range of case studies highlighting where things are working well and where innovation is supporting trusts to recover services. Below are a handful of examples:

1. A podcast with King's College Hospital NHS Foundation Trust, Clive Kay, chief executive, and Ranjeev Bhangoo, head of neurosurgery, explains how the neurosurgery team is using extra theatre time and capacity to carry out 750 more operations a year for patients with time-critical brain tumours and spinal cord compression to prevent backlogs building. https://nhsproviders.org/providers-deliver-tackling-the-care-backlog
2. Digital innovation helping patients and staff across Northumbria. https://nhsproviders.org/nhs-activity-tracker-2022/november-2022
3. Surgical robot helping to cure patients with prostate cancer at Cambridge University Hospitals NHS Trust. https://nhsproviders.org/nhs-activity-tracker-2022/september-2022
4. Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust gastro surgical team have developed a care pathway for patients to help quicken diagnostic testing for certain types of cancer. https://nhsproviders.org/nhs-activity-tracker-2022/august-2022
5. Tackling backlogs across mental health, community and the ambulance service. https://nhsproviders.org/providers-deliver-tackling-the-care-backlog
6. The Black Country Provider Collaborative created two elective hubs for the system (north and south) to deliver almost all the elective orthopaedic activity across the Black Country to make better use of existing capacity so they can tackle their elective backlog more quickly. https://nhsproviders.org/media/694060/collabs-benefits-report-1e.pdf
7. The Clatterbridge Cancer Centre NHS Foundation Trust have been working alongside urgent care and cancer care partners as part of the Cheshire and Merseyside urgent cancer care board. The group supports appropriate and timely urgent care close to home with the goal of improving quality of care and patient experience. https://nhsproviders.org/providers-deliver-trusts-in-systems
8. Maidstone and Tunbridge Wells NHS Trust have eliminated 52-week waits for elective care, enabling them to support neighbouring trusts to address backlogs. https://nhsproviders.org/providers-deliver-trusts-in-systems

November 2022

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