NHS0038

 

Written evidence submitted by Versus Arthritis

 

 

  1. Versus Arthritis welcomes the opportunity to provide input into the Public Accounts Committee’s call for evidence for the inquiry ‘Managing NHS backlogs & waiting times’

 

  1. Versus Arthritis is the charity formed by Arthritis Research UK and Arthritis Care joining together. We work alongside volunteers, healthcare professionals, researchers, and friends to do everything we can to push back against arthritis. Together, we develop breakthrough treatments, campaign for arthritis to be a priority and provide support for people living with Arthritis and musculoskeletal conditions and their parents and carers. Our remit convers all musculoskeletal conditions which affect the joints, bones and muscles including osteoarthritis, rheumatoid arthritis, back pain, and osteoporosis.[1]

 

  1. Arthritis and related musculoskeletal conditions affect 20.3 million people in the UK[2] and are the single biggest cause of pain and disability in the UK. Cumulatively, the healthcare costs of osteoarthritis and rheumatoid arthritis will reach £118.6 billion over the next decade.[3] In 2020 Musculoskeletal (MSK) conditions accounted for 15.4% of sickness absences[4] and in 2019 28.4M working days were lost due to MSK conditions.[5]

 

  1. For people with arthritis, waiting for joint replacement surgery can have a devastating impact on their lives. People live with often high levels of pain, their mobility can be substantially reduced and as highlighted above, others are forced to leave work because of their condition. It is therefore vital that waiting times are reduced so people with arthritis do not spend long periods of time with their quality of life significantly lowered.

 

  1. This submission addresses the following themes outlined in the call for evidence including:

 

 

  1. Summary points:

The design of national recovery plans

Ringfencing of elective care

  1. Versus Arthritis continue to call for the ring-fencing of orthopaedic beds and staff to maintain elective capacity levels to tackle long waiting lists. The main means by which this can be achieved is through the surgical hubs model. Surgical hubs provide an effective way of providing high volume low complexity surgery, as previously recommended by the Royal College of Surgeons of England[6], with particular emphasis on specialties like orthopaedics.

 

  1. Given this, Versus Arthritis also welcomed the announcement[7] of over 50 new surgical hubs which will provide at least 100 more operating theatres and over 1,000 beds. It will also deliver almost 2 million extra routine operations to reduce waiting lists over the next 3 years.

Support for people travelling for travelling surgery

  1. Alongside the ringfencing of elective care there also needs to be a package of support for people with arthritis who require joint replacement surgery. This includes those who will have to travel out of area for their surgery. Based on polling by YouGov and Versus Arthritis[8] in April 2022, people with osteoarthritis in England are likely to be willing to travel for their surgery if they are supported to do so. 91% are willing to travel for surgery, 43% are willing to travel within their region/county for surgery although it should be noted that only 11% are willing to travel nationwide.

 

  1. As part of the aforementioned polling, there were several comments that people with osteoarthritis made about decisions relating to travel for surgery including:

 

  1. In addition, a Versus Arthritis survey in September 2022 found that 17% of respondents said that they (or the person they know/care for) are finding it more difficult to travel to health appointments compared to this time last year[9]. Given this, for those who are willing to travel for surgery, trusts should offer personalised support to allow them to travel, such as financial support, or travel assistance.

 

  1. There is also a cohort who are unable to travel at all due to their condition. In the polling 4% of people stated they would not travel for surgery.[10] For those who were only able to travel very short distances, the following reasons were given:

 

  1. For those who cannot travel, timely access to treatment and surgery must be offered locally in line with their legal rights. People should not be disadvantaged due to their inability to travel to surgical hubs in other geographical areas. Likewise people should not be penalised for their inability to pay upfront for any transport costs. Ultimately, people should not have to choose between paying their essential bills and their transport costs to attend a hospital outside of their local area.

Communication for people waiting – My Planned Care Platform

  1. The My Planned Care website is a national patient communication platform created to empower people waiting for surgery by providing links to support offers and information on waiting times.

 

  1. In our 2022 survey[11] few people with osteoarthritis knew about the My Planned Care platform. Upon reading the survey description of the platform, people said the following:

 

  1. Of those who stated they are fairly or very likely to use it, 32% said it would be informative, while 18% said it would be helpful / useful. (N=603) Others suggested the platform should contain information on the following:

 

  1. Given this data Versus Arthritis recommends that NHS England should:

Potential for digital exclusion

  1. The My Planned Care platform will be the main conduit used by NHSE to empower patients with information regarding their treatment and surgery. To avoid health inequalities related to digital exclusion, there needs to be consideration for those unable to get online or without the digital skills to effectively use the Platform. While the My Planned Care Platform is a useful digital tool to empower patients, it must not replace face to face support offers. People waiting for surgery should be entitled to copies of this information in a range of accessible formats, including print.

Further support for people’s physical and mental health

  1. Versus Arthritis has been calling for personalised self-management support to be provided to people as they wait for surgery. Therefore, physical activity programmes designed to help people with arthritis stay active and prepare for surgery should be actively promoted and practical advice on how to manage pain or fatigue while exercising should be provided by all healthcare professionals supporting people with arthritis.

 

  1. Versus Arthritis has been calling for mental health support to be offered to help every person with arthritis to manage their pain and any associated depression and anxiety. Living with chronic pain such as that caused by osteoarthritis is linked to low mood and anxiety. Depression is four times more common amongst people in persistent pain compared to those without pain.[12]

 

  1. This approach to personalised self-management support is outlined in Versus Arthritis Joint Replacement Support Package[13]. This is a six-point package that local health systems should provide to those waiting for joint replacements. It is not intended to be a substitute for joint replacement surgery, but an important resource to ensure patients receive the holistic care and support they need while waiting for their operation. The self-management support measures recommended in our Support Package report could also help to reduce the demand and need for joint replacement surgery in future years by preventing MSK symptoms developing to a point where treatment is required.

Implementation of the recovery plans, including the use of independent sector providers

Use of the independent sector

  1. The contribution of independent sector providers (ISPs) in delivering NHS-funded care has rapidly grown over time. Analysis from the Institute for Fiscal Studies (IFS) suggests that ISPs provided approximately 386,800 NHS-funded elective episodes in 2020-21 – or approximately 5.2% of all NHS elective activity. This trend has also been observed across trauma and orthopaedics. In 2016-17, approximately 29% of knee and 20% of hip replacements were delivered by ISPs, up from 20% and 14% respectively in 2012-13.[14]

 

  1. NHS England’s Elective Recovery Plan states, that systems will incorporate local independent sector capacity as a core element of elective recovery plans to deliver improved outcomes for patients and reduce waiting times sustainably.[15] Versus Arthritis believes that the independent sector has a role to play in addressing the elective care backlog. However, it’s important to note the impact the use of the independent sector can have in creating or exacerbating health inequalities.

 

  1. The distribution and concentration of ISPs is critical in terms of shaping health inequalities. Where provision is higher, for example in the South East, this additional capacity could potentially see waiting lists and backlogs in NHS care tackled more rapidly. In contrast, those areas with a smaller ISP presence, particularly in more rural areas, are unlikely to be able to rely on this ‘expansion’ of capacity.[16]

 

  1. There are notable regional differences in the use of ISPs for NHS care across England. Although independent hospitals are present across the country, there is an uneven distribution of providers willing and able to provide treatment for publicly funded patients.[17] Moreover, there are further geographical variations in the types of procedure carried out for the NHS. ISPs in the East Midlands and the South East are responsible for delivering over 40% of NHS-funded hip replacements, compared to just one in 10 (11%) in London.[18]

 

  1. It has also been suggested[19] that ISPs are able to cherry-pick who to treat. Many ISPs do not have facilities for emergency care or staffing arrangements to deal with complex patients, and so those who have more complex surgery or are at higher risk (owing for example to having multiple long term conditions) may not be able to have their surgery undertaken by the independent sector. This means that those patients with complex needs and/or morbidities may only be able to be treated for their joint replacement surgery on the NHS.

 

Orthopaedic workforce issues

  1. A British Orthopedic Association study found that in August 2021[20], trauma and orthopaedic consultants and specialty and associate specialist surgeons in the NHS were not yet back to their pre-pandemic number of operating lists per week. On average they reported doing 28% fewer sessions of elective operating (from average of 2.5 pre-pandemic to 1.8 per week).

 

  1. Recruitment into orthopaedics has been an issue in recent years which has aligned with the major changes to medical school curricula. There has been an increased allocation for primary care and community placements, while surgical specialties such as orthopaedics have occupied a much smaller percentage of the curriculum. There has also been a significant reduction in the proportion of junior doctors, following completion of their foundation training, who are entering specialty training directly. In 2018, this figure was 37.7% – a stark contrast to 2011 when 71.3% entered specialty training straight away. [21]

 

  1. As well as a lack of people entering the orthopaedic workforce there is also increasing retirement rates. As of August 2021 a quarter of consultants over 45 intend to retire in the next three years, which is double the rate seen in a 2019 survey by the Royal College of Physicians, in which 12% of consultants over 45 intended to retire in the subsequent 3 years.[22] Changes to the pension tax regime have exacerbated concerns regarding the future surgical workforce with many senior surgeons reducing their hours, declining extra sessions, and some even considering early retirement to avoid facing higher tax bills on their pensions.

 

  1. Finally, there is concern about the observed levels of fatigue, burnout and low morale in surgical teams who have been frequently redeployed for extended periods to ITU and Covid wards during the pandemic. [23]

 

  1. The issues of recruitment and attracting the workforce into trauma and orthopaedics and losing the existing workforce to retirement have the potential to create a perfect storm which will make elective recovery more difficult.

Winter pressures

A 2022 survey of members of the NHS confederation, found that with “many metrics this summer looking far worse than a usual winter, there are clear signs that this winter will be the most challenging the service has ever faced.[24] One member told them that preparing for winter is ‘all consuming’ and they are already concerned about how they are going to meet their six targets.

 

  1. In addition, a report[25] released in November 2022 found that doctors and nurses are “absolutely frightened and petrified” about how bad this winter will be for the NHS in England:

 

  1. These impacts on the NHS this winter are only going to add to the challenges in bringing down the number of people waiting for surgery.

 

Early progress/challenges in recovering services.

Success on two year waiters

  1. The target[26] to eliminate the longest waits of over two years in England (excluding when the wait is the patient’s choice) by July 2022 was successful and integral in ensuring those longest waiters received the survey they required. They were not eliminated by the end of July, but the number was reduced to 3,000, having stood at 22,000 in January.[27] This success was echoed for people waiting for T&O surgery where, as of September 2021, 800 people (0.1%) on the waiting list were waiting longer than 104 weeks/two years. This was a monthly decrease of 16% compared to the previous month and down from 5,528 people in January 2022. [28]

Remaining long waiters

  1. Despite the success on bringing down 2 year waiters, the focus on this cohort has led to other parts of the waiting list growing. In September 2022, 60,812 people (8%) on the waiting list for T&O treatment were waiting longer than 1 year. [29] This was higher than the rate seen in February 2022 (56,902). There are clear tradeoffs when deciding how to bring waiting lists down.

 

  1. There is also the size of the overall waiting list which still remains at an all-time high. As of September 2022, 792,277 people in England are waiting for T&O treatment, this is a 1% increase since the previous month and around 51% higher than the average number of people waiting in 2019. [30] In addition, there remain 349,490 people (44%) waiting longer than 18 weeks. This contravenes the NHS Constitution which sets out that patients should wait no longer than 18 weeks from GP referral to treatment. [31]

 

  1. These persistent waiting lists also continue to face new and rising pressures. In September 2022, 157,215 people were added to the T&O waiting list.[32]

Number of people still paying out of pocket

  1. Research from Versus Arthritis[33] shows that the cost of accessing private surgery is hitting people on lower incomes the hardest. Most people who received joint replacement surgery did so using NHS services. However, as long waiting lists persist a minority of people chose to pay privately.

 

  1. The research[34] found that those on lower incomes (in categories C2DE - skilled manual occupations; semi-skilled or unskilled workers) were more likely to pay out of pocket, whilst those on higher incomes (ABC1 categories - upper managerial; middle managerial; supervisory or clerical roles) were more likely to pay using private health insurance. This further highlights a disparity in to the use of private surgery a greater financial burden for those on lower incomes.

Impact of cost of living

  1. The cost of living crisis has arisen alongside record waiting times for surgery emerging from the pandemic. Therefore, people with arthritis will be facing the added costs of waiting for surgery and managing their condition alongside the rising cost of living. It is also likely that the cutbacks people have to make to afford their cost of living will impact their health.

 

  1. In a survey of 3873 people with arthritis or MSK conditions (and those close to them) in September 2022[35], 20% of respondents (or someone they know/care for) were waiting for joint replacement surgery. Of those waiting, 36% had been waiting more than 2 years and 9% have been waiting more than 5 years.

 

  1. Other findings illustrated the clear impact the cost of living will have on people’s condition:

 

  1. These are tangible cutbacks people are having to make to the essentials needed to keep them healthy, which will have a severe impact on their arthritis. This will only increase the future need on T&O waiting lists.

[1] About Us. Versus Arthritis. Available here: https://www.versusarthritis.org/about-us/

[2] (Global Burden of Disease Collaborative Network (2020). Global Burden of Disease Study 2019 (GBD 2019) Results. Institute for Health Metrics and Evaluation (IHME), Seattle.)

[3] York Health Economics (2017). The Cost of Arthritis: Calculation conducted on behalf of Arthritis Research UK.

[4] (Office for National Statistics. (2021). Sickness absence in the UK labour market 2020. Accessed here: https://www.ons.gov.uk/employmentandlabourmarket/peopleinwork/labourproductivity/articles/sicknessabsenceinthelabourmarket/2020

[5] (Office for National Statistics. (2021). Sickness absence in the UK labour market 2020. Accessed here: https://www.ons.gov.uk/employmentandlabourmarket/peopleinwork/labourproductivity/articles/sicknessabsenceinthelabourmarket/2020)

[6] Royal College of Surgeons (2022) The case for surgical hubs. Accessed here: https://www.rcseng.ac.uk/about-the-rcs/government-relations-and-consultation/position-statements-and-reports/the-case-for-surgical-hubs/

[7] UK Government (2021). Over 50 new surgical hubs set to open across England to help bust the COVID-19 backlogs. Accessed here: https://www.gov.uk/government/news/over-50-new-surgical-hubs-set-to-open-across-england-to-help-bust-the-covid-backlogs

[8] Versus Arthritis (2022). Elective Recovery Plan Survey. Available upon request

[9] Versus Arthritis (2022). Cost of living survey. Available upon request

[10] Versus Arthritis (2022). Elective Recovery Plan Survey. Available upon request

[11] Versus Arthritis (2022). Elective Recovery Plan Survey. Available upon request

[12] Kleiber B, Jain S, Trivedi MH (2005).  Depression and pain: implications for symptomatic presentation and pharmacological treatments. Accessed here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3000181/#:~:text=Worldwide%2C%2022%20percent%20of%20all,patients%20who%20are%20pain%2Dfree.

[13] Versus Arthritis (2021). Joint Replacement Support Package. Accessed here: https://www.versusarthritis.org/campaign-with-us/joint-replacement-support-package/

[14] IFS (2019). Recent trends in independent sector provision of NHS-funded elective hospital care in England. Accessed here: https://ifs.org.uk/uploads/BN268-Recent-trends-in-independent-sector-provision-of-NHS-funded-elective-hospital-care-in-England1.pdf

[15] NHS England (2022). Elective Recovery Plan. Accessed here: https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2022/02/C1466-delivery-plan-for-tackling-the-covid-19-backlog-of-elective-care.pdf

[16] Health Foundation (2020). Elective care in England - Assessing the impact of COVID-19 in 2020 and where next. Accessed here: https://www.health.org.uk/publications/long-reads/elective-care-in-england-assessing-the-impact-of-covid-19-and-where-next

[17] Health Foundation (2020). Elective care in England - Assessing the impact of COVID-19 in 2020 and where next. Accessed here: https://www.health.org.uk/publications/long-reads/elective-care-in-england-assessing-the-impact-of-covid-19-and-where-next

[18] IFS (2019). Recent trends in independent sector provision of NHS-funded elective hospital care in England. Accessed here: https://ifs.org.uk/uploads/BN268-Recent-trends-in-independent-sector-provision-of-NHS-funded-elective-hospital-care-in-England1.pdf

[19] NEF (2014). The wrong medicine A review of the impacts of NHS reforms in England. Accessed here: https://neweconomics.org/uploads/files/295a135f8d05864461_87m6iyt2s.pdf

[20] BOA (2021) Workforce Survey – August 2021. Accessed here: https://www.boa.ac.uk/policy-engagement/workforce-surveys.html

[21] BOA (2021) Workforce Survey – August 2021. Accessed here: https://www.boa.ac.uk/policy-engagement/workforce-surveys.html

[22] BOA (2021) Workforce Survey – August 2021. Accessed here: https://www.boa.ac.uk/policy-engagement/workforce-surveys.html

[23] BOA (2021) Workforce Survey – August 2021. Accessed here: https://www.boa.ac.uk/policy-engagement/workforce-surveys.html

[24] NHS Confederation (2022). Analysis: the latest statistics on NHS England’s six key metrics for winter. Accessed here: https://www.nhsconfed.org/articles/analysis-latest-statistics-nhs-englands-six-key-metrics-winter

[25] Guardian (2022). NHS staff ‘petrified’ of how bad winter will be at hospitals in England Accessed here: https://www.theguardian.com/society/2022/nov/15/nhs-staff-petrified-bad-winter-hospitals-england

[26] NHS England (2022). Elective Recovery Plan. Accessed here: https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2022/02/C1466-delivery-plan-for-tackling-the-covid-19-backlog-of-elective-care.pdf

[27] NHS England (2022). Consultant-led Referral to Treatment Waiting Times Data 2022-23. Accessed here: https://www.england.nhs.uk/statistics/statistical-work-areas/rtt-waiting-times/rtt-data-2022-23/

[28] NHS England (2022). Consultant-led Referral to Treatment Waiting Times Data 2022-23. Accessed here: https://www.england.nhs.uk/statistics/statistical-work-areas/rtt-waiting-times/rtt-data-2022-23/

[29] NHS England (2022). Consultant-led Referral to Treatment Waiting Times Data 2022-23. Accessed here: https://www.england.nhs.uk/statistics/statistical-work-areas/rtt-waiting-times/rtt-data-2022-23/

[30] NHS England (2022). Consultant-led Referral to Treatment Waiting Times Data 2022-23. Accessed here: https://www.england.nhs.uk/statistics/statistical-work-areas/rtt-waiting-times/rtt-data-2022-23/

[31] NHS England (2022). Consultant-led Referral to Treatment Waiting Times Data 2022-23. Accessed here: https://www.england.nhs.uk/statistics/statistical-work-areas/rtt-waiting-times/rtt-data-2022-23/

[32] NHS England (2022). Consultant-led Referral to Treatment Waiting Times Data 2022-23. Accessed here: https://www.england.nhs.uk/statistics/statistical-work-areas/rtt-waiting-times/rtt-data-2022-23/

[33] Versus Arthritis (2022). Elective Recovery Plan Survey. Available upon request

[34] Versus Arthritis (2022). Elective Recovery Plan Survey. Available upon request

[35] Versus Arthritis (2022). Cost of living survey. Available upon request

 

 

November 2022