Written evidence submitted The Health Foundation
The Health Foundation is an independent charity committed to bringing about a healthier UK population, supported by high quality healthcare that can be equitably accessed. Its work includes providing grants to those working on the front line and carrying out research and policy analysis.
To support the Public Accounts Committee’s Inquiry on Managing the NHS backlog and waiting times, we are sharing our recent analysis and research that will provide useful context for the Committee when it questions officials from NHS England and the Department for Health and Social Care, on Monday 28 November.
Our short submission draws on two areas of recent research:
• Findings from our recent round of public polling which explore the public’s view of how to tackle the care backlog
• Analysis of the role of the independent sector in tackling waiting times
The NHS faces the daunting task of recovering the backlogs of care exacerbated by the impact of the COVID-19 pandemic. In particular, the elective waiting list currently stands at over 7 million. As part of the Government’s elective recovery plan, the NHS committed to increase elective activity by 30% compared to pre-COVID activity, and to make greater use of independent sector healthcare providers (ISPs). However, as of September 2022, activity is yet to consistently exceed pre-pandemic levels.
There are pressures across other services too, with performance in areas including cancer treatment, A&E waiting times and ambulance response times all below key targets. Meanwhile, referrals to community and mental health services have risen markedly and despite the number of appointments in general practice exceeding prepandemic levels, increasing numbers of people report poor experiences of accessing primary care.
In the Autumn Statement on 17 November, the Chancellor promised a further £3.3 billion for the NHS in each of the next two years, meaning a real terms increase of 2% on average, higher than planned last year. However, while the top up to the Spending Review settlement is welcome, the healthcare sector is going to face a difficult period ahead, given a range of pressures from higher inflation, rising demand The Health Foundation: Written evidence submission, Managing the NHS backlog and waiting times and ongoing costs from COVID 19, staff shortages and challenging efficiency requirements.
Whether the NHS has the resources it needs to address the backlog remains to be seen but it is right that the NHS and the Government have made tackling it a priority. In September, we published new polling in partnership with Ipsos about the public’s views on how to manage the backlog. The findings show that tackling the waiting list, as well as supporting and building the NHS workforce, are top priorities for the public. The polling also explored public opinion on the use of the independent sector in tackling waiting lists. We found that the public is split on whether the NHS should be paying for more patients to be treated in private hospitals. While 39% supported this measure, even if this means taking away budget from other areas of the NHS, 34% opposed it.
We also have analysis that we published in July, looking at the role of the independent sector in delivering NHS-funded elective care between April 2018 and March 2022. Before the pandemic, ISPs delivered around 12% of total NHS-funded planned treatments requiring hospital admission and 7% of outpatient treatments. As of March 2022, the share of care delivered by ISPs was higher than it was before the pandemic. For care requiring hospital admission, the volume of ISP provided care grew by 9%, equating to an increase in share from 12% to 16%. At the same time, the total number of NHS and ISP provided treatment was 14% lower. Therefore, overall activity levels had yet to reach the numbers required to enable the NHS to tackle the backlog.
Also, despite the increase in the overall share of care delivered by ISPs since June 2021, the increase had not been across all types of care it delivers. For example, whilst the share of NHS-funded ophthalmology care delivered by ISPs increased from 18% to 34%, for gastroenterology care the share fell from 20% to 14%. This raises questions that the Committee may like to explore, such as whether the increased use of ISPs is serving to limit waiting list growth or whether it is actually showing displacement of activity from NHS provided services to independent ones.
In September, we presented findings from the second survey in our programme of research into public perceptions of health and social care, delivered in partnership
with Ipsos, about what approaches they support for managing the current backlog, which we hope will support the Committee when they question officials about the design of national recovery plans.
We found strong public support for giving patients better information about how long they will wait (93%), more choice over their place of treatment (89%) and more practical support while they wait (86%). People were more split on the NHS making more use of the independent sector to address the elective backlog. While the main milestones set by government and NHS England focus on reducing very long waits, the public favours prioritising treatment based on urgency rather than length of wait.
Below is a more detailed breakdown of the public’s responses to our survey question, to what extent do you support or oppose each of the following approaches to managing the current backlog?
Priorities for diagnosis and treatment
• 81% support prioritising the treatment of patients who are most urgent, even if other patients have waited longer.
• 74% support diagnosing all patients as quickly as possible, even if some may then wait longer for treatments.
• 54% support a maximum waiting time for any procedure or treatment, regardless of what the procedure is or how urgent it is.
• 17% support prioritising treatment of patients who have waited longest, even if other patients are more urgent.
Measures for addressing the backlog and supporting patients
• 93% support giving patients better information about how long they will wait.
• 89% support giving patients more choice over where they are treated, for example, the option of being treated in a hospital in their local area if there is a shorter wait.
• 86% support giving patients more practical support while they wait, for example, how to manage their condition at home.
• 39% support paying more for NHS patients to be treated in private hospitals, even if this means taking away budget from other areas of the NHS. However, 34% opposed this and 24% said neither support nor oppose.
In July, we published analysis looking at the role of the independent sector in delivering NHS-funded elective care between April 2018 and March 2022, which we hope will be helpful to the Committee when it scrutinises officials about implementation of the recovery plans and the use of independent sector providers.
ISPs have been contributing to the delivery of NHS-funded elective care since the early 2000s. Around 250 ISPs provide elective care at Independent Sector Treatment Centres (treating only NHS-funded patients) or private hospitals.
ISPs of NHS-funded care differ from NHS providers in several ways. First, while most providers across the NHS and independent sector provide care that covers multiple specialties, ISPs tend to cover a narrower range. For example, around one in four (23%) independent sector providers of NHS-funded care cover only ophthalmology. Second, these providers are not evenly distributed across the country, they are mainly concentrated in London and the North West of England.
As of March 2022, for admitted care, where people are admitted to hospital for treatment (either as inpatients, or day-admission cases), NHS providers and ISPs’ combined numbers of treatments started had not returned to pre-pandemic levels, but the proportion of treatments delivered by ISPs had stabilised at a higher level than before the pandemic (an average of 16% between June 2021 and March 2022 compared with an average of 12% in the pre-pandemic period). In the period between June 2021 and March 2022, the average number of NHS providers and ISPs combined monthly treatments was 14% lower than the pre-pandemic level. For NHS-provided care it was 17% lower, while for ISPs it was 9% higher.
For non-admitted care, where people are not admitted to hospital, but instead receive treatment via outpatient clinics (for example), which accounted for around four times more activity than admitted care, this pattern is not repeated. Overall volumes had largely recovered, which is unsurprising as a greater share of nonadmitted care can be provided remotely or via outpatient clinics. The proportion of treatments delivered by ISPs was also similar to pre-pandemic levels, at 7%, and much lower than for admitted care.
This suggests that, as of March 2022, overall activity levels, especially for admitted treatments, had yet to reach the numbers required to enable the NHS to tackle the waiting list which continues to grow. And as our polling shows, the public is split on whether the NHS should be paying for more patients to be treated in private hospitals.
The independent sector, however, is responsible for a higher proportion of admitted treatments than pre-pandemic. Given activity levels are not where they need to be and the public’s scepticism, this requires further scrutiny. Could the increased proportion of treatments being delivered by the independent sector be helping to limit waiting list growth, by delivering care that otherwise could not be delivered by the NHS? Or does this represent displacement of activity from the NHS to the independent sector? In the context of value-for-money concerns about the use of the independent sector raised by NHS England, and the ongoing disruption to elective care being caused by COVID-19, this is important.
 Waiting for NHS hospital care: the role of the independent sector, The Health Foundation, 28 July 2022
 Public perceptions of health and social care: what the new government should know, The Health Foundation, September 2022
 Based on Consultant-led Referral to Treatment pathways in 2021/22.