Written evidence submitted by NHS Providers (CBP0027)

 

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

 

 

 

What is the anticipated size of the backlog and pent-up demand from patients for different healthcare services including, for example, elective surgery; mental health services; cancer services; GP services; and more widely across the healthcare system?

  1. It is currently difficult to anticipate the true size of the backlog as the impact of COVID-19 on NHS waiting times is still emerging. The number of people waiting for NHS treatment in England rose to 5.45 million by August 2021 – the highest figure since records began a decade ago.[1] There was also a sharp drop in the number of referrals during the pandemic, and it is currently unknown how many of these referrals will ‘bounce back’[2], and what the impact of COVID-related care will be on referrals. However, it is becoming increasingly clear that the scale of the backlog – across the acute, community and mental health sectors – is very concerning. Tackling the problem will take significant time and resources, with the worst affected trusts reporting that it could take three to five years to clear the backlog.
  2. Trust leaders are reporting that their organisations are facing the toughest pressures they have ever known. Frontline NHS staff are working tirelessly to reduce the backlog of care and planned care activity continues to increase. Looking at the acute sector, as of August 2021, the number of referrals for elective care is exceeding capacity and the number of people waiting over 52 weeks has increased by 503% compared to a year ago.[3] The size of the waiting list in August 2021 is 41.3% greater than the same month a year ago during the first wave of the pandemic and 24.1% greater than two years ago before the pandemic.[4]
  3. Mental health trusts are facing growing demand, often with increased acuity and complexity, with the pandemic having a clear and significant impact. The number of people in contact with mental health services has grown steadily in recent months, and in August 2021 the number of people being referred for mental health services increased by 12.4% compared to the same month the previous year.[5] The current waiting list for mental health services stands at 1.6 million. In an NHS Providers survey carried out in May 2021, 78% of mental health trust leaders said they are extremely (47%) or moderately (31%) concerned about the ability of their trust or local system(s) to meet the level of anticipated demand within the next 12-18 months for mental health care amongst children and young people. All mental health trust leaders surveyed said that the demand they are experiencing for children and young people services is significantly (80%) or moderately (20%) increasing compared to six months previously.[6]
  4. Prior to the pandemic, the demand mental health trusts were facing for their services was already far outstripping their capacity, despite the substantial progress made in recent years with new services and higher levels of investment.[7] This makes current trends all the more concerning as the mental health consequences of the last 18 months are likely to be present for longer and peak later than the COVID-19 pandemic itself.
  5. A November 2020 report by the Strategy Unit hosted by Midlands and Lancashire Commissioning Support Unit estimated a 33% increase in mental health demand over the next three years, with the next 9 months particularly demanding on services.[8] We have also heard from mental health trust leaders that they will need to factor in a new and unknown level of mental health need as a result of the pandemic. Meeting this on top of existing demand in the new COVID-19 context will be complex, difficult and challenging, and in the absence of increased staffing and funding, will require prioritisation.
  6. With the next phase of the pandemic focusing on rehabilitation and recovery, community service providers are expecting an increase in demand, with some providers anticipating that waiting lists will take months to clear. By May 2021, the number of people waiting longer than a year for their care reached 340,000 – a 200-fold increase on pre-pandemic levels. This will create increased demand as community teams will need to support more people waiting for hospital care, and more people through rehabilitation and reablement services after receiving care.[9] The impact of long COVID will add to this demand. Community providers have also raised particular concerns about the anticipated rise in demand for children's services after a substantial fall in referrals during the pandemic.

What capacity is available within the NHS to deal with the current backlog? To what extent are the required resources in place, including the right number of staff with the right skills mix, to address the backlog?

  1. The pandemic has exacerbated the mismatch between capacity and demand that already existed. In addition to the research NHS Providers conducted with mental health trust leaders which showed demand is increasing, national performance and activity data for mental health and physical health services shows rising demand and lengthening waiting times for services. For example, in July 2021 the most serious 999 category 1 calls for an ambulance increased by 32% compared to July 2019 before the pandemic with waiting times falling to the worst on record since the new ambulance standards were introduced in 2017.[10] Similarly, pressure across the urgent and emergency care pathway over the summer has once again shown that demand is outstripping capacity. The NHS struggled with capacity before the pandemic often running at over 95% in the winter months. However, the NHS has around 5,000 fewer beds than it did two years ago as a result of increased infection control measures.[11] Trust are also cohorting services, splitting them into COVID-19 and non-COVID-19 areas. This further reduces the capacity available to trusts who no longer have as flexible a bed base to allocate to patients. This is particularly important when addressing the backlog as trusts need COVID free capacity available to manage cancer and elective care patients as well retaining enough capacity for non COVID-19 emergency patients.
  2. It is clear that the right resources are not yet in place to address the backlog. The speed of recovering the backlog will significantly be determined by the amount of investment the NHS receives to increase capacity and address pinch points such as the significant demand for diagnostics and children and young people’s mental health services for eating disorders.  Workforce challenges and physical capacity are the key rate limiting factors – and these will differ across specialities and sectors. It is currently difficult to determine how these factors interact and which will be the greater problem until trusts have clarity on the full plan for addressing the backlog and the amount of investment available to them.
  3. Trusts are working hard to clear the backlog of care that built up during the pandemic. In national guidance, they were asked to work at 70% of pre-pandemic levels of operations from April 2021 with a 5% increase each month.[12] Yet trusts have been working faster and are carrying out 90% of activity against the 2019 baselines[13] despite the challenges from growing numbers of COVID-19 hospital admissions, record high levels of demand for urgent and emergency care, and the service entering peak summer leave season – the impact from which is expected to be significantly higher this year given the amount of leave which has been held over from previous COVID-19 waves. In June, the NHS carried out 84,000 more diagnostic tests than the previous month, checked 230,000 people for cancer and reduced the number of people waiting for surgery for more than one year by 32,000.[14]
  4. At the same time, trusts are facing considerable capacity staffing constraints and uncertainties. The service entered the pandemic with over 100,000 workforce vacancies. Now, the NHS workforce is exhausted and overstretched having worked flat out throughout the pandemic. In a June 2021 survey, half of trust leaders reported concerns about the levels of staff leaving their organisations due to early retirement, burnout, or the impact of working in a pandemic.[15] In addition, as COVID-19 community infection rates have been rising, increasing numbers of staff have needed to self-isolate, creating additional strain on the staff still able to work. Trust leaders have told us that exhausted staff are also, understandably, less willing to take on bank shifts to cover this extra work, which increases the cost of payment for these shifts to either encourage existing staff to take them on or to bring in external locums. NHS sickness absence data showed that, as of 4 August, there were 73,850 staff absences in total, 24% of which were COVID-related absences.[16] Retention of NHS staff is central to tackling the backlog of care and there needs to be a fully funded long term workforce plan.
  5. Trusts are facing the continuing loss of capacity as a result of the need to protect patients, service users and staff from nosocomial infection. According to the Health Service Journal, in May 2021, acute hospitals were having to operate on around 12% fewer beds than between 2015-19 due to adhering to social distancing guidance.[17] Trusts have had to create separate areas: red for COVID-19 patients, amber for patients waiting for test results, and green for non-COVID-19 patients, which has reduced capacity by up to 20% while planned surgery is slowed or disrupted by the time consuming need to don and doff personal protective equipment.
  6. It is also important when considering the scale of the backlogs and how trusts are tackling them to take into account the cumulative impact of the various factors at play. For example:
    1. Demand for urgent and emergency care reached record levels in June 2021 with many patients – who may otherwise have received care earlier – now presenting late or with more complex conditions leading to concerns that plans to clear the backlog of care risks being disrupted because of the need to prioritise demand for urgent and emergency care.
    2. Trusts are also concerned about the winter period which is expected to be particularly challenging due to a combination of the potential for another wave of COVID-19 infections and an expected spike in flu and other respiratory illnesses beyond usual seasonal levels. This would follow straight on the heels of a highly pressured summer.
    3. The ability of any given trust to address its care backlog will also vary due to a range of factors which may be specific to them, or beyond their control or their immediate ability to change, such as site configuration and the care needs of their local communities.

How much financial investment will be needed to tackle the backlog over the short, medium, and long-term; and how should such investment be distributed? To what extent is the financial investment received to date adequate to manage the backlog?

  1. Providing appropriate financial investment is crucial to reducing the care backlog. As an immediate next step, it is vital that the Government urgently confirms funding for the second half of the financial year (H2). Due to the uncertainties of COVID-19, NHS budgets have so far only been set for the first half of this financial year (H1). The decisions made on H2 funding will be a key determinant of the NHS’ ability to cope with the extreme set of pressures it is facing, including recovering care backlogs across hospital, mental health and community services, and responding to increased pressures on ambulance services.[18] 
  2. In the longer term, it must be recognised that the care backlog presents ongoing costs that will require continued funding. The Elective Recovery Fund (ERF) has helped acute trusts recover elective activity faster than expected and has been an important catalyst to reduce waiting times for patients.[19] However, most of the £1bn currently allocated to the ERF will be used up in the first half of the year. There are also care backlogs across mental health and community services. It is important that these trusts, as well as other primary care providers including general practice, can access appropriate funding. Taken together – the £2bn annual cost of the ERF, additional funds to tackle the backlogs in mental health and community care, and other estimates that have been made in recent weeks[20] – we believe this indicates a range of £2-4bn annually for the next three years. However, given the unpredictability set out above, it is vital that the level of investment required is kept under review.
  3. We anticipate that a detailed plan for tackling the care backlog will be finalised as part of the Spending Review, building on the significant amount of work already undertaken by NHS leaders nationally and locally. Trust leaders believe this is the right timing as we will know what funding will be available and how it will be phased. We will be able to draw on the lessons of the accelerator sites[21], which will give a clear idea of where investment impact can be maximised, and we will have some further evidence on the size of the referral bounce back.
  4. The plan will need to address a number of important issues:
  1. A tailored approach to the different challenges for each of the different areas of the backlog will be required. It is important to remember this is not only about elective and cancer backlogs and acute hospital services. There are significant backlogs and huge pressures in community and mental health services too. For example, children and young people’s eating disorder services
  2. Trusts are going to need to use innovative approaches, as well as ‘tried and tested’ methods new innovations will need to be appropriately funded
  3. Plans will need to address where investment should go – e.g. community diagnostics; overtime; temporary operating theatres; IS capacity; new technology
  4. Temporary capacity or permanent capacity expansion – there will be some temporary measures that are more relevant over the next 6-12 months, while others will need to be in place over the next 3 or more years
  5. What the target recovery trajectory should look like in terms of speed of recovery – targets will need to be realistic, taking into account system capacity and available funding
  6. Waiting lists will need to be managed proactively including identifying priority patients and finding alternative treatment approaches where appropriate
  7. How to manage backlog recovery in a way that maximises reduction of health inequalities - plans will need to consider the prioritisation of services/service user and population groups for greatest impact to help address inequalities. For example, considering the prioritisation of patients who historically have lower uptake of services
  1. Waiting times for NHS patients have been challenging before. The NHS tackled comparable waiting lists in the early 2000s. A key part of the solution was five successive years of 7%+ real terms increase in annual NHS funding. This is more than double current plans.[22]
  2. Furthermore, a holistic approach is required to ensure that the wider system is equipped to meet the challenges presented by the backlog. The discharge to assess model should be allocated dedicated funding on a permanent basis as it is crucial to continue recovering care backlogs at maximum speed.[23] Trust leaders have also highlighted their inability to access relatively small amounts of capital to speed up backlog recovery.[24] Trusts require an emergency injection of capital in this financial year, as well as an adequate multi-year settlement confirmed at the Spending Review.

How might the organisation and work of the NHS and care services be reformed in order to effectively deal with the backlog, in the short-term, medium-term, and long-term?

  1. In relation to the elective care backlog, there has been some initial progress via the accelerator sites[25] and/or systems working together to organise themselves differently. These include the use of hot and cold acute sites, creating surgical hubs across systems and provider collaboratives, and making better use of the capacity of the independent sector.
  2. However, it is clear that there is no one size fits all approach. The geography of a trust or system, the local population, the way estates are configured, and the given provider and system network are all key in determining what will work where. Therefore, how services can be reformed or redesigned will need to remain flexible and be tailored to the trust and system.

Hot and cold sites

  1. Some acute hospital trusts are configured in such a way that it has been possible to split their estate into hot and cold sites. This means that they have one site for COVID and emergency care activity (hot site) and another locality which they keep for planned care including elective surgery and sometimes cancer care (cold site). Configuring estates in this way enables trusts to better plan elective activity as the bed base is split and bed capacity is more protected from surges in urgent and emergency care.
  2. It is also worth highlighting that the type of elective surgery carried out on cold sites is likely to be the lowest risk and most routine surgery as often cold sites are without the intensive care facilities needed for a significant proportion of surgery. Therefore, this approach is not going to work for certain specialities.
  3. Although this approach is effective at helping trusts retain elective activity, this hot/cold site reconfiguration is not feasible across many trusts and is only possible where current estates and service configuration lend themselves to this split. Some trusts may only have one site, making this a non-starter. Across multi-site trusts, many factors need to considered including workforce availability, location of A&E, quality of estates, location of theatres and ICU, the local geography, and whether any additional capital funding is accessible.

Creating surgical hubs through system working and provider collaboratives

  1. System working and the emerging local provider collaborative structures are and will continue to be helpful vehicles to help tackle backlogs of care in a different way. Depending on the system and the provider landscape across the system, many are already working together to manage waiting lists across multiple trusts.  This allows trusts to work together to manage their elective care or bed capacity across systems, whilst ensuring they can prioritise the most urgent cases in both acute and mental health services. We know that trusts and systems are also factoring in how they are going to try to reduce health inequalities whilst tackling the backlog by looking at their waiting lists by different determinants of health such as ethnicity, social deprivation and learning disability.
  2. Systems and, increasingly, provider collaboratives are vehicles to reorganise services across different specialities and pathways. Some provider collaboratives have set up surgical hubs which aim to pool resources and to work collaboratively to deliver increased activity across different specialities, particularly high-volume pathways such as orthopaedics, ophthalmology, urology and ENT. Examples include the fast tracking of centralised surgical hubs across the five integrated care systems (ICSs) in London.

Better use of independent sector capacity

  1. Contracting for independent sector (IS) capacity is currently carried out at both local and national level. This means contracting can be complicated, however trusts have been clear in telling us they do not want to lose the regional and local relationships that are in place.

 

  1. Trust leaders felt that there is more to do to ensure the IS is considered a strategic partner. Requests for support can sometimes be too short term and at very short notice, for example over the winter period in 2019/20. Trust leaders felt there is an opportunity to address this, particularly given the current context and the size of the backlog. There is a need to work collaboratively with the IS as a key part of the solution over the next few years.

 

  1. It is important to note that IS capacity is not uniform across the country, with different levels of provision across regions.  In some areas of England there is no IS provision, so again this model cannot be seen as one size fits all solution.

 

  1. On the whole, IS provision is used for supporting certain types of NHS work, most commonly diagnostics or low risk operations. This is because the type of patient the IS can see is usually limited to less serious or less risky treatments. Most IS sites do not have emergency care/ICU facilities, which are often needed as a safety net to supplement more serious or complex operations/treatments. Given the geographic spread of IS services, there is also a concern that there is a concern that high use of the IS could potentially exacerbate health inequalities. Therefore, the IS should be viewed as part of the solution for very specific pathways and treatments and in some localities the IS will not be an option to help reduce the backlog in the most serious or urgent cases.

 

  1. Workforce considerations must also be applied to IS capacity. Members flagged to us that there is often some overlap between the NHS and IS workforce, particularly for consultations and diagnostic staff. Therefore, those planning NHS and IS resourcing must ensure they do not double count capacity. Similarly, any proposed national initiatives to tackle waiting lists, as well as trusts delivering care, will need to be mindful of the potential for staff burnout as this will apply to staff working in both sectors.

 

  1. Taking into account the considerations set out above, it is clear that the IS should be a strategic partner for addressing the backlog with longer term fully funded contracts in place to help provide trusts with more stability that allows them to plan activity.

Workforce changes

  1. It is important that the wellbeing of the NHS workforce is protected to ensure that there are enough staff to fill workforce gaps and to build flexibility into the system thereby allowing staff to manage the backlog effectively. The pandemic brought about rapid implementation of workforce flexibilities and innovations and it is important that these valuable developments are not lost after the pandemic. For example, the pandemic has shown the opportunities for joined up recruitment and workforce planning, and a more streamlined regulatory environment during the pandemic has facilitated rapid action and decision-making between different health and care organisations.
  2. Staff wellbeing is at the forefront of trust leaders' minds and the pandemic has brought about new approaches including:
    1. increases in the provision of counselling services, to support staff at this stage and in preparation for the longer-term effects of work-related trauma;
    2. the development of wellbeing teams and organisation-wide listening exercises, to ensure that leaders are addressing the most pressing issues for their workforce; and
    3. repurposing of empty spaces into places where staff can rest and access free hot drinks and food.

Long term funding is needed to ensure that these local wellbeing initiatives can be sustained.

  1. Recent changes to pension taxation rules have had an adverse effect on the NHS workforce over the past three years, with tax free annual and lifetime pension growth limits impacting senior managers, consultant doctors and other senior clinicians in particular. Following discussions with NHS Providers, the BMA, the NHS Confederation and other key stakeholders shortly after the 2019 general election, the government introduced new rules to raise annual thresholds and reduce the impact of the ‘taper’ on higher earners within the NHS pension scheme (and across the wider economy). The change to tax rules was a welcome development for senior clinicians and managers and served to mitigate the problem. However, it has not entirely resolved the disincentive for senior consultants, in particular, to work beyond minimum contracted hours while concerns persist around the impact of large one-off bills on senior staff taking promotions, and the effect of the unaltered lifetime allowance charges on retirement decisions for many clinicians and managers.
  2. Reports in recent months from the BMA[26] and Senior Salaries Review Body[27] have highlighted persisting concerns around the effect of pension tax issues on the NHS workforce and, crucially, trusts’ efforts to ensure adequate staffing and leadership capacity on an ongoing basis. The stakes are raised within an operating environment that demands a significant increase in senior clinical capacity – alongside continuity of effective leadership – to help clear the backlog caused by the pandemic. Concerns around an onset of early retirement across the workforce will also not be assuaged by continued speculation around further plans from the Chancellor to increase pension taxation in a number of ways.[28]

What positive lessons can be learnt from how healthcare services have been redesigned during the pandemic? How could this support the future work of the NHS and care services?

  1. The pandemic acted as a catalyst for change, in particular by enabling greater collaboration across the system to find better ways of working. This has resulted in significant achievements such as the creation of 33,000 extra beds early on in the pandemic. The NHS is accelerating whole system working, both horizontally at ICS level bringing together acute services, or community and primary care services, across a larger geographic footprint, and ‘vertically’ in place-based partnerships across community services, mental health, primary care and local acute services, as well as other partners such as local authorities and the voluntary sector.
  2. It is important to note how COVID-19 has highlighted and exacerbated health inequalities across the country, with the most disadvantaged being hardest hit by the pandemic. This focus on inequalities provides an opportunity for trust leaders to contribute to a lasting change in how inequalities in care are understood, acknowledged and dealt with across the health service as it recovers from the pandemic. Together with national NHS leaders, trusts are taking concerted action on the inequalities faced by those from deprived backgrounds, minority ethnic groups, people with autism and people with learning disabilities, and other protected characteristics.  The Health and Care Bill makes provision for the secretary of state to delegate the exercise of the Department’s public health functions to NHS England or an integrated care board, which we would hope will support better coordination and collaboration in delivery of these services.
  3. Collaboration has also strengthened between primary and secondary care during the pandemic. Here, we saw new approaches embraced, improved communications and shared information across organisations, and the adoption of digital transformation and new technologies. For example, at one trust GPs are able to request advice from consultants and send images relating to the request, which then enables consultants to make decisions, potentially avoiding the need for an initial outpatient consultation and as well as speeding up the patient journey. As providers across primary and secondary care increasingly work together in a range of new collaborative arrangements, new partnerships will be required to sustain and accelerate the drive to reduce the care backlog generated during the most disruptive days of the pandemic.

How effectively has the 111 call-first system for A&E Departments been? What can be done to improve this?

  1. The beginning of the pandemic saw more people arriving in A&Es, placing a significant strain on services and also increasing the risk of COVID-19 transmissions. Following the national rollout of NHS 111 First[29], several trusts have reported positive feedback from both patients and staff. For one ambulance trust, nearly, 43,000 appointments have been made using the 111 First service, avoiding the need for patients to wait in crowded A&Es. Another ambulance trust reported that the 111 First model has allowed them to manage patient flow during periods of increased activity which enabled the speeding up of access to care and one ambulance trust reported that as of May 2021, 27% of 111 patient referrals were managed without requiring attendance at A&E. 111 First has also worked effectively in conjunction with the clinical assessment service model (CAS)[30] and facilitated huge strides in the use of video patient consultations.[31]
  2. The ambulance sector is contributing substantially across a number of ICSs towards delivery of key NHS priorities in transforming care navigation and ensuring people are treated in the right place at the right time. As part of the evolving policy landscape relating to ICSs, ambulance trusts must be involved in regional, ICS and place-level decision making about service design, including defining what single point of access means in practice and over what size footprint. The ambulance sector has traditionally been at the forefront of digital developments, and it will require greater access to both capital and revenue funding in order to build upon the progress made during the pandemic, ensure smooth running of the whole system, and allow capacity to tackle the backlog.

What can the Department of Health & Social Care, national bodies and local systems do to facilitate innovation as services evolve to meet emerging challenges?

  1. As the government sets funding for the NHS for the next three years, it is vital that it listens to the needs of trusts and provides sufficient investment as outlined above. There also needs to be realistic expectations around the scale of the task ahead, and the resources and time needed to tackle it. Public expectations of what the NHS can achieve must be managed to avoid setting the NHS an impossible task and further impacting staff morale.
  2. Providing appropriate capital investment is crucial to facilitating innovation. The government must set an appropriate multi-year capital settlement, and reform the system for accessing and allocating capital, to tackle the care backlog recovery and transformation efforts, and ensure future resilience. The benefits that could be unlocked by an appropriate multi-year capital settlement are significant – for example, transforming and upgrading existing facilities, enhancing digital capabilities and expanding diagnostic capacity.

 

To what extent is long-covid contributing to the backlog of healthcare services? How can individuals suffering from long-covid be better supported?

  1. It is currently unclear how long COVID is contributing to the backlog of healthcare services as the extent and pattern of long COVID is still developing. We do know that community providers are facing new and often more complex demand arising from cases of long COVID, alongside increased demand for services more generally (the last year has seen a 15% increase)[32], rolling out the vaccination programme and working to recover services. We heard from one trust that one community-led assessment service has seen approximately 800 long COVID patients between January to July 2021 with a current waiting time of twelve weeks. There is also a knock-on impact on waiting times where patients have needed an onward referral and teams are already dealing with waiting list backlogs.
  2. Providers are facing the challenge of setting up a new service, where the clinical evidence is complex and evolving, on fixed term funding. The temporary workforce needed to deliver such a high-profile service is a risk not only to this service but other services where staff have been seconded and the substantive service cannot backfill. Longer term investment to support the delivery of long COVID services is needed, especially as community providers cannot access the ERF.

Sept 2021

12

 


[1] https://www.england.nhs.uk/statistics/statistical-work-areas/

[2] During the pandemic, there was a fall in the number of referrals as patients were not presenting to primary care as access was limited and patient behaviour changed. The demand at primary care is now returning although it is not known how much demand there will be.

[3] https://www.england.nhs.uk/statistics/statistical-work-areas/ 

[4] https://www.england.nhs.uk/statistics/statistical-work-areas/ 

[5] https://www.england.nhs.uk/statistics/statistical-work-areas/ 

[6] https://nhsproviders.org/resource-library/surveys/children-and-young-peoples-mental-health-survey

[7] https://nhsproviders.org/mental-health-services-addressing-the-care-deficit/the-demand-challenge

[8] https://www.strategyunitwm.nhs.uk/sites/default/files/2020-11/Modelling%20covid-19%20%20MH%20services%20in%20England_20201109_v2.pdf

[9] https://ifs.org.uk/publications/15557

[10] https://www.england.nhs.uk/statistics/statistical-work-areas/ambulance-quality-indicators/

 

[11] https://www.england.nhs.uk/statistics/wp-content/uploads/sites/2/2021/08/Beds-Timeseries-2010-11-onwards-Q1-2021-22-FTGYH.xls

[12] https://www.england.nhs.uk/publication/2021-22-priorities-and-operational-planning-guidance/

[13] https://www.england.nhs.uk/statistics/statistical-work-areas/ 

[14] https://www.england.nhs.uk/statistics/statistical-work-areas/ 

[15] https://nhsproviders.org/media/691644/nhs-providers-survey-on-operational-pressures-covid-19-winter-and-recovery-plans.pdf

[16] https://www.england.nhs.uk/statistics/wp-content/uploads/sites/2/2021/08/Covid-Publication-12-08-2021.xlsx

[17] https://nhsproviders.org/news-blogs/blogs/nhs-trust-pressures-addressing-demand-when-capacity-is-constrained

[18] https://nhsproviders.org/media/691810/2021-07-26-letter-from-nhs-providers-on-nhs-pressures-and-funding.pdf

[19] https://www.england.nhs.uk/wp-content/uploads/2021/06/240621-board-meeting-item-4ii-operational-performance-update.pdf

[20] https://ifs.org.uk/publications/15557

[21] NHS England is seeking to accelerate recovery of the backlog by trialling new ways of working in a dozen areas and five specialist children’s hospitals.

[22] https://nhsproviders.org/news-blogs/blogs/what-trust-leaders-need-to-tackle-the-backlog

[23] https://nhsproviders.org/resource-library/briefings/discharge-to-assess-the-case-for-permanent-funding

[24] https://nhsproviders.org/media/691810/2021-07-26-letter-from-nhs-providers-on-nhs-pressures-and-funding.pdf

[25] https://www.england.nhs.uk/2021/05/nhss-160-million-accelerator-sites-to-tackle-waiting-lists/

[26] https://www.bma.org.uk/bma-media-centre/thousands-of-overworked-doctors-plan-to-leave-the-nhs-bma-finds

[27] https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1009002/Senior_Salaries_Review_Body_Report_2021_Web_Accessible.pdf

[28] https://www.ft.com/content/a5fb198e-8657-4bf5-879f-b2861192040b

[29] The NHS 111 First scheme was introduced on 1 December 2020 which allowed patients to call NHS 111 first before going to their A&Eexcept in absolute emergencies – and then they could book an appointment in A&E or at an alternative health service. The aim of the scheme is to enable patients to be seen by an appropriate service and to avoid overcrowding in EDs.

[30] The model is designed around having a single point of access for UEC, through which a patient can then access the appropriate service. This means scarce resources are not duplicated in multiple CASs, and patient flow is streamlined, leading to a better patient experience. It also allows for effective strategic commissioning, whereby local needs can be identified and resources matched accordingly, for example ensuring there is additional mental health expertise as part of the CAS in areas of high need.

[31] https://nhsproviders.org/rapid-response

[32] https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/12/important-for-action-operational-priorities-winter-and-2021-22-sent-23-december-2020.pdf