Written evidence submitted by Versus Arthritis (CBP0036)


  1. Versus Arthritis welcomes the opportunity to respond to the Health & Social Care Committee Inquiry on Clearing the backlog caused by the pandemic.[1]


  1. Versus Arthritis is the charity formed when Arthritis Research UK and Arthritis Care joined together in 2018. We work alongside volunteers, healthcare professionals, researchers and people with arthritis 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. Our remit covers all musculoskeletal conditions which affect the joints, bones and muscles including osteoarthritis, rheumatoid arthritis, back pain and osteoporosis.[2]


  1. Arthritis and related musculoskeletal conditions affect 18.8 million people in the UK 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 2018, MSK problems were the second most common cause of sickness absence, accounting for 27.8 million days in work lost and a fifth (19.7%) of all sickness absences.[4]


  1. This submission responds to the following questions from the Committee:


  1. This submission focuses primarily on the delivery of Orthopaedic surgery (specifically hip and knee joint replacements) and elective surgery more broadly. Over 90% of hip and knee joint replacements are carried out on people with osteoarthritis.[5]


  1. Summary points:

Inquiry Questions

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. Waiting times for Trauma and Orthopaedic surgery (including hip and knee replacements) were already rising before the pandemic. COVID-19 has accelerated this trend with a significant increase in the number of people with arthritis now waiting a year or more for joint replacement surgery in England. [7]


  1. Trauma and Orthopaedic surgery was particularly affected by the postponement and cancellation of elective operations in 2020.  In frameworks used by clinicians to prioritise surgery, patients requiring operations like hip and knee replacements were designated as lower risk and priority compared to other treatment.[8] This has contributed to orthopaedic surgery recovering at a slower pace compared to other specialties and to higher waiting lists which has had a significant impact on the quality of life for people waiting for joint replacement surgery.


  1. Recent analysis from the Health Foundation has provided further insight into the length of time people were waiting for a hip replacement operation, the impact on the quality of life of those waiting and the pace that operations were recovered across England last year.[9]


  1. As of January 2021, the Health Foundation estimated that 58,000 people had waited an additional 25 weeks for a hip replacement operation, equivalent to a loss of 80 days in perfect health” (as measured by the EQ-5D model). This impact was also reflected in the post-surgery outcomes of those waiting for care.[10]


  1. The Health Foundation analysis also showed the regional variation in the recovery of hip replacement operations last year.  Their analysis found that only London and the South East managed to recover their pre-pandemic rates of admissions for hip replacement operations in 2020. In addition, the number of admissions for hip replacement operations were only half (60,000) of what they were projected to be, with regions like the Midlands (15,000) and North East & Yorkshire (11,000) facing a greater deficit of admissions compared to London (3,000).


  1. Furthermore, evidence published in April 2021 found that patients living in the most deprived CCG areas in England (as measured by the Index of Multiple Deprivation) had experienced the most disruption from the fall in elective activity, with lower numbers of completed treatment pathways compared to the least deprived CCG areas.[11]


  1. NHS England and Improvement reflected the growing urgency to tackle waiting lists for MSK and orthopaedics by designating these areas a priority for recovering non-COVID services, in guidance to local areas in both December 2020 and March 2021.[12]


  1. The latest Referral to Treatment (RTT) figures that were published by NHS England and Improvement in early August showed the size of the Trauma and Orthopaedic waiting list in June 2021 as follows:



  1. Whilst the number of people waiting more than 52 weeks has decreased in the last two months (reflecting NHS priorities), the overall numbers waiting for this length of time has increased significantly since the start of the pandemic.


  1. NHS England has also started to record the numbers of people waiting up to two years or 104 weeks for Trauma and Orthopaedic treatment. As the figures below demonstrate, at least 64,277 people had been waiting between 52 and 104 weeks for treatment as of June 2021.


Table 1: RTT Waiting Times, June 2021 (52-104 weeks)

Waiting time

June 2021

Previous month (May 2021)

GT 52 to 62 weeks

13,053 (2.0%)

10,566 (1.6%)

GT 62 to 72 weeks

18,734 (2.8%)

31,523 (4.9%)

GT 72 to 82 weeks

17,906 (2.7%)

15,725 (2.4%)

GT 82 to 92 weeks

9,229 (1.4%)

8,191 (1.3%)

GT 92 to 102 weeks

3,719 (0.6%)

3,198 (0.5%)

GT 102 to 104 weeks

407 (0.1%)

304 (0.1%)

GT 104 weeks (2 years)

1,229 (0.2%)

812 (0.1%)

GT 52 weeks




  1. Lengthening waiting times for joint replacement surgery over the last year have had a significant impact on people with arthritis.  Between 22nd October and 4th December 2020, Versus Arthritis surveyed people waiting for joint replacement surgery and found that[13]:


  1. These findings have been reinforced in a more recent survey of 549 respondents waiting for joint replacement surgery carried out by Versus Arthritis in May and June 2021.  In response to the question “What has been impacted by the wait for surgery?” (respondents could choose more than one option) the results were as follows:[14]


  1. The results of these surveys, along with the evidence from the Health Foundation and the BOA, highlight the need for supporting people with arthritis on waiting lists for hip and knee joint replacement surgery. Later in this submission, Versus Arthritis sets out some proposals for how people with arthritis can be better supported as they wait for treatment over longer periods.

Research backlog

  1. The disruption to elective surgery over the last year has had an impact on research into arthritis and musculoskeletal conditions in a number of different areas. Firstly, it has had an impact on the recruitment of patients for and numbers of patients entered into studies and clinical trials. The backlog has also had an impact on the supply of human tissue for experimental research carried out by researchers funded by Versus Arthritis.


  1. Secondly, the pandemic has had an impact on the research workforce and the time allocated to research in the NHS.  In 2020, Versus Arthritis estimated that 80% of our clinical researchers had been seconded to patient care and all of our Clinical Research Fellows (who are undertaking a PhD)[15] returned to the NHS and paused their research.


  1. Since returning to their research posts, all of the Clinical Research Fellows funded by Versus Arthritis have extended their fellowships between 3-7 months and the charity is expecting further extension requests. 


  1. Finally, the pandemic has had an impact on research studies like PASHiOn, which is testing new techniques to improve the outcomes for joint realignment surgery like High Tibial Osteotomy (HTO).[16]


  1. HTO involves changing the alignment of the tibia to correct joint alignment and has been shown to reduce pain and improve function for early-stage knee osteoarthritis.  Well performed HTO can delay the need for knee replacement by 10 years and in some cases can avoid the need for surgery altogether.


  1. The aim of the PASHiOn trial is to assess patients with early to mid-stage osteoarthritis of the knee to produce a more accurate correction of joint alignment.  This will help patients have better outcomes compared to standard HTO.  If successful the study could help to reduce the need for joint replacement and future revisions. 


  1. The new procedure (ToKa) has been developed with MRC and Versus Arthritis funding, and the study was due to start recruitment in July 2020.  As the study sites were focusing on urgent public health research the study was halted, with further delays caused by the suspension of elective surgery last year.  The study is now over a year behind schedule.


  1. There is a large backlog of patients waiting for HTO treatment. However, a number of these have waited more than three months for surgery which may impact their ability to enter the trial.


  1. Overall, the continued disruption to research studies by the backlog will impact the UK’s competitiveness for the delivery of clinical research.

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. Since the onset of the COVID-19 pandemic, there has been severe disruption to the delivery of elective surgery in England due to an increase in demand for hospital bed space linked to COVID-19 infections. Elective surgery was postponed across the whole of England from April to July 2020, and some local areas chose to suspend elective surgery during periods where COVID-19 infections had increased (particularly Winter 2020-21 and the start of July 2021).


  1. Survey work carried out by the British Orthopaedic Association (BOA) and the British Orthopaedic Directors Society (BODS) in 2020 highlighted the challenges faced by Trusts when orthopaedic services were restarted last Summer. BOA/BODS found significant regional variation in the recovery of elective orthopaedic services, recommending that additional resources were required to help Trusts meet NHS England targets.[17]


  1. The disruption to elective surgery during 2020 and 2021 has led to significant increases in waiting lists and highlighted the limits in the current capacity within the NHS to be able to deliver elective surgery alongside being able to respond to future COVID-19 infection outbreaks.


  1. Reducing the backlog for elective surgery in the fastest possible time will require increasing capacity within the NHS and expanding capacity by partnering with the independent sector.


  1. A study published in Bone Joint Open last year concluded that through the development of COVID-free pathways, it is possible for elective surgery to restart safely with low viral transmission rates from COVID-19.[18] However, analysis of data from the National Joint Registry recently suggested that capacity would need to be increased by at least 10% over five years to sustain the recovery of joint replacement operations.[19]


  1. To increase capacity within the NHS, the Royal College of Surgeons and other professional bodies have supported expanding the adoption of surgical hubs across England for specialties like orthopaedics to help increase capacity within the NHS.[20] Recent analysis from the Health Foundation has suggested that adopting the surgical hub model could be a factor in explaining the degree of elective recovery in London last year compared to other regions.[21]  A survey contained in the Royal College of Surgeons’ Action Plan for England cited that six in ten (58%) UK adults said that it would be “important for them to be treated in a surgical hub hospital” if they needed an operation.


  1. Alongside increasing capacity in the NHS, more effective deployment of independent sector capacity could help reduce NHS waiting lists for elective surgery (especially orthopaedic treatment like hip and knee joint replacements).


  1. It is important that the NHS in England learns lessons from last year, where an estimated two-thirds of independent sector capacity block booked by the NHS was not used between June and the end of September 2020. Such arrangements contributed to a missed opportunity to reduce the backlog of non-COVID treatment that increased following the suspension of elective surgery between April and July 2020. In this case payment to independent sector providers was based on making capacity made available, rather than activity they delivered.[22]


  1. The think tank Policy Exchange has suggested that such an outcome could be averted by the NHS issuing long-term contracts with clear volume-based outcomes that ensure the maximum number of operations can be delivered for the money spent. [23]


  1. Increasing capacity to reduce waiting lists for elective surgery (including hip and knee joint replacements), and to support patients whilst they wait for surgery will also require the workforce to deliver this treatment and care.  Versus Arthritis’ Joint Replacement Support Package report highlighted the role of a range of primary and secondary care professionals in providing the range of support required by people with arthritis on waiting lists.[24]


  1. Policy Exchange have submitted a number of recommendations to expand the elective care workforce, including investment in diagnostic capacity, a fund to hire data managers to improve the quality of waiting lists and ensuring planned care is a priority within a national workforce strategy.[25]


  1. In their submission to this Committee’s inquiry, the British Orthopaedic Association (BOA) has highlighted a number of issues that need to be addressed to ensure the orthopaedic surgical workforce is sustainable and can meet the growing demand for orthopaedic surgery (such as hip and knee joint replacements) in the near future.  This includes resolving issues around pensions and tax liability, and delays to training for newly qualified staff. 


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. In May 2020, the Health Foundation measured the cost of returning NHS waiting times to 18 weeks for routine treatment in the period before the COVID-19 pandemic. [26]


  1. The Health Foundation’s base estimate was that £380m per year was required to keep pace with demand (200,000 additional patients being treated), plus £3.6bn to clear the backlog (1.3 million patients). If spread evenly over next four years, this would amount to a total annual cost of £1.3bn.


  1. For the Spending Review in November 2020, the Health Foundation estimated that tackling the backlog of demand for elective care and restoring waiting times standards by 2023/24 would cost an extra £1.9 bn in each of the next three years.[27]


  1. The Elective Recovery Fund was announced as part of the UK Government’s Spending Review in 2020 to provide £1 billion to local systems “to begin tackling the elective backlog, enough funding to enable hospitals to cut long waits for care by carrying out up to one million extra checks, scans and additional operations or other procedures.”[28]


  1. In March 2021, NHSE/I published the Elective Recovery Framework which provided the criteria that local systems would have to meet to qualify for funding.  This included the level of activity delivered and a number of other criteria such as waiting list management and using waiting list data to support the most vulnerable patients.


  1. The Royal College of Surgeons has proposed that the Elective Recovery Fund for England should be continued for a further five years “to tackle the elective surgical backlog.”[29]


  1. In June 2021, NHS Providers wrote to the Prime Minister, Treasury Ministers and Health Secretary to call for the Elective Recovery Fund to be increased, arguing that most funding would be used up in the first half of the year.  This additional funding would be used to reduce care backlogs in mental health and long waiting times for procedures undertaken by community trusts.[30]


  1. In August 2021, the Institute for Fiscal Studies outlined a range of funding options for reducing the overall elective care backlog. One of their scenarios estimated an annual cost of at least £1 billion (even before accounting for the need for any additional infrastructure).  This scenario assumed 75% of patients returned, the NHS operated at 100% capacity (i.e. at 2019 levels of activity) in 2021 and 2022, as well as adding an additional 5% of capacity from 2023 (equivalent to treating an additional 800,000 patients per year).[31]


  1. According to this estimate, waiting lists would rise before falling gradually by the end of 2025.  However, by this stage waiting lists would still be at double the pre-pandemic level at around 8.6 million people.


  1. The Elective Recovery Fund for England should be extended (at the same level as 2020/21) for the duration of the next Spending Review to reduce the time that people with arthritis are waiting for operations and so they can receive support while they wait.


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. The Best MSK Health Programme – which is being led by NHS England and Improvement - is developing solutions and pathways that can improve the experience of care for people with arthritis and musculoskeletal conditions in England.


  1. As highlighted in our survey results above, the legacy of elective surgery and other health services being postponed or cancelled across England during 2020 has contributed to the condition of many people with arthritis deteriorating over the last eighteen months.  This means that those who have been referred for hip and knee joint replacement surgery are more likely to require greater support while they wait.


  1. In June 2021, Versus Arthritis published a Joint Replacement Support Package report in June 2021[32], calling on local areas to provide greater support to people with arthritis on waiting lists. The main recommendations in the report were as follows:



  1. Our calls have been reflected by organisations like the Royal College of Surgeons, who in their Action Plan for Surgery called for Integrated Care Systems (ICSs) to “urgently consider what measures can be put in place to support patients facing long waits for surgery, including the best and most efficient use of new technologies to support this.”[33]


  1. Implementing 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.


  1. The NHS could also consider making changes to the way waiting times for elective care are measured to ensure that the experience of patients waiting for treatment is improved. However, it is important that any proposals brought forward in the review of Clinically-led NHS Access Standards uphold existing patient rights to access treatment within maximum waiting times in the NHS Constitution.[34][35]


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. Many local areas in England are piloting new projects to support people with arthritis and similar conditions on waiting lists, putting into practice the recommendations set out in our Joint Replacement Support Package.  Examples include:



  1. Extending the Elective Recovery Fund beyond 2020-21 could help local areas to scale up these projects and ensure that more people on waiting lists can be supported. 


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


  1. Most estimates (using a range of datasets) suggest that between 14-30% of people who are infected by COVID-19 experience some level of Long COVID symptoms (defined as symptoms lasting at least 12 weeks post infection). This roughly translates to anywhere between 1 and 2 million people with Long COVID symptoms.


  1. Data published by the Office for National Statistics (ONS) on the prevalence of Long COVID has highlighted the prevalence of symptoms that are associated with musculoskeletal pain. [37]   This data suggests that the burden of musculoskeletal conditions may be increasing as a result of the number of people developing symptoms of Long COVID.


  1. Research suggests that the reporting of Long COVID in primary care records is significantly lower than the actual number affected, which is likely due to misdiagnosis, poor coding and low rates of presentations.  This suggests that even if Long COVID is not currently adding to existing pressures on health services, it still represents a significant threat to sustainably restarting services over the long term. Integrating Long COVID care into existing patient treatment pathways will be important for tackling the backlog.


  1. It has been noted in research that there is significant overlap between the high-risk populations for Long COVID and autoimmune MSK diseases, and that Long-COVID in patients often presents in similar ways to some existing conditions of chronic pain and fatigue which affect the MSK system.  Overlap in diagnosis techniques, treatment and management can therefore be expected as more long-term guidance on treatment in developed.


  1. Additionally, if MSK symptoms associated with Long COVID become chronic it will increase the demand for key healthcare professionals involved in MSK treatment pathways (such as physiotherapists) who are also in the MDT teams put together to treat Long-COVID patients based on current NICE guidance. Staffing issues affect the ability to deliver care to both Long COVID and patients on waiting lists.


  1. More research is required to form a greater understanding of the nature and prevalence of Long-COVID, including the following issues:


Jonathan Canty (Policy Officer)


For further information please contact policy@versusarthritis.org


[1] HoC Health and Social Care Select Committee. Call for evidence. Accessed here: https://committees.parliament.uk/call-for-evidence/547/

[2] Versus Arthritis (2020).  About Us. Accessed here: https://www.versusarthritis.org/about-us/

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

[4] Office for National Statistics (ONS). Sickness Absence Report 2017.

[5] National Joint Registry (2020). Summary of key facts about joint replacement during the 2019 calendar year.  Accessed here: https://reports.njrcentre.org.uk/Portals/0/PDFdownloads/NJR%2017th%20AR%20Summary%20key%20facts%202019.pdf

[6] The Lancet Rheumatology (2021). Too long to wait: the impact of COVID-19 on elective surgery. Accessed here: https://www.thelancet.com/journals/lanrhe/article/PIIS2665-9913(21)00001-1/fulltext

[7] NHS England (2021) Referral to Treatment waiting times. Accessed here: https://www.england.nhs.uk/statistics/statistical-work-areas/rtt-waiting-times/rtt-data-2021-22/#May21

[8] RCS (2020). Clinical guide to surgical prioritisation during the coronavirus pandemic. Accessed here: https://www.rcseng.ac.uk/coronavirus/surgical-prioritisation-guidance/

[9] The Health Foundation (2021). Waiting for care: Understanding the pandemic’s effects on people’s health and quality of life. Accessed here: https://www.health.org.uk/publications/long-reads/waiting-for-care

[10] The Health Foundation (2021). Waiting for care: Understanding the pandemic’s effects on people’s health and quality of life. Accessed here: https://www.health.org.uk/publications/long-reads/waiting-for-care

[11] The Health Foundation (2021). Longer waits, missing patients and catch up: How is elective care in England coping with the continuing impact of COVID-19. Accessed here: https://www.health.org.uk/news-and-comment/charts-and-infographics/how-is-elective-care-coping-with-the-continuing-impact-of-covid-19

[12] NHS England and Improvement (2020). Operational priorities for Winter and 2021/22. Accessed here: 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

[13] Versus Arthritis (2020) Impossible to Ignore Joint Replacement Surgery Survey. Available upon request.

[14] Versus Arthritis (2021) Impossible to Ignore Survey. Available upon request.

[15] Versus Arthritis (2021). Types of Fellowship. Accessed here: https://www.versusarthritis.org/research/information-for-researchers/fellowships/types-of-fellowship/

[16] Oxford Clinical Trials Research Unit (2021). PASHiOn Trial. Accessed here: https://pashion.octru.ox.ac.uk/welcome-pashion-trial

[17] BOA (2020). BODS/BOA Survey on impact of COVID-19 on UK orthopaedic practice and implications on restoration of elective services.  Accessed here: https://www.boa.ac.uk/resources/knowledge-hub/bods-boa-survey-of-impact-of-covid-19-on-uk-orthopaedic-practice-and-implications-on-restoration-of-elective-services.html

[18] Bone & Joint Open (2020). Elective orthopaedic surgery with a designated COVID-19 free pathway results in low perioperative viral transmission rates.  Accessed here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7659660/

[19] Derek Pegg et al. (June 2021) Effects of COVID-19 pandemic on hip and knee joint replacement surgery in 2020 as demonstrated by data from the National Joint Registry (NJR). Accessed here: https://www.boa.ac.uk/resources/knowledge-hub/jto-june-2021.html

[20] RCS (2021). A New Deal for Surgery: Action Plan for England. Accessed here: https://www.rcseng.ac.uk/about-the-rcs/government-relations-and-consultation/position-statements-and-reports/action-plan-for-england/

[21] The Health Foundation (2021). Waiting for care: Understanding the pandemic’s effects on people’s health and quality of life. Accessed here: https://www.health.org.uk/publications/long-reads/waiting-for-care

[22] HSJ (2020). Leaks reveal two-thirds of private hospital capacity went unused by NHS. Accessed here: https://www.hsj.co.uk/finance-and-efficiency/leaks-reveal-two-thirds-of-private-hospital-capacity-went-unused-by-nhs/7029000.article

[23] Policy Exchange (2021). A Wait on Your Mind. Accessed here: https://policyexchange.org.uk/publication/a-wait-on-your-mind/

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

[25] Policy Exchange (2021). A Wait on Your Mind. Accessed here: https://policyexchange.org.uk/publication/a-wait-on-your-mind/

[26] The Health Foundation (2020). Returning NHS waiting times to 18 weeks. Accessed here: https://www.health.org.uk/publications/long-reads/returning-nhs-waiting-times-to-18-weeks

[27] The Health Foundation (2020). Spending Review: Priorities for the NHS, social care and the nation’s health.  Accessed here: https://health.org.uk/publications/long-reads/spending-review-2020

[28] HM Treasury. Spending Review 2020.  Accessed here: https://www.gov.uk/government/publications/spending-review-2020-documents/spending-review-2020

[29] RCS (2021). A New Deal for Surgery: Action Plan for England. Accessed here: https://www.rcseng.ac.uk/about-the-rcs/government-relations-and-consultation/position-statements-and-reports/action-plan-for-england/

[30] NHS Providers (2021). Government support for the NHS given current and future pressures. Accessed here: https://nhsproviders.org/media/691810/2021-07-26-letter-from-nhs-providers-on-nhs-pressures-and-funding.pdf

[31] Institute of Fiscal Studies (2021). Could waiting lists really reach 13 million? Accessed here: https://ifs.org.uk/publications/15557

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

[33] RCS (2021). A New Deal for Surgery: Action Plan for England. Accessed here: https://www.rcseng.ac.uk/about-the-rcs/government-relations-and-consultation/position-statements-and-reports/action-plan-for-england/

[34] NHS England (2021). Clinically-led review of NHS Access Standards.  Accessed here: https://www.england.nhs.uk/clinically-led-review-nhs-access-standards/

[35] Department of Health and Social Care (2021). Handbook to the NHS Constitution. Accessed here: https://bit.ly/3yBFfz2

[36] Meridian PCN (2021). Worthwhile Waiting: A service that supports patients on waiting lists.  Accessed here: https://worthwhilewaiting.meridianpcn.nhs.uk/

[37]ONS (2020). Prevalence of long-COVID symptoms and COVID-19 complications. Accessed here: https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandlifeexpectancies/datasets/prevalenceoflongcovidsymptomsandcovid19complications


Sept 2021