Looking at the referral-to-treatment (RTT) elective care waiting list data between January 2020 and June 2021, we saw that 7.4 million fewer patients started new RTT pathways than would normally be expected. Although we would not expect all 7.4 million ‘missing’ new starts to present and require referral, if 80% are eventually referred, the system will need to plan for around 6 million new pathways in addition to business-as-usual activity and the record-level waiting list of 5.45 million.
Official data on GP activity suggests that consultations by GPs for non-Covid activity had returned to pre-pandemic levels by June 2021. When all consultation activity by general practice is taken into account, general practice is approaching consultation levels that exceed pre-pandemic levels. Anecdotal reports suggest that activity is now above the levels for which we have most recently published data.
There have been media reports of GPs reducing the use of digital triaging as a mechanism to throttle demand. The DHC understands why GPs are taking this decision, but we believe it is a short-term reaction to a wider systemic problem of demand exceeding supply. Further, it is counter-productive because we can cite examples of where well-executed digital triaging in the context of wider planning and effective patient communications can help manage demand more effectively (see answer to question 5 below).
Before Covid, we were already seeing signs that demand was outstripping supply. For example, in the five years to the end of 2019, elective waiting lists had grown from 2.9 million in December 2014 to 4.4 million in December 2019.
So, while we can debate the exact size of the problem, the evidence suggests that the system was already struggling to meet demand. In turn, it is unlikely that across the country as a whole we would be able to handle considerable activity above normal levels even if we were to magically revert to pre-pandemic conditions.
It is therefore clear that simply exhorting an over-stretched workforce to do more is not a long-term sustainable solution. Further, even if we can reduce the backlog to pre-pandemic levels within, say, five years, there will be many people who during that time will experience extremely long waits, potentially with significantly worsening conditions.
It is important to note that digital provision is not just about changing where services are delivered, it is about improving capacity and being more effective. For example, long before the pandemic, providers of digital healthcare consultations were making good use of fully trained clinicians who were looking for more flexible and family friendly ways of working. The response to Covid presents even more reasons to ensure we make the most of all available staff and provide ways for them to contribute that avoid burnout. Increasing capacity and improving how we use that capacity will be key, and it is important to recognise that digital solutions have a key role to play (see our answers to questions 4 and 5 to see why).
There are other organisations better placed to propose a specific figure that needs to be invested. However, we have important observations about how that financial investment should be made:
As discussed in our answer to question one, the scale of the elective backlog is significant, and one of its most concerning components are the people who we would have expected to have begun elective pathways over the past 18 months, but who for a variety of different reasons did not present for treatment. In the short term, we need to ensure that those patients are encouraged to seek care. This is important primarily to ensure that conditions do not worsen unnecessarily. It also will help understanding about the size and nature of the backlog in turn allowing appropriate plans to be put in place.
Inevitably, as well as a larger number of people waiting, many people will also wait for longer. In turn, we need to make sure that they are appropriately triaged and the conditions are managed effectively while they are waiting.
A sizeable portion of diagnosed cancers are identified from patients in the elective pathway following their first outpatient appointments rather from suspected cancer referrals by GPs. Given there is currently only limited triaging of patients before their first outpatient appointment, long delays mean that we inevitably will miss the opportunity for the early treatment that is necessary to save lives.
We also know that some patients will have conditions that are likely to deteriorate considerably while waiting for treatment.
We therefore believe there need to be fundamental changes in the way we manage waiting lists. Rapid and early access to diagnostics needs to become a standard part of referral. This should include triaging beyond the current four categories of waiting so patients’ conditions can be managed more effectively while waiting for care.
We believe there is a considerable contribution that digital provision can make to all elements of this process. The examples below are just a sample of how Digital Healthcare Council members are contributing:
We welcome the greater utilisation of digital solutions and the cultural shift towards prioritising the implementations of solutions with immediate practical benefit. However, there is much more to do.
We have also seen mixed results in some areas and believe it is important to identify what distinguishes those approaches that have been successful, from those that seem similar on the face of it, but that have turned out to be less effective.
For example, over the past 18 months, several DHC members have demonstrated that digital can be extremely effective at relieving demands and improving the quality of care. For example, when Klinik’s prioryCARE digital triaging solution was implemented in Priory Medical Group primary care network, they saw patient satisfaction figures jump from 24% to 87%, and patient access that was 99% telephone driven come down to just 30%.
Although there have been reports from GPs arguing against the always on, 24/7 nature of such services, evidence suggests that effective engagement and implementation improves patient access and reduces pressure on GP services. In turn, when we get that right, patients are more likely to embrace the technology and the benefits can show to the full.
It is important to see that shutting the door to patients at nights and weekends is a short-term and potentially dangerous way to manage demand in general practice. While we fully understand why practices choose to respond in that way, it prioritises those patients who can work the system effectively, while discriminating against others many of whom will already be facing greater health needs. We believe that we need to improve how we measure access to general practice, to ensure that we can capture the full extent of the bottleneck, and then respond accordingly.
It is important to recognise that innovation is a fundamental driver that will allow health and care services to evolve and meet emerging challenges. However, there are several points that must be addressed if innovation is to happen to the full.
Significant hurdles to adopting innovation include:
We can make improvements in each of these problematic areas by:
A separate but related issue is the number and complexity of frameworks which frankly are confusing even to suppliers that have sales and marketing teams that are 100% focused on the NHS. For NHS customers, the complexity of frameworks is often frankly bewildering.
Frameworks therefore need significant reform. They need to be simplified, rationalised, and restructured to allow developers and innovators to present their full value propositions with far fewer bureaucratic hurdles. Rather than stripping out innovation to meet a fixed price point, providers should be encouraged to set their prices to match their propositions, giving the market a clear choice to choose solutions that work for them.