Written evidence submitted by The NHS Confederation (CBP0058)

 

 

Part 2 – Detailed responses

 

NHS Confederation: 3 September 2021

 

About us             

1.      The NHS Confederation is the membership organisation that brings together, supports and speaks for the whole healthcare system in England, Wales and Northern Ireland. The members we represent employ 1.5 million staff, care for more than 1 million patients a day and control £150 billion of public expenditure. We promote collaboration and partnership working as the key to improving population health, delivering high-quality care and reducing health inequalities.
 

2.      This document addresses each of the Committee’s questions in detail and is intended to provide supplementary information, further to our main submission.

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?


Elective surgery
 

  1. Since the beginning of the pandemic, the number of people waiting for elective procedures has grown to 5.45 million – the highest number on record.[1] This is largely due to a combination of a sharp fall in patients presenting for treatment in the spring and summer of 2020 and resources being allocated to COVID-19 patients.
     
  2. There have also been 7.42 million fewer referrals for elective care than normally expected since the beginning of 2020 – the ‘missing’ waiting list.[2]  The sustained impact of the pandemic will leave a backlog of care in excess of anything seen over the last 12 years.
     
  3. Much of the growth in waiting lists comes from low priority, high-volume procedures such as painful bone and joint conditions, ear, nose and throat (ENT) and ophthalmology. However, the scale and complexity of what the NHS now needs to deliver is unprecedented as people’s conditions worsened when they were unable or reticent to present for treatment during the pandemic; 42 per cent of patients who needed an appointment in the past 12 months avoided making one.[3] Across all specialties, there have been 24 per cent fewer new referrals than we would have expected since the beginning of 2020.[4] In trauma and orthopaedics there were 35 per cent fewer referrals, ophthalmology is down by 28 per cent and ENT 31 per cent below expected.[5] What is unclear, however, is how many of these people will present for care, or when.

 


Figure 1: estimates of missing referrals

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1 Chart showing estimate of missing referrals broken down by speciality. Taken from NHS Confederation (2021) Building back inclusively: Radical approaches to tackling the elective backlog [In Press]. ‘Other’ is a broad category including mental health, paediatric and surgical procedures, as well as ‘other medical services’.
 

  1. The NHS should prepare for the number of people waiting to grow considerably higher. The Institute for Fiscal Studies suggested that the health secretary’s warning of a 13 million waiting list ‘is by no means beyond the realms of possibility’, and even in their most optimistic scenario the waiting list rises to over 9 million in 2022.[6]
     
  2. As the NHS moves beyond the emergency phase of the pandemic, it is anticipated that the health service will see considerable growth in the number of people waiting; statistical anomalies that could be potentially misleading (for example, as the waiting list grows, the average time spent waiting will initially fall); more local variation; increased pressure on GPs; and surges in unplanned activity, including COVID-19 admissions.[7]

Mental health services

  1. Members from our Mental Health Network report an increase in urgent referrals to mental health crisis teams across all ages during the pandemic and concern around an increase in the acuity of cases.
     
  2. The biggest rise in demand for mental health services is seen among children and young people (CYP).[8] Between March 2020 and February 2021, there was a 29 per cent increase in the number of CYP in contact with mental health service. According to modelling by the Centre for Mental Health, mental health services in England will need additional capacity for 8.5 million adults and 1.5 million CYP, who may need new or additional mental health support as a direct consequence of the pandemic, over the next three to five years.[9]
     
  3. As many as 1.5 million CYP may need new or additional mental health support as a result of the pandemic.[10] The number of young people completing an urgent or routine pathway for eating disorders has increased by 141 per cent between quarter four in 2019/20 and quarter one in 2021/22, and the number of urgent cases still waiting has more than doubled over the last year.[11]

 

  1. Mental health demand is being felt across the system. Our PCN Network, which represents primary care networks (PCNs) across England, reports that its members have seen a 50 per cent increase in mental health problems, particularly for CYP and ambulance services report an increase in the number of calls concerning mental health issues in all ages.


Cancer services

 

  1. There has been a return to pre-pandemic capacity in cancer services, with 27,000 people starting treatment in June 2021 and 228,000 people checked for cancer in the same month, the second highest figure on record. However, cancer services are far from recovered.[12]
     
  2. In June, 26.7 per cent of patients had not had their first definitive treatment within 62 days of an urgent GP referral for all cancers (the standard is 85 per cent treated).[13] The standard hasn’t been reached in an individual month since December 2015, and while the figure is an improvement on January 2021, the figures are behind the monthly average for 2019/20 for example (22.8 per cent not starting treatment within 62 days of an urgent referral).

 

Primary care services
 

  1. It is difficult to quantify the size of the backlog or pent-up demand for primary care services due to the nature of primary care provision, a lack of comprehensive data on demand and activity, analytics and business intelligence support and infrastructure.[14]
     
  2. Analysis from the British Medical Association (BMA) states essential services appointments have increased by 3.5 million in June 2021 compared to June 2019.[15] Although this demonstrates an increased workload, implying capacity issues, it is difficult to establish causation between backlog or pent-up demand for primary care services or elsewhere in the system.
     
  3. Anecdotally, PCN Network members estimate it will take them two years to achieve patient health outcomes seen pre-COVID-19. This is further exacerbated by delays in other parts of the system, for example, secondary and community services, that are unable to offer the access to services previously experienced and primary care having to manage those patients on waiting lists.[16]

Health inequalities

 

  1. Our analysis of available data has shown a relationship between levels of local deprivation and waiting time trends.[17] Evidence suggests that increases in waiting list numbers are associated with areas of greater deprivation, especially in neurology, general surgery, and dermatology;[18] increases in admissions for specialties such as trauma and orthopaedics and ENT are associated with areas of less deprivation;[19] and overall levels of waiting per head of population are associated with areas of greater deprivation.[20] We urge the government, therefore, to consider approaches to tackling the elective backlog that consider deprivation and equality of outcomes.

 

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. A survey of 100 leaders from across the healthcare system found that over four in five were not confident that the NHS will be able to meet public expectations on treatment waiting times.[21]


Figure 2: Results from Health Leaders Panel survey[22]

 

 

 

 

 

 

 

 

 

 

  1. The NHS faced significant capacity issues for delivering elective care before the pandemic, with high vacancy levels in nursing affecting theatre nurses and in anaesthetists and operating department assistants. The overall medical workforce has increased, including more surgeons, but royal college analysis indicates that demand has grown faster.[23]
     
  2. Pre-pandemic, mental health and learning disabilities services saw some of the highest levels of vacancies across the system, with around 10 per cent of roles unfilled by permanent staff. There has been modest growth in the mental health workforce since 2017[24]; however, we are still some way off achieving the Stepping Forward target around workforce expansion. The Mental Health Implementation Plan also states that an additional 27,000 (above the Stepping Forward target) are required to implement the NHS Long Term Plan.[25]
     
  3. COVID-19 has exacerbated workforce capacity issues across primary and secondary care. Despite additional investment in the primary care workforce through the Additional Roles Reimbursement Scheme, many of these new roles remain to be filled and they do not address the increasing retention problems with general practitioners.

 

  1. NHS workers have made huge sacrifices over the last 18 months, and sadly many have lost their lives – including a disproportionate number of black and minority ethnic (BME) employees.[26] The BMA has estimated that even if the NHS were to run at 110 per cent of its pre-COVID-19 capacity, it could take up to five years to reduce the backlog of elective care in England back down to (already high) 2019 levels.[27] The number of total vacancies (as of June 2021) stands at 93,806, including 38,952 nursing vacancies and 9,691 medical vacancies.[28]
     
  2. Despite the remarkable levels of redeployment achieved during the first and second waves, there are challenges around the distribution of capacity across the system. Our members have called for guidance on a consistent approach to incentivising staff to take on extra work, especially in advance of winter pressures.
     
  3. Our members report that staff sickness and self-isolation absence rates have been falling since the end of July, which may in part be attributed to the exemption for frontline staff to attend work in exceptional circumstances in England.
     
  4. While staff absence has stabilised back down towards pre-COVID-19 levels (4.1 per cent absence in April 2021 as compared with 6.2 per cent in April 2020),[29] rates are still high and have a disruptive impact at current levels, especially in areas of the country where they are higher. There remain concerns, for example, over the longer-term mental health impact of COVID-19, the number of staff with long COVID and potential disruptive impact of school-based outbreaks on working parents. An understanding of current capacity must factor in the disproportionate number of clinicians affected by the impact of COVID-19 that are from BME communities.[30]
     
  5. A recent study also showed that the mental health-related absences among the UK’s NHS workforce have increased by 37 per cent, with almost 4,000 more staff off work in June 2021 compared to June 2020.[31]
     
  6. Workload is identified as a key issue for primary care. For many PCNs, their workload has led to fatigue, burnout and insufficient time for PCN development as they grapple with strategic and operational demands alongside their clinical commitments. 96 per cent agreed that the workload has been even higher than expected.[32] The required skills mix in primary care will depend on the backlogs elsewhere in the system and how they affect clinical, administrative and managerial, as well as the strategic skills required in primary care.
     
  7. Our members are concerned that the proportion of staff considering leaving the NHS is rising. Staff have stayed through the crisis out of commitment to the NHS. While leaver rates have not risen significantly, there is a risk they will do so, and this would put further pressure on the workforce. Latest data shows vacancy rates have worsened markedly in last quarter (rising from 73,000 to 94,000) and are on a rising trend.[33]
     
  8. There is a risk of losing thousands of NHS staff unless they are given the time and space to recover from the pandemic. The 3 per cent consolidated pay increase awarded to doctors and dentists for 2021/22 was a welcome support, but pensions and taxation remain key issues in relation to the reward package for senior clinicians. It will be important to ensure staff are supported by adequate reward packages and certainty as they carry out the difficult task of recovering elective care.
     
  9. Unlike during the first and second waves, NHS trusts are no longer being given exclusive rights to independent sector hospitals. Some of our members are calling for a different kind of relationship with the independent sector that allows the ICS to direct or influence the type of cases that independent sector partners take on. As ICS move onto a statutory footing, defining the relationship between NHS and independent sector will be important to maximise the impact of the independent sector on elective recovery.
     
  10. Long-term approaches are needed. The current funding uncertainty means trusts are unable to plan beyond 12-month fixed-term contracts for key skilled professionals or to tap into overseas or large-scale recruitment projects that require additional up-front investment.
     

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. Reducing the elective backlog will take sustained investment over many years across the entire system. This will be a key issue at the forthcoming Spending Review, and subsequent spending reviews up until 2025 and beyond. The sheer scale of the challenge, when combined with reduced productivity and workforce shortages, mean funding to date is insufficient.
     
  2. The Health Foundation REAL Centre estimates that the average annual cost of treating the elective care backlog ranges from £2.1bn (90 per cent of missing patients returning) to £1.5bn (50 per cent of patients returning) over ten years. In this analysis, 600,000 extra patients would be admitted per year (a fifth of all 2019/20 activity). This would see the elective backlog from COVID-19 cleared down by the end of 2024/25, with the bulk of the cost falling over the first four years.[34]
     
  3. In less ambitious modelling that sees the COVID-19 backlog cleared down by the end of 2028/29, the annual cost is lower (between £2bn and £1.3bn), spreading it over a longer time period.[35] However, these lower average annual costs would also be accompanied by negative health impacts for patients waiting longer for treatment, which may impact other services, including primary care. Investment upstream in primary and community services will be required if patients are to ‘wait well’ and, where appropriate, shift services out of hospital, to prevent the conditions of those waiting for care from deteriorating.
     
  4. The Institute for Fiscal Studies meanwhile estimate that, even in the most optimistic scenario, whereby the NHS increase capacity by 5 per cent in 2021/22 compared to 2019, the NHS will need £2 billion extra per year, even before any infrastructure costs.[36]
     
  5. We have written to the Chancellor Rishi Sunak about the urgent need for clarity on funding.[37] The lack of financial certainty for October onwards means NHS providers may be forced into a decision to either take on more staff and make changes to their theatre capacity at significant financial risk or face spiralling demand. This could also create serious bottlenecks to joined-up patient care.[38]
     
  6. We have called for access to quick capital funding so that our members can make key changes to wards, theatres and other areas of elective capacity such as creating ‘hot and cold’ hospital sites.
     
  7. Funding allocations will to an extent involve some known unknowns, in the form of the ‘missing waiting list’ of people who are yet to present at both primary and secondary levels. In the face of uncertainty, clarity and openness from the government will be key.
     
  8. Our members from the acute sector were disheartened when the Elective Recovery Fund (ERF) thresholds were changed at short notice. The government must provide clarity on the ERF and ensure that there is an equal distribution of benefit across the system. The higher thresholds have led to some trusts having less funding than expected, leading to difficult decisions around scaling back elective activity, such as independent sector contracts.
     
  9. Despite the increased investment in primary care set out in a five-year investment plan, more is needed if it is to adjust to the additional workload pressure and complexity that is now appearing. Primary care estate infrastructure needs a radical overhaul if it is to be fit for the 21st century, provide a more integrated service to its communities and house its workforce in a way that enables a more multi-disciplinary approach to patient care.
     
  10. The government should also extend discharge-to-assess funding as soon as possible. The scheme freed up 30,000 beds during the first COVID-19 wave with a 28 per cent reduction in patients staying more than 21 days between winter 2019/20 and winter 2020/21.[39] A failure to continue this funding poses huge risks for the NHS, social care and patients. Together with NHS Providers, the Confederation and our Community Network has set out the case for permanent funding.[40][41]
     

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. Our members have called for a new policy framework and a comprehensive, long-term and transparent strategy for bringing elective care back over the coming years. Meaningful progress cannot be made with piecemeal short-term plans and targets. We believe there must be a stronger focus on staff burnout and a more integrated and targeted approach to population health management. The experience of the pandemic has demonstrated the need for integration at a local level to better manage resources and improve care, while embedding innovation. We strongly believe the health and care bill is the right vehicle for achieving this change, and will allow integrated care systems (ICSs) to make progress on reducing inequalities and improving the health of their populations.
     
  2. The NHS needs a new approach to waiting lists and a new funding and regulatory framework that focuses less on rigid performance standards and more on collaboration, health inequality and patient wellbeing.
     
  3. The NHS Constitution commitments, to treat 92 per cent of patients within 18 weeks and that no one should wait beyond one year, no longer work for the circumstances we now face. The pandemic has shown the need to consider equity of experience and outcomes, not simply access, and to align performance incentives to allow systems achievement of this change. Constitutional commitments should therefore include:
  4. This needs to be accompanied by a more integrated and targeted approach to population health management across all health and care providers, backed up by more integration between health and social care at the level of pooled budgets. This was identified in a recent survey of health leaders as a crucial factor in responding to increased demand.[43]
     
  5. Reform needs to be accompanied by clear messaging from the government that the elective situation will not be resolved in 12 months and that waiting times will be managed differently as the NHS recovers. We therefore call on the government for a new commitment to openness, transparency and public engagement, being realistic with the public about the demands on the service, the importance of seeking care promptly, and why prioritisation is important to protect the most vulnerable and improve overall outcomes.[44]


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. Despite the immense pressure the pandemic has inflicted on the system, NHS staff have mobilised to implement innovative changes to patient pathways to improve both quality and responsiveness. Examples include new intermediate pathways for CYP presenting with an eating disorder to avoid admission; effective use of nurse triage models in rapid assessment areas; same-day access to diagnostics; virtual wards in the community; better use of advice and guidance with generalists and specialists working better together to avoid admission; and effective management of the patient treatment list by sharing patient data.[45]
     
  2. Some innovations will be particularly useful for addressing the elective backlog. The accelerated implementation of ‘hot’ and ‘cold’ sites’ to separate urgent from planned care has significantly improved performance across the NHS. Implementation of ‘waiting well’ models through alternative workforce or digital approaches, also provide an effective system solution for staying in touch with patients on the waiting list. Effective use of pre-hab models have been used to improve post-surgical outcomes. Moreover, our members are clear that the stepping down of high degrees of regulation during the pandemic has been essential for reducing the bureaucratic pressures on staff, allowing them the headspace to respond to pandemic pressure and innovate at scale.[46]
     
  3. The pandemic has accelerated the use of technologies to support continued access to care and manage demand. Embedding and sustaining new technology-enabled approaches can support improving quality and efficiency and clearing the elective backlog. For example, ‘virtual wards’ whereby a patient is managed at home has the potential to facilitate early discharge, avoid patient admission, streamline a care pathway and reduce both staff time and physical bed occupancy where possible and clinically safe to do so.
     
  4. The COVID-19 virtual care ward established at West Hertfordshire Hospitals NHS Trust saved nearly 300 bed days over a three-week period at the height of the first wave. A latterly used patient monitoring app called Medopad more than doubled the number of patients monitored at home.[47] Norfolk and Norwich University Hospitals NHS Foundation Trust is now scaling the virtual ward model to support recovery and beyond. The trust now has almost ten live care pathways and is developing more condition-specific virtual wards, including diabetes and heart failure.
     
  5. The delivery of primary care services virtually during the pandemic catalysed innovation in service delivery and modes of access. However, remote consultation has resulted in an increased workload of 25 per cent to 31 per cent (online and video respectively)[48], with evidence suggesting that ease of access fuels demand.[49] As argued by the PCN network, the pandemic experience demonstrates that virtual care should be used when it results in enhanced patient and staff outcomes.[50]
     
  6. The vaccination programme has provided further proof of concept for the delivery of primary care at scale at neighbourhood-level through PCNs and demonstrated the value of primary care at greater scale at the place-level. ‘Networks of networks’ have organically developed to distribute vaccines to where they are needed, while GP federations have played an integral role.[51] As the NHS recovers from the pandemic, the opportunities of primary care at scale presents must be front and centre.

 

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

  1. Our members have some concerns about the effectiveness of the 111 call-first system. A common criticism has been that NHS111 is directing patients with the wrong profile to emergency departments (EDs), including those needing stitches removed or with very minor injuries, which could be dealt with in primary or community settings. A similar theme is repeated by PCN network members where practices are holding appointments for NHS111 patients that are either not used or used inappropriately by patients who have to be re-referred.
     
  2. Other members believe that the full potential of the 111 call-first service in smoothing their demand peaks has not been realised. They found that the highest volume of 111 calls have been occurring at the same time as typical emergency demand peaks, and one trust showed us figures suggesting over 85 per cent of referrals from NHS 111 were for patients to present at the ED within one hour, which exacerbates that problem. They felt that this was one of the major selling points of 111 call-first for EDs and represented a “missed opportunity”.
     
  3. Multiple trusts felt that the algorithm appeared to be risk averse. This should be mitigated by patients being clinically validated before being directed to an ED.
    Several members felt that the message “don’t present to the nearest ED, ring 111 first” had not cut through to the public; something that could be rectified by a clear marketing strategy.

     

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

 

  1. Local leaders are best placed to decide on the most effective interventions locally to manage waiting lists. The Department of Health and Social Care (DHSC), national bodies and local systems should work with leaders across the NHS to support them to innovate by supplying the commensurate funding and workforce.
     
  2. The government and national bodies need to support the NHS to manage the realities of recovering services, not set unrealistic targets and impose financial penalties. A key part of this is an oversight framework which enables local leaders to lead and innovate.

 

  1. Waiting well initiatives in particular need ongoing support from DHSC and national bodies. This can be promoted through rapid access to diagnostics and smarter triaging; clinical status reviews to systematically prioritise patients with comorbidities or whose conditions would significantly worsen with long delays; and supporting patients with comorbidities to improve their outcomes while waiting through ongoing support, advice and guidance.
     
  2. To continue developing hot and cold sites at pace, DHSC and its national bodies should allocate small amounts of capital at pace and without many of the drawn out and cumbersome bidding and allocation processes seen in the past. As a minimum, existing capital allocations should be brought forward. With low interest rates, additional capital investment will contribute to the government’s levelling-up agenda and pay wider dividends to economic recovery.[52]
     
  3. To capitalise on recent technological progress and to ensure this lasts beyond the pandemic, the right digital infrastructure and staffing need to be in place. The upcoming Spending Review offers an opportunity to explicitly address the workforce and skills the NHS needs and support less technologically advanced NHS providers. A recent survey of NHS staff by the Health Foundation highlighted sufficient staffing as one of the top challenges of capitalising on recent technological progress, alongside infrastructure.[53] DHSC should fund the development of tools to scan for early symptoms of life-threatening conditions such as cancer as part of routine interactions with patients and support the use of diagnostic hubs to optimise resources in deprived populations.
     
  4. As outlined above, the pandemic has accelerated a trend of organisations across the health and care system working collaboratively to streamline support and improve pathways. The health and care bill will help codify some of this work, but DHSC and national bodies must offer additional support and equitable incentives to enable primary and secondary providers to collaborate in assessing and managing the backlog. For example, support should be given to GPs to manage day-to-day administrative pressures and to avoid lower threshold referrals as a pressure release mechanism, with instruments in place to incentive cooperation through rewarding activity and/or outcome accordingly. Achieving cross-provider collaboration and cooperation requires a partnership of equals, and this culture change must be encouraged at a national level. Peer review support and closer working between generalists and specialists should be developed to provide direct access to rapid diagnostics and direct to procedure referrals for some procedures. Clinicians should be supported to manage high volume low complexity work separately from fast access cancer pathways and pathways likely to be disrupted by further COVID-19 waves. It will be important to gain the support and active buy-in of clinicians, especially when these reforms change existing working patterns. Another reason why consistent workforce planning and support is so important.[54]

     

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

 

  1. As of 4 July 2021 an estimated 945,000 people are experiencing self-reported ‘long COVID’, a number which is decreasing as prevalence of COVID-19 decreases.[55] Since the variety of symptoms associated with long COVID is broad, there are inconsistencies in how it is coded in health records. This makes it hard to plan, project and design services and research.
     
  2. Increased NHS capacity is needed to manage people with long COVID across all healthcare services. Long COVID can reduce capacity, both in terms of staff who have long COVID, and also formal and informal carers who are affected. Long COVID compounds demand challenges associated with complexity of care, with mental health and pandemic related delayed presentations.
     
  3. The majority of long COVID care is being delivered in primary care, with community services, mental health and A&E also picking up significant amounts of this work. Members call for a combination of specialist services (in part to exclude other diagnoses) and equal investment in primary care and communities to provide long term support and rehabilitation for those affected by long COVID syndromes.
     
  4. The Office for National Statistics estimates that 122,000 healthcare personnel were affected by long COVID in April 2021 – nearly 4 per cent of the total workforce.[56] Uncertainties around how the condition will affect staff over time make it difficult to plan and could clearly have a serious impact in some areas on experienced long serving staff and could trigger early retirement. There is particular concern among NHS employers about the impact of long COVID on BME staff. Our members report psychological issues and long COVID are playing a growing role in sickness absences, which inhibit elective recovery. NHS staff who are suffering from long COVID should be supported with long-term COVID-19 sick pay and leave arrangements, including where there is a resurgence in symptoms warranting repeated periods of leave.[57]

 

References


[1] NHS England (2021) Consultant-led referral to treatment waiting times: https://www.england.nhs.uk/statistics/statistical-work-areas/rtt-waiting-times/

[2] NHS Confederation (2021) Building back inclusively: Radical approaches to tackling the elective backlog [In press].

[3] GP Patient Survey (2021) Surveys and Reports Fieldwork January – March 2021:
https://gp-patient.co.uk/surveysandreports

[4] NHS Confederation (2021) Building back inclusively: Radical approaches to tackling the elective backlog [In press].

[5] Ibid.

[6] Institute for Fiscal Studies (2021) What could happen to NHS waiting lists in England? https://ifs.org.uk/nhs-waiting-lists

[7] NHS Confederation (2021) Building back inclusively: Radical approaches to tackling the elective backlog [In press].

[8] NHS Confederation analysis of NHS Digital (2021) Mental health services data set (MHSDS):
https://digital.nhs.uk/data-and-information/data-collections-and-data-sets/data-sets/mental-health-services-data-set

[9] Centre for Mental Health (2021) Covid-19 and the nation’s mental health: https://www.centreformentalhealth.org.uk/publications/covid-19-and-nations-mental-health-may-2021

[10] NHS Confederation: Mental Health Network (2021) Reaching the tipping point: children and young people’s mental health: https://www.nhsconfed.org/publications/reaching-tipping-point

[11] NHS Confederation analysis of NHS England (2021) Children and young people with an eating disorder waiting times:
https://www.england.nhs.uk/statistics/statistical-work-areas/cyped-waiting-times/

[12] NHS Confederation analysis of NHS England (2021) Provider-based Cancer Waiting Times:
https://www.england.nhs.uk/statistics/statistical-work-areas/cancer-waiting-times/monthly-prov-cwt/2021-22-monthly-provider-cancer-waiting-times-statistics/provider-based-cancer-waiting-times-for-may-2021-22-provisional/

[13] Ibid.

[14] NHS Confederation (2021) Primary care networks: two years on: https://www.nhsconfed.org/sites/default/files/2021-08/Primary-care-networks-two-years-on-01.pdf

[15] British Medical Association (2021) Pressures in general practice:
https://www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/pressures/pressures-in-general-practice

[16] NHS Confederation (2021) Primary care networks: two years on: https://www.nhsconfed.org/sites/default/files/2021-08/Primary-care-networks-two-years-on-01.pdf

[17] NHS Confederation (2021) Building back inclusively: Radical approaches to tackling the elective backlog [In press].

[18] Ibid.

[19] Ibid.

[20] Ibid.

[21] NHS Confederation (2021) Manifesto for recovery: the health and care system after COVID-19 [In press].

[22] Ibid.

[23] The Royal College of Surgeons of England (2021) Action Plan for the Recovery of Surgical Services in England: https://www.rcseng.ac.uk/about-the-rcs/government-relations-and-consultation/position-statements-and-reports/action-plan-for-england/

[24] NHS England (2019) NHS Mental Health Implementation Plan 2019/20 – 2023/24: https://www.longtermplan.nhs.uk/wp-content/uploads/2019/07/nhs-mental-health-implementation-plan-2019-20-2023-24.pdf

[25] Centre for Mental Health (2021) Covid-19 and the nation’s mental health: https://www.centreformentalhealth.org.uk/publications/covid-19-and-nations-mental-health-may-2021

[26] NHS England (2021), Addressing impact of COVID-19 on BAME staff in the NHS: https://www.england.nhs.uk/coronavirus/workforce/addressing-impact-of-covid-19-on-bame-staff-in-the-nhs/

[27] British Medical Association (2021) Rest, recover, restore: Getting UK health services back on track: https://www.bma.org.uk/media/3910/nhs-staff-recover-report-final.pdf

[28] NHS Digital (2021) NHS Vacancy Statistics England April 2015-June 2021: https://digital.nhs.uk/data-and-information/publications/statistical/nhs-vacancies-survey/april-2015---june-2021-experimental-statistics

[29] NHS Digital (2021) NHS Sickness Absence Rates – April 2021 Provisional Statistics: https://digital.nhs.uk/data-and-information/publications/statistical/nhs-sickness-absence-rates/april-2021-provisional-statistics

[30] NHS England (2021) Workforce Race Equality Standard (MWRES): https://www.england.nhs.uk/wp-content/uploads/2021/07/MWRES-DIGITAL-2020_FINAL.pdf

[31] Nursing Times (2021) Spike in mental health absences among NHS staff after difficult winter:
https://www.nursingtimes.net/news/mental-health/spike-in-mental-health-absences-among-nhs-staff-after-difficult-winter-06-08-2021/

[32] NHS Confederation (2021) Primary care networks: two years on: https://www.nhsconfed.org/sites/default/files/2021-08/Primary-care-networks-two-years-on-01.pdf

[33] NHS Digital (2021) NHS Vacancy Statistics England April 2015 – June 2021 Experimental Statistics: https://digital.nhs.uk/data-and-information/publications/statistical/nhs-vacancies-survey/april-2015---june-2021-experimental-statistics

[34] Health Foundation REAL Centre (2021) Health and social care funding projections 2021 [In press].

[35] Ibid.

[36] Institute for Fiscal Studies (2021): Could NHS waiting lists really reach 13 million? https://ifs.org.uk/publications/15557

[37] NHS Confederation (2021) Letter to the Chancellor about addressing the elective care backlog: https://www.nhsconfed.org/publications/letter-chancellor-about-addressing-elective-care-backlog

[38] NHS Confederation (2021) Winter in summer: the NHS at crunch point: https://www.nhsconfed.org/publications/winter-summer-nhs-crunch-point

[39] National Audit Office (2020) Readying the NHS and adult social care in England for COVID-19: https://www.nao.org.uk/wp-content/uploads/2020/06/Readying-the-NHS-and-adult-social-care-in-England-for-COVID-19-Summary.pdf

[40] NHS Confederation Community Network (2021) Discharge to assess: The case for permanent funding: https://www.nhsconfed.org/publications/discharge-assess

[41] NHS Confederation (2021) Discharge to assess – we must not lose progress: https://www.nhsconfed.org/articles/discharge-assess-we-must-not-lose-progress

[42] NHS Confederation (2021) Building back inclusively: Radical approaches to tackling the elective backlog [In press].

[43] NHS Confederation (2021) Manifesto for recovery: the health and care system after COVID-19 [In press].

[44] NHS Confederation (2021) Building back elective care: a new framework for recovery: https://www.nhsconfed.org/publications/building-back-elective-care

[45] NHS Confederation (2021) A system approach to the demand crunch: https://www.nhsconfed.org/publications/system-approach-demand-crunch

[46] NHS Confederation (2020) Lean, light and agile: governance and regulation in the aftermath of COVID-19: https://www.nhsconfed.org/publications/lean-light-and-agile

[47] British Medical Journal (2021) The “virtual wards” supporting patients with covid-19 in the community: https://www.bmj.com/content/369/bmj.m2119

[48] Journal of Medical Internet Research (2020) The Impact of Digital-First Consultations on Workload in General Practice: Modeling Study: https://www.jmir.org/2020/6/e18203/

[49] Nuffield Trust (2017) Meeting need or fuelling demand? Improved access to primary care and supply-induced demand: https://www.nuffieldtrust.org.uk/files/2017-01/meeting-need-or-fuelling-demand-web-final.pdf

[50] NHS Confederation (2021), Primary care networks: two years on: https://www.nhsconfed.org/sites/default/files/2021-08/Primary-care-networks-two-years-on-01.pdf

[51] NHS Confederation (2021) How primary care federations have supported the COVID-19 vaccination programme: https://www.nhsconfed.org/publications/how-primary-care-federations-have-supported-covid-19-vaccination-programme

[52]NHS Confederation (2021) Building back elective care: a new framework for recovery: https://www.nhsconfed.org/publications/building-back-elective-care

[53] The Health Foundation (2021) Securing a positive health care technology legacy from COVID-19: https://www.health.org.uk/publications/long-reads/securing-a-positive-health-care-technology-legacy-from-covid-19

[54] NHS Confederation (2021), Building back inclusively: Radical approaches to tackling the elective backlog [In press].

[55] Office for National Statistics (2021) Prevalence of ongoing symptoms following coronavirus (COVID-19) infection in the UK: 5 August 2021: https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsanddiseases/bulletins/prevalenceofongoingsymptomsfollowingcoronaviruscovid19infectionintheuk/5august2021

[56] inews (2021): ‘Tens of thousands’ of NHS staff are suffering with long Covid: https://inews.co.uk/news/uk/tens-thousands-nhs-staff-suffering-long-covid-941457

[57] Royal College of Nursing (2020) The impact of long term COVID-19 on the nursing workforce: https://www.rcn.org.uk/news-and-events/blogs/the-impact-of-long-term-covid-19-on-the-nursing-workforce

 

Sept 2021