Written evidence submitted by The Health Foundation (CBP0066)
About the Health Foundation
The Health Foundation is an independent charity committed to bringing about better health and health care for people in the UK. Our aim is a healthier population, supported by high quality health care that can be equitably accessed. We learn what works to make people’s lives healthier and improve the health care system. From giving grants to those working at the front line to carrying out research and policy analysis, we shine a light on how to make successful change happen.
Below we set the Health Foundation’s assessment of the key issues related to the elective care backlog in the NHS, with reference to new and already published analysis. We have provided answers to the questions where we have evidence and insight that will be most helpful to the Committee, including new modelling on what it may cost to clear the elective care backlog. We also provide an annex at the end of this submission.
Given the scale of the backlog, recovery to pre-pandemic levels will take several years, and we welcome the Committee’s acknowledgement of the need to look beyond the short-term response. If the health and care system can create and deliver a long-term framework for recovery that is efficient, safe, person-centred and equitable, there is an opportunity to embed sustainable improvements in the design and delivery of elective care. While delivering care to those who need it in the short-term, this could also help to realise some long-term aspirations for the service, including reform of outpatient services, increasing patient involvement in their care and speeding up the adoption and spread of technological and digitally enabled care.
The solutions and approach used for reducing elective waiting lists in the past, which included significant financial investment to expand capacity, and the use of competition, financial incentives and targets to drive additional activity in individual organisations, will need to change to take account of the current challenge and policy context. This changed context includes financial constraints, the capacity and wellbeing of the health and social care workforce post-pandemic, the direction of system reform in developing whole system working to achieve better integration of care, and increased recognition of inequalities in access to care.
The NHS recognises the need to address this wider set of objectives, for example in the approach to payments increased activity levels through the Elective Recovery Fund, which now includes incentives to address health inequalities and support staff recovery. A comprehensive framework, including a clinically informed measurement approach, realistic recovery trajectories, and support for integrated care systems to develop the data, improvement approaches and systems that enable mutual aid and learning between Trusts, would further help support providers to meet these objectives.
Enabled by a supportive policy framework, the NHS will need to think and act innovatively in how it redesigns pathways to address the elective care backlog. Independent sector capacity will be a part of the answer, although as we describe in this submission, this is not a perfect match for the need, and risks exacerbating inequalities in access to care. The NHS has already established the Accelerator Sites programme, and existing initiatives such as the Getting it Right First Time programme can support sharing of knowledge and approaches across the NHS.
Q. 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 care backlog
Projections of elective backlog need from the Health Foundation’s REAL Centre upcoming report
Our upcoming report Health and Social Care Funding Projections 2021 details our estimates of the anticipated size of the elective care backlog and analysis of the costs. A range of estimates are presented as there is uncertainty about: the number of “returning patients” (i.e. those not referred during the pandemic who will be subsequently), the cost of treating those patients, and the policy decisions about how quickly to treat them (which may affect costs in a number of different ways).
The last time the 18-week referral to treatment (RTT) waiting times target was met was in February 2016. Although activity generally increases each year - and so the size of the waiting list for which the 18-week RTT target can be met also grows (’18-week manageable waiting list’) - the waiting list (‘actual waiting list’) has been growing faster than the rate at which the target can be met (Figure 1).
During the COVID-19 pandemic millions of patients who would have been expected to be referred for treatment were not. In our modelling we allow for some growth in referrals year-on-year and estimate the number of ‘missing patients’ may now be approaching 8 million.
While the size of the waiting list dipped during the pandemic, since then it has grown sharply. As services resume, some of the ‘missing patients’ would be expected to return but there is significant uncertainty over how many (here we show a range: 50%, 75% and 90%; below we estimate costs for 50% and 75% only) and when. If sizeable numbers of patients do return and activity reverts to pre-pandemic trends, we estimate the waiting list could grow to 10.5-13.7 million (with 50-90% of missing patients returning over three years).
The elective care backlog is therefore the difference between the estimated waiting list size and the manageable waiting list size i.e. the total number of patients that would need to be treated to get back to the 18-week manageable level. There is also some recurring activity needed to ensure the list stays at this manageable level (given the waiting list has in recent years been growing faster than activity).
Figure 1 – Actual and projected elective waiting list size
Key outputs: What will it cost to get the NHS and social care on the road to recovery? https://www.health.org.uk/news-and-comment/blogs/what-will-it-cost-to-get-the-nhs-and-social-care-on-the-road-to-recovery
Our key findings and modelling assumptions on the cost of meeting the elective backlog as a result of these trends are presented below.
Key information about the waiting list during and before the pandemic are presented in the Annex below.
Impacts on health and wellbeing of waiting for care
The growth in the elective care waiting list has occurred despite a significant disruption to GP services: a common route of referral to secondary care.
There were an estimated 23 million fewer primary care consultations in 2020 compared with 2019. Almost 16 million (70%) of these were for people who hadn’t been diagnosed with common pre-existing non-communicable diseases.
There was a relatively smaller fall in activity for patients with pre-existing non-communicable disease. The largest falls in activity are for young people without illness. Again, this raises the question of how much of this is unmet demand for care, or a fall in need for care.
The disruption to GP services makes unclear the extent to which the current elective wait list is underrepresenting levels of need. Looking at primary care data we observe a clear and sustained reduction in routine referrals.
The stark reduction in routine referrals followed guidance from NHS England aimed at relieving pressure on acute care services. Referral rates had not recovered by the end of January 2021, resulting in an estimated 4.5 million missing referrals from 2020 in total.
By autumn 2020, the rates of 2-week wait referrals (for suspected cancer) and urgent referrals were broadly the same as in previous years.
However, 2-week wait referrals did not increase enough to account for the substantial reduction in the first lockdown. Around 250,000 estimated 2-week wait referrals were missing by the end of January 2021.
Long read on initial impact of pandemic on primary care: https://www.health.org.uk/news-and-comment/charts-and-infographics/use-of-primary-care-during-the-covid-19-pandemic
Reviewing cancer waiting times data we can see how the types of activity that has come through the system has been affected by COVID-19.
Lots of aspects of care and treatments pathways have suffered as a result of the pandemic, but cancer screening has been particularly affected. We analyse the number of patients who have gone from a new cancer diagnosis to a first treatment for cancer.
Source: NHS England cancer wait times data, analysis by the Health Foundation’s REAL Centre, code for analysis available at https://gitlab.com/tlswatt/cancer-wait-times
The impact of the disruption of the pandemic is clear, by mid-2021 the cumulative difference between observed and predicted first treatments is more than 40,000. This implies there are more than 40,000 patients who are living with undiagnosed cancer, have died with undiagnosed cancer, or have decided not to undergo treatment.
This effect has come from the reduction in consultations and referrals, the necessary pressure on secondary care to focus on the pandemic and a dramatic reduction in attendance of cancer screening. Of this 40,000 plus backlog of missing cancer patients, over 10,000 are missing from the normal diagnosis numbers following a screening.
Source: NHS England cancer wait times data, analysis by the Health Foundation’s REAL Centre, code for analysis available at https://gitlab.com/tlswatt/cancer-wait-times
Recently published data from the National Cancer Registry and Analysis Service (NCRAS) show clear socioeconomic inequalities in the impact of COVID-19 on cancer.
We know cancer incidence rates are higher in more deprived areas. These data show that urgent referrals for cancer (orange) and first treatments for new cancer (blue) fell significantly more for people living in the most deprived areas of the country.
Q. 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?
In 2020 we estimated that to meet the elective backlog an additional 4,100 consultants and 17,100 nurses would be needed.[i] Since then the number of additional treatments needed to meet the backlog as grown.
If 75% of missing patients return, we estimate that meeting the RTT target by 2024/25 would require 13% more pathways to be completed each year than in 2019/20; this equates to an additional 4,440 consultants and 18,310 nurses each year.
Under a more conservative scenario, under which the system is on course to return to 18/19 level of performance by 2028/29, the number of pathways would need to be 7% higher than 2019/20; this would mean an estimated 2,270 extra consultants and 9,370 nurses would be needed each year.
Figure 7 - Estimated additional resources required (75% missing patients returning)
Extra resources needed
Returning to 18/19 levels of performance
Meeting the RTT target (2021/22-2024/25)
While the independent sector can contribute to addressing the backlog, it is not a perfect substitute for NHS capacity and is not evenly distributed within England.[ii] There are at least four issues with independent sector (IS) capacity that we have identified:
Supporting staff wellbeing as part of the NHS recovery:
Q. 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?
Analysis from the Health Foundation’s REAL Centre projections report
Our estimates show that clearing the backlog to return to the 18-week RTT target would cost £11.7bn (50% of ‘missing patients’ returning) to £15.7bn (75%) over the remainder of this parliament (up to 2024/25). In addition, some recurring cost of around £300m would be needed each year to reach and maintain the 92% target. In all, over this parliament, an additional £12.8bn to £16.8bn in additional funding would be needed.
That funding would enable the NHS to clear the backlog of people waiting for routine elective care – a record 5.5million people now waiting for care – including returning ‘missing patients’ by treating an additional 1.7milion to 2.2million people a year.
By these estimates, between £3.2bn and £4.2bn a year in additional funding would be needed each year from 2021/22 to 2024/25 to meet the 18 weeks target. However, even with this funding, there may not be capacity to treat this number of patients over the next 4 years. It would mean almost 800,000 extra hospital admissions a year, on top of the [2.5%] growth in activity needed to keep pace with underlying growth in demand.
The NHS was given £1bn for 2021/22 to address the waiting times backlog, considerably less than the REAL Centre’s estimate of what would be needed.
How we calculated the figure
As set out above waiting lists were growing prior to the pandemic and a number of “missing patients” who were not referred after COVID-19 may return for treatment (we estimate the number of ‘missing patients’ is now approaching 8 million). As services resume, some of these patients are expected to present to the NHS needing care, although precise numbers are uncertain. Our analysis suggests the waiting list could grow to 10.5-12.5 million if 50-75% of people do return and activity continues as usual.
We model two options facing the government: to clear the backlog over the course of this Parliament - which will present significant challenges in terms of boosting staffing levels and capacity – or address the waiting list over a longer time-period. Meeting the target in 2024/25 means bringing the waiting list down to 3.8million by March 2025. Alternatively, by our modelling, tackling the backlog by 2028/29 could mean running with a waiting list of 7-8million (50%-75% of patients returning) in March 2025.
To meet constitutional waiting times standards, the NHS would therefore need to do two things: first, undertake more activity on an ongoing basis to stop waiting lists from growing; and second, clear the backlog for elective care[iii]. The first corresponds to a recurrent or ongoing cost. The second, clearing the backlog, is modelled as a one-off increase in activity to treat those already waiting and returning ‘missing patients’[iv].
Costs are based on a weighted average of outpatient and inpatient costs of admission. Only some patients will require a hospital admission. In 2018/19, 22% of all completed pathways were admitted. Looking only at those completed over 18 weeks, a higher proportion were admitted (39%). We assume 39% of those in the backlog, including missing patients, are admitted.
Furthermore, the non-recurrent costs of clearing the backlog are uprated to account for the price premium associated with using more bank and agency staff or capacity in the private sector. The extra costs associated with hiring more temporary staff are likely to be substantial. While bank and agency staff account for around 8% of the NHS workforce on average, REAL Centre analysis indicates that they cost on average 90% more than establishment staff per whole time equivalent[v]. We account for the expected higher costs by adding a cost premium to the usual costs of treating patients. We assume this is 50% and 25% cost premium, respectively, associated with clearing the backlog over a 4 or 8-year horizon.
Below, we show two charts:
Note, the costs of meeting the backlog also need to be weighed against the health impacts of delayed care including potentially greater severity and cost[vi] and any wider losses to the whole economy from higher sickness rates.
Q. 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?
As we set out in our overview to this submission, recovering elective care services will not only need significant financial investment and support for a tired workforce, but also action on several other fronts. Enabled by a supportive policy framework, the NHS will need to think and act innovatively in how it redesigns pathways to address the elective care backlog.
In this question, we set out work on identifying seven promising models of care and ways of working that could support recovery.
Since April 2021, the Health Foundation has engaged in conversations with frontline NHS staff to determine the key issues impacting and influencing their response to the elective backlog. In June 2021 we held two research sessions with members of the Q community (a network of over 4,000 members with improvement expertise) to explore issues and challenges connected to backlogs and waiting times for health and care services. Through this work and our wider conversations with staff leading recovery efforts, we have surfaced a range of promising solutions being trialled. This is not intended to be a comprehensive overview of all the ways in which NHS services can be reformed.
Alongside the effective management of waiting lists to ensure people receive care and waiting times are reduced, it is equally important to improve the waiting process. A recent National Voices report described the impact that a poorly managed waiting time can have on peoples’ physical and mental health and highlighted the need to understand the importance of the waiting experience, invest in developing patient-centred communication and information and ensuring people know about and can access support to help them manage their health and care while they wait.
Voluntary, community and social enterprise (VCSE) organisations and their staff have provided unprecedented levels of support to the NHS since the pandemic began. They are now also providing much needed support to different patient groups, particularly those with long-term conditions and those awaiting elective surgery. This is not a free resource. The commitment from the VCSE sector needs to be acknowledged and supported, including financially.
There is increasing recognition that what happens before and after surgery has significant impact on the quality and efficiency of care. The Centre for Perioperative Care (CPOC) has recently published guidance on preoperative assessment and optimisation for adult surgery.
The guidance calls for the establishment of pre-operative pathways that include optimisation of comorbidities, nutritional status, psychological preparedness or functional capacity (fitness). Viewing ‘waiting lists’ as ‘preparation lists’ that optimise patients prior to surgery, has the potential to reduce last minute cancellations, increase chances of a successful procedure, and address longstanding causes of poor health. Embedding shared-decision making (SDM) throughout perioperative pathways is a key component. There is good evidence that when done well, SDM often leads to more conservative treatment decisions, reducing demand for surgery.
The pandemic has seen increased use of digital technology to support care delivery, which has potential to support elective recovery.
For example, the development of ‘virtual wards’ aims to support patients to leave hospital earlier, through enabling them to record their own clinical data at home and submit this to their clinical teams via home devices or apps. NHS X has developed ‘digital playbooks’ advising how technology can be used to deliver more care and advice remotely. It is important these approaches are tested and well evaluated to understand their impact.
Reforming outpatient care has long been an ambition of the NHS and Patient Initiated Follow Up (where patients decide when they need contact with their secondary care team rather than attending appointments at arbitrary or fixed intervals determined by the service) is considered a key part of the solution, reinforced most recently in the Long-Term Plan.
Patient Initiated Follow Up has the potential to reduce unnecessary outpatient appointments, providing patients with care when needed the most, and improving patient and clinician satisfaction. For this to be a success, patients need to be supported and given confidence to act on their symptoms and pathways need to be integrated to ensure patients do not get ‘lost’ in the system. Technology also needs to be thoughtfully optimised to include co-produced questionnaires with patients and clinicians, professional initiated data-led recall, and easy access to information for both patients and clinicians.
Several providers have told us that there is a strong desire to ensure patients are prioritised appropriately, but this is not straightforward. There is often a tension between prioritising those who have been waiting the longest and a desire to ensure patients are prioritised according to their clinical need. A recent Health Foundation publication exploring differences in waiting times for hip replacements and diabetes care across England highlighted wider factors that may also be relevant, including impact on an individual’s quality of life or personal finances or a desire to reduce inequalities. Frontline staff would benefit from national support and sharing of good practice to enable them to balance the moral, financial and political tensions as they prioritise patients waiting for care.
Better data is also needed to aid prioritisation decisions. Further guidance and investment in analytical capability is needed to allow providers to develop local patient databases with detailed demographic and clinical information to allow them to monitor patients on the waiting list and make more informed prioritisation decisions. NHS providers have told us that they are also keen to utilise the formation of Integrated Care Systems to facilitate a system-wide single waiting list and sharing workforce and operating space where possible. This does however require strong leadership, especially where multiple providers within the same region only provide sub-specialist care, and when patients may be unable or reluctant to access care from centres that are further away.
The pandemic has seen an increase in the use of advice and guidance services. This has been of particular benefit to primary care clinicians who are potentially able to seek specialist secondary care advice electronically within a designated period of time, often reducing the need for onward referral. Careful consideration is needed to ensure clinicians in both primary and secondary care have sufficient time to manage this alongside pre-existing clinical commitments.
The implementation of new infection control policies to reduce nosocomial COVID-19 transmission has had a significant impact on the use of NHS facilities and estates. Space has become an important commodity and many NHS providers have rapidly procured new facilities in order to deliver routine procedures. An example includes NHS Nightingale Hospital Exeter which has been purchased by NHS organisations in the South West and is being used to provide diagnostic scans including CTs and MRIs, host a vaccination trial and train international nurses. Royal Devon and Exeter is one of the accelerator sites announced in May 2021 and also pledged to create purpose-built modular units to facilitate an increased number of eye operations in the community. University Hospitals Dorset NHS Trust announced that it would be setting up a “health pop up village” in a local shopping centre as part of its efforts to address backlogs in care.
Whilst acquiring more space is an attractive solution in the short-term as infection control policies remain, this creates additional burden on staff and patients having to travel away from their usual site. It also raises questions about how these sites are governed and regulated to ensure quality and safety standards are maintained.
Key Health Foundation outputs
Q. 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?
The COVID-19 pandemic shone a spotlight on the commitment, resilience and agility of frontline health and care workers.
The pandemic has led to rapid and significant changes in how NHS services are delivered and used. In September 2020 we published a long-read that draws on expertise from the frontline and highlighted enablers and barriers to implementing change within the NHS. We also considered what is needed to sustain these changes and generated a high-level model to depict these (Figure 9).
Figure 9: A high level model for sustainable change
This work was not intended to provide a systematic review of all of the service shifts during Covid-19 (and see work by the Beneficial Changes Network and Accelerated Access Collaborative to understand these shifts more fully) but rather to provide a snapshot of the key shifts (see Table 1) and distil the key enablers of these changes, the potential barriers to sustaining them and to set out a framework to help teams, organisations and system leaders to understand where attention is needed if these changes are to be retained in the longer term.
Table 1: Examples of the service shifts emerging during the COVID-19 pandemic
Primary and community
Specialist diagnosis and treatment
Source: stakeholder interviews, grey and other literature.
An important lesson from the service shifts that occurred during the pandemic is the need for the right balance of central coordination and guidance with greater autonomy for those on the frontline to lead change – what we describe in our paper as “a combination of top-down clarity and bottom-up agency”.
One critical factor in creating that bottom-up agency was freeing up capacity. Staff were released from other duties to concentrate on implementing and delivering change, enabled by a significant reduction in services. As normal services resume, transformation ambitions will once again collide with workforce pressures. If we want the NHS to have the kind of capacity for innovation that we saw during COVID as part of business as usual, there will need to be increases in the clinical and improvement workforce.
Understanding and sustaining the health care service shifts accelerated by COVID-19, Health Foundation 2020
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
Switched on: How do we get the best out of automation and AI in health care?: https://doi.org/10.37829/HF-2021-I03
Digital transformation in the NHS. National Audit Office. May 2020. https://www.nao.org.uk/wp-content/uploads/2019/05/Digital-transformation-in-the-NHS.pdf
Q. What can the Department of Health & Social Care, national bodies and local systems do to facilitate innovation as services evolve to meet emerging challenges?
As set out above, recovering the backlog will require a comprehensive policy approach, including financial investment, support for the capacity and wellbeing of the workforce, a clinically informed measurement approach, realistic recovery trajectories, and support for integrated care systems to develop the data, improvement approaches and systems that enable mutual aid and learning between Trusts.
Our research on service innovation during the pandemic concluded that the right balance between top-down authority and bottom-up agency and effective dispersed leadership at national, regional and local levels was key to enabling innovation, as was finding ways to build on the shared purpose that drove much of the rapid innovation and improvement during COVID-19. In addition to the policy action described above, there are three things that leaders at all levels of the system can do to facilitate innovation in recovery.
In addition to funding for specific approaches or “solutions” to address backlogs in care, teams need the capability to implement them well. How successfully reforms like new technologies and models of care are implemented will ultimately be critical to realising their benefits. Key enablers include digital infrastructure, leadership and management capability and Quality Improvement and analytical skills.
This underlying ability to improve is critical in enabling the service to adapt to challenges. A 2020 survey of Q Community members showed that those organisations that had invested in building improvement capability before the pandemic were better able to use improvement skills and approaches to develop effective responses and support strategic decision making during the pandemic. For example, Northumbria Healthcare NHS Foundation Trust had a long history of investing in improvement and prioritising patient and staff experience and were able to quickly adapt a project focused on using real-time staff feedback for improvement to create Corona Voice which they used to make more effective decisions, including on procuring personal protective equipment and supporting staff working from home.
As is clear from the examples in Q4, there are many ways in which frontline staff, teams and organisations are seeking to innovate and redesign services and pathways to address the backlogs in care. It is important that these are evaluated and that learning from the successes and failures is shared transparently and used for further improvement.
However, it is also important that people can learn and act quickly given the urgency of the challenges. Investing in rapid and robust evaluation methods, such as those used by the NIHR funded BRACE and RSET teams, or the Health Foundation’s own Improvement Analytics Unit, and building analytical capability across the system must be an urgent priority. As a starting point, NHS England should be clear about how they are supporting evaluation of the Elective Recovery Accelerator sites and what measures it will include beyond a focus on increasing levels of activity, which are important but not sufficient.
A clear message from the frontline staff we have spoken to is that they feel there is a real gap around how people can learn from each other about how they are tackling challenges. This is important to ensure that people are not constantly reinventing the wheel, to provide a space for people to share challenges and problem solve collectively and to enable people to learn from an adapt ideas to the specific challenges they face.
In The Spread Challenge, our 2019 report on the adoption of spread and innovation in the NHS, we asked teams who had been involved in adopting innovations as part of Health Foundation programmes what would have made the biggest difference in helping them adopt the innovation successfully. Their top answer was providing more opportunities to share learning and experiences with one another.
We have seen a number of individually led initiatives being coordinated and facilitated to try and fill this gap in relation to addressing backlog challenges such the Proud2bOps National Network working with staff leading elective recovery and sharing insights via the twitter hashtag #SharingElectiveStuff and through informal online discussions to share innovative examples and facilitate wider discussion. This is being done on a voluntary basis by staff who are already under significant pressure to address backlogs of care in their organisations or local systems. Many would welcome more national support to facilitate these conversations and shared learning and ensure it reaches a larger audience. Supporting this work at all levels of the system could also help in creating anew a sense of shared mission that was so critical during the pandemic.
The Q Community also has an important contribution to make in connecting improvers tackling the challenges of service recovery and generating and sharing insights. Throughout 2020 and 2021, the Q Team at the Health Foundation, working with our partners, have undertaken a number of workstreams to surface and share learning and insights to support improvers work to respond to the pandemic and address emerging challenges, including backlogs in care. Through the Q Exchange programme, we are also funding 30 teams, led by Q members, focused on embedding positive changes emerging through new collaborations or partnerships during COVID-19. As part of the funding, teams agree to share their learning and insights with the Q Community and more widely.
Annex A – key waiting times data
Elective waiting time – key facts
Pre COVID-19 how many patients flowed onto the waiting list each month and how many were coming off?
During COVID-19 how many patients flowed onto and off the waiting list?
What was the waiting time pre-COVID-19 and during the pandemic?
What was the share of admitted and non-admitted patients before and during the pandemic?
How much of waiting list is orthopaedics, mental health, eyes and cancer?
Cancer and mental health waiting lists not published on comparable basis:
What proportion of those of waiting list are 65 and over, and which regions have the longest list
68.8% of waiting list in England within 18 weeks in Jun 2021 (83.2% in Jun 2019)
Regions in Jun 2021 (best to worst):
Biggest falls in Midlands (2nd best in Jun 2019) and North West (3rd best).
All numbers sourced from:
NHS England. Consultant-led Referral to Treatment Waiting Times Data.
 Note, our estimate here includes a growth in referrals of 1.8% year-on-year, which is estimated based on historic data. This may reflect factors such as a growing and ageing population.
 Estimated over the period January 2017 -December 2019
 AsthmaAtrial Fibrillation, Cancer, Coronary heart disease, COPD, Drepression / anxiety or other neuroses, Diabetes (types I & II), Heart failure, Stroke (T.I.A)
 There are several reasons for extending this assumption to returning missing patients. For one, aadmitted patient care fell more significantly than non-admitted patient care during the pandemic. Another is that returning patient are likely to be of relatively high severity, both because GPs are more likely to refer those in greater need and because ‘missing’ patients, by definition, are being referred later than usual.
 This is an estimate based on the fact that vacancy rates for total NHS workforce have averaged 8% since 2018/19 and that most vacancies are filled by bank and agency staff according to latest data.
[i] REAL Centre, Spending Review 2020: Managing Uncertainty, 24 November 2020 https://www.health.org.uk/publications/long-reads/managing-uncertainty
[ii] Gardner T, Fraser C, Peytrignet S. Assessing the impact of COVID-19 in 2020 and where next ; Health Foundation; 2020 (https://www.health.org.uk/publications/long-reads/elective-care-in-england-assessing-the-impact-of-covid-19-and-where-next)
[iii] Findlay R. Revealed: The cost of restoring 18-week waits. Health Service Journal; 2017 (https://www.hsj.co.uk/finance-and-efficiency/revealed-the-cost-of-restoring-18-week-waits/7021025.article)
[iv] NHS England. Consultant-led Referral to Treatment Waiting Times. NHS England; 2021 (https://www.england.nhs.uk/statistics/statistical-work-areas/rtt-waiting-times/).
[v] REAL Centre. Nurse supply model. Projecting the future nursing workforce supply in England [webpage]. Health Foundation; no date (https://www.health.org.uk/what-we-do/real-centre/nurse-supply-model).
[vi] Krelle H, Barclay C, Tallack C. Waiting for care: Understanding the pandemic’s effects on people’s health and quality of life . Health Foundation; 2021. (https://www.health.org.uk/publications/long-reads/waiting-for-care)