NHS0010

Written evidence submitted by NHS Voices of Covid-19 at the University of Manchester

Our evidence submission draws on testimonies from NHS staff, clinical leaders, policymakers, and patients about the impacts and consequences of the pandemic on their personal and working lives and wider communities. The material is being gathered through the NHS Voices of Covid-19 (NHSVoC) project[1] which is creating a national collection of testimonies in partnership with the British Library that will form a permanent resource for research and policymaking. To date upwards of 2,000 interviews have been collected amounting to around 1,500 hours of audio recording. Voices from England, Wales, Scotland, and Northern Ireland are represented in the collection. Our use of oral history methodology facilitates sense-making and reflection on the part of interviewees. It evidences the scale and depth of the effects and longer term consequences of the pandemic on staff and on health services more broadly. A unique strength of NHSVoC evidence is its contextualisation within the longer history of the NHS through building on the NHS at 70 project which began work in 2017 to create the first oral history of the NHS through recording interviews with patients, staff and the wider public across the UK. More than 800 interviews were collected before the pandemic and provide a baseline for comparison and contrast.

Summary

• The COVID-19 crisis has exacerbated many pre-existing weaknesses in the health system which included long waiting times and particularly affected backlogs in ‘Cinderella’ services such as mental health services.
• Historical analysis can play a critical role through evidencing the longer trajectories of structural and cultural issues in the health system and providing learning to inform policy change.
• Backlogs are evident across the spread of NHS services. The effects of long waiting times in one part of the system are having significant impact on other parts of the system. Lengthy waiting times for patients referred by GPs to hospitals for example, translates into additional work for primary care staff to manage the care of these patients whilst they are waiting for specialist treatment.
• Since summer 2021 there has been significant increase in patient dissatisfaction with backlogs and waiting times. Whilst public attitudes to the NHS were extremely positive during the first phase of Covid-19, staff are now reporting abusive behaviour from patients unhappy with the length of waits for treatment.
• The impact on the physical and mental health of NHS staff working under these conditions is enormous. Workforce shortages together with staff reporting burnout and deciding to leave the NHS were a chronic problem before the pandemic. Since March 2020 these stresses have increased and our evidence shows that staff are responding by seeking to reduce their hours or leave the Service all together.

Recommendations

• Establishing a transparent dialogue with the public to communicate realistic expectations about the backlog in treatments and waiting times in the recovery period would be of benefit by both addressing patient dissatisfaction and relieving pressure on staff who are facing complaints and abuse.
• Supporting staff recovery from the physical and emotional effects of working through the pandemic and retaining staff who are considering leaving is a matter of priority. There is a global shortage of healthcare workers and though there may be political intentions to train more healthcare workers in the UK the immediate imperative is to retain current staff.

1. NHS waiting times in historical perspective

Waiting times have been a feature of the NHS since its creation in 1948. From the 1980s waiting times became a criteria for measuring performance across clinical areas, and from the 2000s, targets for length of wait were set for things such as GP patient referral to treatment, and attendance in Accident and Emergency departments. Workforce shortages were also a chronic problem before the pandemic and thus the current NHS backlogs and waiting times have been determined by these longer, historical issues as well as the more immediate effects of the pandemic.

1. Waiting times as historical concern

Our evidence shows how NHS waiting times have been a concern for NHS staff and patients prior to the pandemic. Whilst interviewees emphasise an important strength of the NHS as being free at the point of need, both staff and patients also describe long waiting times as a significant weakness of the NHS.

‘The strengths [of the NHS] are that it is open to anybody – it’s quite an amazing system. Weakness… [are] the waiting times and in certain disciplines there are shortfalls. I’m thinking psychiatry is one area that definitely is not tip top’. (001, Female, Nurse, London, 07/06/2021)

2. Waiting times for mental health services

Waiting times for mental health services are of particular concern to interviewees. Pre-pandemic interviewees identified that ‘Cinderella’ services such as mental health services were already at breaking point and the need for mental health services has been intensified by the impact of the pandemic on societal mental health.

‘I’ve had mental health problems, like anxiety or nervousness, because of my health… For mental health I’ve had to wait absolute months. I remember waiting for like four months on a waiting list for something like that, for mental health help, like therapy… It just takes so long to get seen to’. (002, Female, Patient, Location unknown, 18/04/2019)

3. Impact of waiting time targets on NHS staff

The introduction of waiting time targets has generally been welcomed by staff because it brings benefits to patients. However there is also evidence that there are circumstances when, due to staff shortages or other structural issues, NHS staff are not able to meet these targets and this puts them under a lot of pressure.

‘The thing that really fazed everybody was the four-hour target on waiting times. And staff resented that to start with because it was hard to manage. But from a patient point of view when weren’t overwhelmed – as we became overwhelmed – it was good practice for patients. Because it really made you think how that patient was feeling lying on a trolley for more than four hours. So from my point of view it was a good thing in the beginning. But then it became a huge burden when it became impossible to comply with that… It makes hospitals try to find ways round that aren’t necessarily good for patients’. (003, Female, Nurse, North Shields, 21/06/2019)

‘The government eventually brought in the four-hour target. And that focussed people’s attention. The people who needed to do things were then put into posts that didn’t exist. We got bed managers who would plan admissions, who would cancel admissions, who would begin to put some structure in, who would put pressure on the consultant and say, “you need to move these people out”, “you need to be looking to do a ward round on a Saturday”, and getting pharmacy in on a Sunday’. (004, Female, Nurse, Salford, 09/01/2019).

2. Impact of Covid-19 on waiting times

Our evidence shows that backlogs and long waiting times are manifest across all NHS services, including mental health services, non-emergency surgical procedures, pre-emptive screenings, and in primary care.

1. Surgical operations

Patients and NHS staff describe a significant backlog on surgical operations, as elective surgeries were cancelled during the peaks of the virus outbreak. The pandemic has resulted in many months of delays to surgical procedures and NHS staff are cognisant of the challenges of responding to this backlog and the difficulties experienced by patients.

‘An awful lot of the population have waited for operations they should have had over the last 18 months and therefore by the time they get them, if they didn’t get Covid and none of their family did, then they’re not necessarily grateful in the same way… It’s a tricky one because we don’t necessarily want to go in at full pelt, full speed on elective care. But equally we know that we need to be doing – hips and knees for example, we’ve only really done about one or two months of normal operating on that in the past twelve months. So there’s clearly ten months of normal referrals… That’s a lot to get through when that theatre usually works five days a week anyway.  If we are going to do more than that then we need to work out how we are going to do that’. (005, Male, Anaesthetist, Larbert, Scotland, 27/02/2021)

2. Pre-emptive screenings and cancer screenings

Covid-19 has had high impact on pre-emptive screenings. For example, patients describe having a seven-month delay to their breast screening appointment, and services having a backlog of up to a year.  This is particularly concerning for cancer screenings, given the importance of early detection on survival rates. Healthcare workers also emphasise their concern around the secondary impacts of the pandemic, cancer survival rates being one of them. Patients are being admitted to treatment with more advanced cancers and the fear of Covid-19 has also a been a contributing factor to this aspect.

‘Breast screening up here was stopped anyway for four months, okay, because of Covid. So, for example, I should have been called last July and I still haven’t, so you know, they are way behind – they said we’re about a year behind because of closing for four months, though even if you go on to Public Health England they say no breast screening has closed during the pandemic’. (006, Female, Patient, Berwick Upon Tweed, 15/03/2021)

‘[In summer/autumn 2020] we started to see the side effects of lockdown… Some of the patients ending up having their treatment delayed. Potentially we were seeing people coming in with more advanced cancer than they would have been if they could have had their operation in March or April.  We felt guilt that, you know, we’d made this big fuss because Covid was coming and you had to prepare, but look at all the people we let down by doing that’. (007, Female, ICU consultant, South Wales, 26/01/2021)

3. Primary care

The backlog in outpatient appointments in hospitals means that more long-term chronic conditions are being managed in primary care. This is adversely affecting the workloads in primary care which is also coping with the vaccination programme and wider winter pressures. Patients are also coming to primary care with multiple issues, which they have ‘saved up’ as a result of the pandemic.

‘Everyone who was supporting the NHS by staying at home and not coming to the doctors with their minor illnesses have saved it all up and decided that “Life’s gone back to normal now and I’m going to take it all to the GP”. So I don’t do a consultation now where there isn’t three or four problems where there used to be maybe one or two. The number of mental health consultations that we’re doing has risen dramatically’. (008, Female, GP, Liverpool, 13/09/2021)

‘Longterm is going to be how do we catch up with all that work that had to go on stand-still? You know, I’ve got a lot of patients who are waiting for outpatient appointments with medical teams, lots of patients waiting for surgeries. All of that is delayed and the consequences of delaying is that risk that patients decondition, or their disease gets worse, or the quality of life deteriorates, which then affects their mental health. Their whole health and mental health worsens. And that is going to go on for a really long time’. (009, Female, GP, South Wales, 24/09/2021)

3. Impact of backlogs on NHS staff

1. Dealing with public dissatisfaction and abuse

The longitudinal evidence gathered since March 2020 shows how public attitudes towards the NHS have ebbed and flowed over the period. Whereas the early period was defined by highly public displays of gratitude and affection through clapping and donations of food to hospitals, the backlogs and waiting times are now provoking dissatisfaction.

‘I think there has been more vocal support for the NHS and its founding principles and recognition of the immense pressure that many healthcare professionals face in their daily jobs. But there is also an underlying, I think, dissatisfaction with things like waiting times – things like cancer, diagnoses being delayed, or cancer treatment being delayed, or the change in the availability of some services’. (010, Male, Junior doctor, Greater Manchester, 22/07/2021)

Since summer 2021 there has been increasing evidence of patients complaining and verbally abusing NHS staff. Interviewees describe a reduction in tolerance from patients for delays in treatments or appointments, and patients becoming less understanding about the impact that Covid-19 is still having on the system’s capacity to provide healthcare.

‘There is a growing animosity towards the NHS, typically primary care services, for A & E services, doctors. And when you explore that it’s because… people are feeling that Covid is now more of an excuse than a reason as to why they can’t get an appointment, or to why things are delayed. And people are actually getting angry. And funnily enough, months and months and months ago – many months ago – more or less at the start of Covid I can remember asking a nurse how she felt about people standing outside doing the clap for frontline primary key workers. And she said, ‘it’s great now but eventually they’ll turn on us.’ And I said, ‘what do you mean?’ And she actually prophesised what’s happening now: because services have been so stretched there is more difficulty accessing those services or accessing a service of the same quality, that there is a growing animosity’. (011, Female, Mental health support worker, Derbyshire, 25/06/2021)

Interviewees also describe having to deal with anger and even abuse from patients as a result of delays to appointments and treatment. This is negatively impacting their experience in the workplace, with many staff reporting low morale. Whilst this is a impacting a range of healthcare workers across services, interviewees highlight that receptionists are facing a disproportionate amount of abuse. Staff are also leaving the profession as a result of patient abuse.

‘Patients have very little patience with us at the moment.  I work in a big practice and we have seventeen thousand patients almost – so a relatively big practice – and so we have quite a lot of receptionists. But we’ve had four receptionists hand in their notice in the last couple of months because they cannot tolerate the level of abuse that they are getting over the phone anymore. And we’ve had countless more who’ve had to go home because they’re distressed and upset by the way they’ve been spoken to, because patients cannot get what they want from their GP practice at the moment.  Despite there being an increase in the number of available appointments, despite us finding new ways for them to contact us, so email consultations being a good example… At the moment it feels like it doesn’t matter what we do our patients are not satisfied... Morale in general practice is at the moment the lowest that I’ve ever known it’. (008, Female, GP, Liverpool, 13/09/2021)

2. Lack of resources to respond to the backlog

Health services were under pressure before the pandemic through a combination of a chronic underfunding and workforce shortages. This has meant that it has not been possible to redirect additional resources to manage the backlog in treatments and procedures. NHS staff express concerns about the lack of ‘slack’ in the system that manifests through less than adequate staffing ratios.

‘The colorectal bods [specialists] have got a massive amount of cancer work to catch up with and inflammatory bowel disease work to catch up with and there just isn’t the facility to house all these people… There isn’t any slack in the system’. (012, Female, Nurse, Greater Manchester, 23/05/2021)

Our evidence suggests that NHS staff are apprehensive about the longterm sustainability of coping with the backlog in a context of chronic underfunding. They raise concerns that responding to the backlog will adversely impact staff’s physical, emotional, and psychological wellbeing to dangerous levels.

‘I think that a lot of patient’s tolerance for delays is running out. So they are now getting increasingly frustrated when there is an 18 month waiting list to be seen at the hospital, for example. We did see an increase in complaints at the end of the last lockdown about minor things such as having to wait for an appointment. That seems to have settled down again now. But I think the difficulty in the longer term is managing how we’re going to deal with the catch up… I think that’s going to be difficult because we don’t have the workforce – or a way to trying catch up without causing complete burnout of medical staff… There’s only so much doctors can absorb’. (013, Female, GP, Canterbury, 21/07/2021)

3. Staff working harder

NHS staff are working harder at individual and collective level to address the backlog and shorten waiting times. This is at a time when staff are still recovering from the physical and emotional impact of working extra hours during the crisis periods of the pandemic. Approaches include working during weekends and identifying more efficient ways of working.

‘They’re doing surgery all weekend at Central Mid and it’s very, very busy. There are lots of patients being brought in’. (014, Female, Nurse, London, 07/06/2021)

‘[W]e’ve obviously got this huge backlog of patients who had been delayed either diagnostics or treatment for various conditions, which means that the actual anaesthetic service is quite far behind, and surgical services in total, are quite far behind where we should be. So the main change is trying to find a way for that to be more efficient. That means noticeably there are lists going on at the weekends, with doubled up consultants trying to get through shorter cases very rapidly to bring down that work list’. (015, Female, Anaesthetist, London, 07/06/2021) 

The physical and emotional toll for NHS staff that comes from responding to the backlog is evidenced through a widespread exhaustion that impacts everyday interactions and morale across the workplace.

‘My team are working hard to catch up on the backlog of work that we paused in order to focus on those key projects during the pandemic. And everyone is exhausted and really tired, but still know that there are patients at the end of it, so’. (016, Male, Manager, London, 07/09/2021)

‘Returning to work in February [from maternity leave] everyone was pretty miserable, exhausted, and a bit more liable to getting angry or upset. I had maybe four or five people cry on me or in response to some questions about how they were in the last few months… There was definitely a noticeable kind of burnout rate or exhaustion rate amongst most of the NHS staff that I was I working with’. (015, Female, Anaesthetist, London, 07/06/2021) 

Staff exhaustion and burnout is a significant concern amongst interviewees, with many highlighting the risk of losing staff through early retirement, or leaving the profession as a result.

‘I think there will be a lot of staffing problems. Because as this crisis recedes, which it will eventually… I think there will be a lot of people will probably leave healthcare and say “sod it, I can do something else”’. (016, Female, GP, Greater Manchester, 15/01/2021)

‘I think if they don’t do something regarding the nurses they are going to leave in droves… It’s a hard task and there’s such demands on them’. (018, Female, Nurse, Greater Manchester, 05/05/2021)

‘We’ve had two doctors here who have left, both citing the pressure of work and needing a better work-life balance as a reason for them leaving’. (008, Female, GP, Liverpool, 13/09/2021)

4. Impact of backlogs on patients

1. Communication issues

Our evidence shows that backlogs are detrimental to the physical and mental health of patients waiting for treatments and procedures. This stems in particular from uncertainty about the timelines and details of treatment. Poor quality communication from healthcare services with regard to the timing and location of appointments has exacerbated the impact on patients.

‘So it was going to be a different place and I would get information on this. And then I got a phone call to say the building wasn’t ready so it would be the following week. And then I got a phone call to say it would be this week, the 17th, and I still haven’t had any information – I’ve got no idea where the venue was or the timing or anything, all I knew was it on that date. So I did a lot of phoning around and found out what the venue was... It was a building they were obviously going to do up specially and you can understand it, they wanted to get rid of this backlog. I would be sent information - well of course I never did get any information, did I’. (006, Female, Patient, Berwick Upon Tweed, 15/03/2021)

Interviewees also point out that current communication issues have a longer history that pre-dates the pandemic.

‘The issue here I think for me to park is that the poor frontline staff who get asked to keep ringing people to change appointments and venues and times and not given the information in order to answer the inevitable questions… I would say this is where we are up to in the NHS but exacerbated by Covid… So the whole issue about lack of communication for patients have been going on in for the 40 years… it's not new. Communications issues are massive and just made worse because of the disintegration in the NHS’. (006, Female, Patient, Berwick Upon Tweed, 15/03/2021)

2. Patients considering turning to private healthcare

Waiting for postponed treatment and the surrounding uncertainties is leading some interviewees to consider private healthcare, despite the additional costs.

‘One of the only challenges is that I have a significant hearing loss and I need support with that from the ENT department, ear nose and throat department, and obviously they are not seeing any non-urgent cases at the moment and I don’t know when that is likely to change and that’s been like that for some time. I have spoken to them and they say, you know, should I require urgent support go to casualty but they have no forecast time of when normal, you know, support services will be available again. So you know I am having to consider going privately and getting support privately, which obviously is a cost implication’. (019, Female, Voluntary sector worker, Scotland, 03/08/2021)

The ability of some patients to access treatments and procedures faster by paying for private healthcare has the potential to intensify health inequalities. As in the case of communication issues, this is not a new concern but one that is heightened in the wake of the pandemic.

3. Exacerbation and deterioration in health conditions

From the outset of the pandemic NHS staff have expressed concern about the impact of backlogs and long waiting times on patients’ health. They note that patients are ‘storing up’ health issues and symptoms before seeking help from healthcare services.

‘Now as we try unpick our way into some kind of normality in terms of services that’s actually generating more work again. It’s all kind of logistical work as opposed to clinical work… Most of us are getting the feeling that patients are storing up problems and symptoms that they want to come and see us about’. (020, Male, Consultant, London, 03/03/2021)

This raises concerns regarding the long-term health implications of this behaviour, particularly for diagnoses such as cancer. In addition to the impact on patient health from delayed appointments and treatments, the experience of lockdown has had a detrimental effect on health.

‘We’re still catching up on a backlog of patients that were not seen… I think the diabetes is gone off to a bad stretch with most people because there’s been quite a lot of weight gain during lockdown, less physical activity, less moving around and that effects their results. So it seems like a non-ending because we have less time to dedicate to that to be able to prioritise the flu vaccine. It does feel quite overwhelming to be honest’. (021, Female, Primary care nurse, London, 06/11/2021)

Deterioration in health due to waiting for treatment is compounded for patients with multiple health conditions, suggesting that there is a cumulative impact on this group of patients.

Background reading

• Emma Jones and Stephanie J Snow, Against the Odds? Black and Minority Ethnic Clinicians and Manchester, 1948-2009, Carnegie Publishing, 2010. (PDF available on request).
• Sheard, S. (2018). Space, place and (waiting) time: Reflections on health policy and politics. Health Economics, Policy and Law, 13(3-4), 226-250. doi:10.1017/S1744133117000366
• Stephanie J Snow and Emma Jones, ‘Immigration and the National Health Service: Putting History to the Forefront’, History & Policy. http://www.historyandpolicy.org/papers/policy-paper-118.html
• Stephanie J Snow, Jolanta Shields, Angela Whitecross, Evidence submitted to the British Academy’s enquiry into the longterm societal effects and impacts of Covid-19, December 2020. https://www.thebritishacademy.ac.uk/publications/covid-decade-nhs-voices-of-covid-19/

December 2021